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B-2018-1659CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2018-1659 21752 COLUMBUS AVE CUPERTINO, CA 95014-4713 (356 18 042) CUPERTINO PLUMBING INC SAN JOSE, CA 95124 OWNER'S NAME: PERKINS WILLIAM FAND ALICE LTRUSTEE DATE ISSUED: 10/01/2018 OWNER'S PHONE: 408-515-1362 PHONE NO: (408) 253-0618 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C36 Lic. #624905 Contractor CUPERTINO PLUMBING INC Date 04/30/2020 X BLDG —ELECT X PLUMB 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: WHOLE HOUSE RE -PIPE COPPER - (9 FIXTURES) 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 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 performance of the work for which this Sq. Ft Floor Area: Valuation: $5000.00 permit is issued. APPLICANT 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 APN Number: Occupancy Type: and state laws relating to building construction, and hereby authorize 356 18 042 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 applicant under tands and will comply with all non -point source regulations per theertino id de, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signatur /" 01-2018 Issued by: Kim Dunbar I D E R DECLARATION Date: 10/01/2018 I hereby affirm that I am exempt from the Contractor's License Law for one of the RE -ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is 1. I, as owner of the 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) 2. I, as owner of the property, am exclusively contracting with licensed Signature ofApplicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 10-01-2018 1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1. 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. HAZARDOUS MATERIALS DISCLOSURE z. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code, for the performance of the work for which this California Health & Safety Code, Sections 25505, 25533, and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the 3. I certify that in the performance of the work for which this permit is issued, I Health & Safety Code, Section 25532(x) should I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the will maintain compliance with the Cupertino Ip de, Chapter 9.12 and the Health & 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 liabilities, judgments, costs, and expenses which may accrue against said City in Lender's Address consequence of the granting of this rmit. Additionally, the applicant understands and will comply with all non- so regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code, Section 9.1,$... 1 understand my plans shall be used as public records. �i tG %��� ' Sig r /" Date 10 -01-2018 Licensed Professional /