HomeMy WebLinkAboutB-2017-0439CITY OF CUPERTINO BUILDING PERMIT
BUIL.DINGADDRESS: CONTRACTOR: PERMIT NO: B-2017-0439
10355 FINCH AVE CUPERTINO, CA 95014-3412 (375 43 020) FIX - IT PLUMBING
SAN JOSE, CA 95132-
3023
OWNER'S NAME: JORDAN DAVID AAND ELISA E
OWNER'S PHONE: 408-896-5742
LICENSED CONIRACTOR'S DECLARATION
License Class C-36 Lic. #906015
Contractor FIX - IT PLUMBING Date 11/30/2017
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 penalty of perjury one of the following two declarations:
1. I have and will maintain a certificate of consent to self -insure for Worker's
mpensation, 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 performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
information is correct. 1 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, judgments, 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.
Sig aturg`� ate 3/16/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec.7044, Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
1
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GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255CUPERTINO
a$LU��BING F-1 MR74ANTC�AT. I IFTFrTRTI'AT nrarerUTT AMUc TTO
(408) 777-3228 •FAX (408) 777-3333 • buiidincaCa7cupertino.or
PROJECT ADDRESS
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USE OF SFD o,DUPLEX MULTI -FAMILY
BUILDING: ❑ COMMERCIAL
PROJECT IN WILDLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN El YES
FLOOD ZONE El NO
IS THE BLDG AN ❑ YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
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TOTAL VALUATION: Z�
RECEIVED BY:
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property own is . beha I have read this
application and the information I have provided is correct. I have read the Description of Rork 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 p oses.
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Signature of Applicant/Agent: Date: /"Z- �•��
S PP MENTAL INFORMATION REQUIRED
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❑ OVER-TiIE-_COUNTER
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❑ MAJOR,
MEPMiscApp_2011.doc revised 06/21/11