B-2018-1074 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1074
1061 R LARRY WAY CUPERTINO,CA 95014-2057(316 02 030) K M F PLUMBING
SANTA CLARA,CA
95054
OWNER'S NAME: DA'Z'E ISSUED:06/26/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 Lie.#6$5200
Contractor K M F PLUMBING Date 10/31/2019 X BLDG—ELECT X PLUMB
I hereby affirm that[am licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL COMMERCIAL
with Section 7000)of Division 3 of Bre Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
REPLACE SEWER LATERAL;INSTALL CLEANOUT
I hereby affirm under penalty of perjury one ofthe following two declarations:
r. I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
�// I have and will maintain Worker's Compensation Insurance,as provided for by
// �„Section 3700 of the Labor Code,for the permce
foranofthe work for which this
�/ permit is issued. Sq.Ft Fluor Are.: Vxluntion:$4300.00
APPLICANTCERT[FICATION
1 certify that I have read this application and slate that the above pPN Number: occn
Information is correct.I agree to comply with all city and county ordinances Penc y Type:
and state laws relating to building construction,and hereby authorize 316 02 030
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,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applic t understands and ill comply with all non-point
source regulatlo s per a Cupertin Mu 1 1 at Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 06-26-2018 Issued by:Kim Dunbar
Date:06/26/2018
OWNER-RUII,DER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law fan.one of the RE-ROOFS:
fallowing two reasons: All roofs shall be inspected prior to any roofing material being installed,Ha roof is
r. 1,as owner ofthe property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
z 1,as owner ofthe property,am exclusively contacting with licensed Signature of Applicunt
contractors to construct the project(Sec.7044,Business&Professions Code). Date:06-26-2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO RE CLASS"A"OR BETTER
r. I have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Cade,for the
perfmmrance ofthe work fm which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as provided for by 1 have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 ofthe Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,had 25534.I will
Permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s. I certify that in the performance ofthe work for which this permit is issued,I Health&Safety Code,Section 25532(n)should I store or handle lurznrdous
shall not employ an manner so as to become subject to the material.Additionally,should I use equipment or devices which craft hazardous
I y y person in any m J air contaminants as defined by the Bay Area Air Quality Man en'""District t
Worker's Compensation laws of California.If,,after making this certificate of will maintain compliance with the Cupertino Municipal Ca , hepter MI and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked, Owner or authorized agent:
APPLICANTCF,RTIFICATION Date:06-26-2018
I certify that I have read this application and stale that the above information is CONSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for Inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against Iiabllilies,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit.Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCIIITECT'S DECLARA'T'ION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 06-26-2018 Professional