B-2016-2576 CITY OF CUPERTINO BUILDING PERMIT
BUH.DINGADDRESS: CONTRACTOR:. PERMIT NO:B-2016-2576
22153 WALLACE DR CUPERTINO,CA 95014-0118(326 02 046) MIKE COUNSIL
PLUMBING INC
SAN JOSE,CA 95131
OWNER'S NAME: MEl1G LUGN AND WU SHARON TRUSTEE DATE ISSUED:08/23/2016
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OWNER'S PHONE:4081596-4568 PHONE NO:(408)272-4900
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Q: $ Licl#,679261 X BLDG _ELECT X PLUMB
Contractor MIKE COUNSIL PLUMBING INC Date 04/30/2017 _MECH X RESIDENTIAL_COMMERCIAL
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. JOB DESCRIPTION:
REPLACE 50 GAL WATER HEATER-SAME LOCATION
I hereby affirm under penalty of perjury one of the following two declarations:
a. 1 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
A -performance of the work for which this permit is issued.
," _I have and wiu 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 issue. Sq.Ft Floor Area: Valuation:$2800.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above APN Number: Occupancy Type:
information is correct.I lagree to comply with all city and county ordinances 326 02 046
and state laws relating�o building construction,and hereby authorize
representatives of this pity to enter upon the above mentioned property for
inspection purposes..Me)agree to save indemnify and keep harmless the
City of Cupertino againlst liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per i he Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Sign Date$/23/2016 Issued by:Abby A eS nde
Date:08/23/2016
RE-ROOFS;
I hereby affirm that I am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed.If a roof is
following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1. I,as owner o the property,or my employees with wages as their sole inspection.
compensatio ,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professions Code)
2. I,as owner 4 the property,am exclusively contracting with licensed Signature of Applicant:
/2016
contractors to construct the project(See.7044,Business&Professions Code). Date:8 3
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I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 1 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 HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
Section 3706 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal:Code,Chapter 9.12 and the
permit is is d. Health&Safety Code,Section 25532(a)should I store or handle hazardous
s, I certify that rn the performance of the work for which this permit is issued,I material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,1,become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
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be deemed revoked. p p Owner or authorized agent•
Labor Code,�I must forthwith complywith such provisions or this permit shall
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APPLICANT CERTIFICATION Date:8/23/2016
CONST RIUCTION LE
I certify that[have red this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance
correct.I agree to co ply with all city and county ordinances and state laws of work's for which this permit is issued(Sec.3097,Civ C.)
relating to building construction,and hereby authorize representatives of this city Lender's Name
to enter upon the abOe mentioned property for inspection purposes. (We)agree
to save indemnify an� keep harmless the City of Cupertino against liabilities, Lender's Address
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally,the applicant understands ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records.
Code,Section 9.18.
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Licensed
Signature Date 8/23/2016 Professional
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GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT,BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
{408)777-3228•FAX(408)777-3333 a building .cupertino.org misc
CUPERT[t4
PLUMBING OMECHANICAL EIELECTRICAL MISCELLANEOUS
PROJECT ADDRESSA 1 f t' (f APN# ®01 j�/I/7,
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CONT CTO NAME LICEN E NUMBER 1ACEN E T PE BUS.LIC# �$}{
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COMPANY NAME E-MAIL FAX
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USE OF FD�+c DUPLEX (3 MULTL-FAMII.Y PROJECT IN WIL.DLAND 0 YE PROJECT IN ❑YES IS THE BLDU AN ®YE
BUB.DINU: Q CO),�MNERCIAL URBAN INTERFACE AREA FLOOD ZONE LA"150. EICHLERHOMR1
DESCRIPTION OF WORk
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Cl® RECH1VW BY
TOTAL VALUATION: C
By-y signature bele}
pp w,I certify to each of the following: I am the property owner or authorized agent to act on the groperty cr's half. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant(Agent: LLi?�_ Fate: d °` '' J 6
SUPPLEMENT !�70p&<FJON REQUIRED OFFICE USE ONLY
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MEPMiscApp_2011.doc revised 06/21/11