11110102 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21979 SAN FERNANDO AVE CONTRACTOR:CITY FACILITIES PERMIT NO: 11110102
OWNER'S NAME: CITY OF CUPERTINO 10300 TORRE AVE DATE ISSUED: 11/18/2011
NER'S PHONE: 4087773140 CUPERTINO,CA 95014 PHONE NO:(408)777.3228
LICENSED CONTRACTOR'S DECLARATION r r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.q
MECH r RESIDENTIAL r- COMMERCIAL
Contractor Date JOB DESCRIPTION:REMOVE AND REPLACE THE WATER HEATER IN THE
HOUSE
I hereby affirm that I am licensed under the provisions of Chapter 9 AT BLACKBERRY FARM
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
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 .
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$0
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for die performance of the work for which this AIN Number:35710008.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
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 Brplicant understands and will comply issued b� Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION
I hereby affirm that I em exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,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)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sce.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Cade,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(x)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as dented by the Bay Area Air Quality Management District I
performance of the work for whichthis permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 21505,25533,and 25534.
Section 3700 of the Labor Code,for The performance of the work for which this
Owner or authorized agent: Date: L4halll
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person many manner so as to become subject to the Worker's
Compensation laws ofCalifomia. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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 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 ARCHITECT'S DECLARATION
emnify and keep harmless the City of Cupertino against liabilities,judgments,
s,and expenses which may accme against said City in consequence of the 1 understand my plans shall be used as public records.
. ting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Dat
ee
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 M '
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• CUPERTINO (408)777-3228 • FAX(408)777-3333• buildinO(zacuoetno.orD
M-IPLUMBING •, MFCHA/N,IC�A'L'�^ ELECTRICAL MISCELLANEOUS
PRDIFR ADDRESS .9 g l•�As". APNP 357/0
OWNER NAME PHONE E-MAIL
77 7- 00
ST0.EE1'ADDAE59 V CITY, FAX
CONTACT NAME PHONE E-MAIL/"
STREETADDRESS CITY,STATE DP FAX
0/1 Em ❑ OWNER-BUBDER O OWNERAGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCNRCLT ❑PNUmmR ❑ OaVELOPFs. ❑TENANr
CONTRACTORNAME LICENSE NUMBER LICENSE TYPE BUS.LIC a
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COMEANYNAME j U E-MAIL FAX
STREET ADDRESS CITY,STATE ZIP PHONE
ARCHTTECTIENOINSER NAME LICENSE NUMBER BUS.LIC N
COMPANY NAME E-MAIL FAX
STREET ADDRESS CTTY,STATE ZIP PHONE
qq SE OF SID mOUPIZX ❑ MULTI-FAMD.Y PROJECT IN WIDLAND ❑ YES PROIEC7 PI ❑YES VTiiE fiIDO AN ❑)'f.4
SUI DBIO: �COMMEROAL URBAN 0MIRFACE AREA MIND FLOOD ZONE �NO DCHLER HOME? NO
DESCRIPTION OF WORK
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7
TOTAL VALUATION: '- RECEIVED BY: 777
J
By my signature below,I certify to each of the fallowing: I am the property owner or authorized agent to act on the property owner's behalf. i have read this
application and the informadou I have provided is correct 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 cauction•I authorize representatives of Cupertino to enter the above-id.— property far inspection puf{ oses.
Signature of ApplicanNAgent' Date:
SUPPLEMENTAL INFORMATION R.EQLJ D JOIFFICE USE ONLY
r OVER-THECOUNTER
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MPPM4cApp_Z01l.doc revised 06/21/11