BLD-2024-0824_SignedPermit.pdf ITY OF
BUILDING PERMIT
CITY HALL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
PHONE 408-777-3228
CUPERTINO WWW.CUPERTINO.ORG
BUILDING ADDRESS: 936 BROOKGROVE LN APN: 375 39 033
PERMIT NO: BLD-2024-0824
OWNER'S NAME: JEDLICKA MICHAEL E AND ANGELINA L TRUSTEE
OWNER'S PHONE:818-402-8534
CONTRACTOR: MIKE COUNSIL PLUMBING LLC
CONTRACTOR PHONE: 408-272-4900
DATE ISSUED: Apr 17. 2024 ISSUED BY:Jasmine Archbold VALUATION: 7455
JOB DESCRIPTION: REPLACE 50 GAL GAS WATER HEATER IN GARAGE - SAME LOCATION
LICENSED CONTRACTOR'S DECLARATION:
NO: 679261 EXP DATE: 02/28/2026
7000) of Division 3 of the Business & Professions
CONTRACTOR: MIKE
I hereby affirm that
Code and that my license
COUNSIL PLUMBING LLC LICENSED CLASS: C36 PLUMBING LICENSED
I am licensed under the provisions of Chapter 9 (commencing with Section
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 under
❑
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
hazardous materials requirements under Chapter 6.95 of the California Health
M I have read the
will maintain compliance
handle hazardous
Air Quality Management
Sections 25505,
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
District I will maintain compliance with the Cupertino Municipal Code,
25533, and 25534.
EPA LEAD -SAFE DISCLOSURE
No:
Certified Renovator will be responsible for this project.
Name: Firm Certification
❑ An EPA Lead -Safe
Certified Firm
✓ No EPA Lead -Safe
Certified Firm is required for this project.
CONSTRUCTION LENDING AGENCY
of the work which this permit is issued
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance
(Section AV7, Civil Code).
Yes
El No
Lender's Name:
Lender's Address:
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 I have
laws relating to building
purposes. (We) agree
accrue against said
source regulations
Signature
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 Apr 17, 2024
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.