BLD-2020-0995ft
CUPERTINO
BUILDING PERMIT
CITY HALL
10300 Torre Avenue . Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTiNO.ORG
OWNER'S PHONE: Not Provided
ISSUED BY: KOUNBAR
JOB DESCRIPTION
ARIOSO APARTMENTS - BLD #1 - CLUB HOUSE - INSTALL SEISMIC EMERGENCY GAS VALVES ON ALL HOUSE LINES BY THE GAS METERS (1)
LICENSED CONTRACTOR DECLARATION
CONTRACTOR:
CONTRACTOR PHONE: 4088949120
VALUATION: $41 i 1
PACIFIC PLUMBING &
UCENSED CLASS:
C36 PLUMBING, A GENT
UCENSED NO:
745976
EXP DATE
05/31/2022
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my
license is In full force and effect.
I hereby affirm under penally of perjury one of the following three declaraltons:
have and will maintain a certificate of consent to self -insure for Worker's Compensation, asprovided for bySection 3700 of
of the work for which this permit is issued.
the Labor Code, for the performance
have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is Issued.
I certify that In the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505. 25533. and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code. Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District i will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534.
EPA LEAD -SAFE DISCLOSURE
An EPA Lead-Safre Certified Renovator will be responsible for this project.
Certified Firm Name: ; j Firm Certification No: j
No EPA Lead -Safe Certified Firm is required for this project.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work which this permit is issued (Section 3097, Civil
Code).
Yes
No
Lender's Name:I
Lenders Address:
APPLICATION CERTIFICATION
I certify that I have read this application and state that the above information is correct. i agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgements, costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18.
Signature: