BLD-2021-1880_SignedPermit.pdfCITY OF
BUILDING PERMIT
CITY HALL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
PHONE 408-777-3228
CUPERTINO WWW.CUPERTINO.ORG
BUILDING ADDRESS: 21081 RED FIR CT APN: 359 05 030
PERMIT NO: BLD-2021-1880
OWNER'S NAME: LUONG HUNG THIEN AND MINH TU TRUSTEE
OWNER'S PHONE:
CONTRACTOR: TRENCHFREE INC
CONTRACTOR PHONE:
DATE ISSUED: 2021-09-30 ISSUED BY: Phuong Devries, P.E. VALUATION: o
JOB DESCRIPTION: REPLACING WATER LINE FROM METER TO UNIT WITH HDPE - (AREA #4) - 21081 RED
FIR/21083 RED FIR/21085 RED FIR/21087 RED FIR/21089 RED FIR/21091 RED FIR/21093 RED
FIR/21095 RED FIR/21097 RED FIR/21099 RED FIR/21101 RED FIR/21103 RED FIR/21105 RED
FIR/21107 RED FIR/21109 RED FIR/21111 RED FIR/21113 RED FIR/21115 RED FIR/21117 RED
FIR/21119 RED FIR
LICENSED CONTRACTOR'S DECLARATION:
NO: EXP DATE: 03/31/2022
971016
7000) of Division 3 of the Business & Professions
CONTRACTOR:
I hereby affirm
Code and
that
that my
under
TRENCHFREE INC LICENSED CLASS: C36 LICENSED
PLUMBIN
I am licensed under the provisions of Chapter 9 (commencing with Section
license is in full force and effect.
penalty of perjury one of the following three declarations:
I have and will maintain a certificate of consent to self -insure for Worker's Compensation,
Labor Code, for the performance of the work for which this permit is issued.
as provided for by Section 3700 of the
I hereby affirm
❑
Section 3700 of the Labor Code, for the
not employ any person in any manner so as to
this certificate of exemption, I become subject to
with such provisions or this permit shall be
I.
I have and will maintain Worker's Compensation Insurance, as provided for by
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
become subject to the Worker's Compensation laws of California. If, after making
the Worker's Compensation provisions of the Labor Code, I must forthwith comply
deemed revoked.
❑
HAZARDOUS MATERIALS DISCLOSURE
& Safety Code, Sections 25505, 25533, and 25534. I
read the
maintain
hazardous
25505,
hazardous materials requirements under Chapter 6.95 of the California Health
M I have
will
handle
Air Quality
Sections
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or
air contaminants as defined by the Bay Area
Chapter 9.12 and the Health & Safety Code,
material. Additionally, should I use equipment or devices which emit hazardous
Management District I will maintain compliance with the Cupertino Municipal Code,
25533, and 25534.
EPA LEAD -SAFE DISCLOSURE
No:
Lead
Firm
Lead
-Safe Certified Renovator will be responsible for this project.
Name: Firm Certification
❑ An EPA
Certified
✓ No EPA
-Safe Certified Firm is required for this project.
CONSTRUCTION LENDING AGENCY
of the work which this permit is issued
I hereby affirm
(Section 3
Lender's
Lender's Address:
under
97, Civil
Yes
Name:
penalty of perjury that there is a construction lending agency for the performance
Code).
la No
APPLICATION CERTIFICATION
with all city and county ordinances and state
the above mentioned property for inspection
judgements, costs, and expenses which may
understands and will comply with all non -point
I certify that
laws relating
purposes.
accrue against
source regulations
Signature
I have
to building
(We) agree
said
read this application and state that the above information is correct. I agree to comply
construction, and hereby authorize representatives of this city to enter upon
to save indemnify and keep harmless the City of Cupertino against liabilities,
City in consequence of the granting of this permit. Additionally, the applicant
per the Cupertino Municipal Code, Section 9.18.
Date Sep 30, 2021
EVERY PERMIT ISSUED SHALL BECOME INVALID UNLESS THE WORK ON THE SITE AUTHORIZED BY SUCH PERMIT IS COMMENCED WITHIN 365 DAYS AFTER ITS ISSUANCE,
OR IF THE WORK AUTHORIZED ON THE SITE BY SUCH PERMIT IS SUSPENDED OR ABANDONED FOR A PERIOD OF 365 DAYS AFTER THE TIME THE WORK IS COMMENCED.