12030032 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1134 KENTWOOD AVE CONTRACTOR:FAST WATER HEATER PERMIT NO: 12030032
OWNER'SNAME: NIAIIDTEHRANI 12601132 AVE NE DATE ISSUED:03106/2012
OWNER'S PUONE: 4082159224 KIRKL.AND,\VA 98034 PRONE NO:(aW)451-8955
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lie.q
(\ITCH r RESIDENTIAL r COMMERCIAL
Contractor Date
beech,•affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE/REPLACE GAS WATER HEATER
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full farce and effect.
1 hereby affirm under penalty of perjure 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 pemtit is issued. Sq.Ft Floor Arco:0 Valuation:$975
1 have mid will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,.for the perfomonce of die work for which this
pemtit is issued. APN Number:35931055.00 Occupancy Type:
APPLICANT CERTIFICATION
1 certify that I have fend this application and state that the above information is
correct.I agree to comply with all city and comnyordinances and state laws relating PERMIT EXPIRES [F WORK IS NOT STARTED
to building construction,and hereby mithorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnity and keep harmless(lie City ofCupertino against liabilities.judgments. 180 DAYS FROM LAST CALLED INSPECTION.
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 nom-point source regulations per the Cupertino Municipal Code,Section Issued by: Date:
9.18.
Signature Date
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION 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
hereby affirm that 1 am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I.as owner of the prop",,or my employees with wages as their sole compensation, Signature of Applicant Date:
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(See.7044.Business&Professions Code).
hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Cole.Sections 25505,25533,and 25534. 1 will maintain
Compensation.as provided for by Section 3700 of die labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the wort:for which this pemtit is issued. Safety Code,Section 25532(a)should t store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additimmlly,should 1 use equipment or devices which colt hazardous an,
Section 3700 of the Labor Code,for the performance of the work for which this contaminant as defined by the Bay Area Air Quality Management Dish let I will
permit is issued, maintain compliance with(he Cupertino Municipal Code,Chapter 9.12 and the
Lleallh&Safety Code,Sections 25505.25533.and 25534.
1 certify that in the performance of die work for which this permit is issued,I shall
nut employ any person in any manner so as to become subject to the Worker's Owner or authorized agent:
Compensation laws of California. If,after making this certificate of exemption,I Date:
become subject to the Worker's Compensation provisions of die Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
I hereby aRinn that there is a construction lending agency for the performance of work's
APPLICANT CF.RTI FICATION for which dais permit is issued(Sec.3097,Civ C.)
1 certifv that I have read this application mid state that the above infomation is Lender's Name
correct.I agree to comply with all city anJ county ordinances mid state laws relating
to building construction,and hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes,(11'e)agree to save
indemnify and keep harmless the City of Cupertino against liabilitiesJudgments. ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the
granting of this perink.Additionally,the applicant understands mid will comply I understand my plans shall be used as public records.
with all non-point source regulmicns per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1134 KENTWOOD AVE CONTRACTOR:FAST WATER HEATER PERMIT NO: 12030032
OWNER'SNAME: NIAIIDTEHRANI 12601132 AVE NE DATE ISSUED:03106/2012
OWNER'S PUONE: 4082159224 KIRKL.AND,\VA 98034 PRONE NO:(aW)451-8955
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lie.q
(\ITCH r RESIDENTIAL r COMMERCIAL
Contractor Date
beech,•affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE/REPLACE GAS WATER HEATER
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full farce and effect.
1 hereby affirm under penalty of perjure 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 pemtit is issued. Sq.Ft Floor Arco:0 Valuation:$975
1 have mid will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,.for the perfomonce of die work for which this
pemtit is issued. APN Number:35931055.00 Occupancy Type:
APPLICANT CERTIFICATION
1 certify that I have fend this application and state that the above information is
correct.I agree to comply with all city and comnyordinances and state laws relating PERMIT EXPIRES [F WORK IS NOT STARTED
to building construction,and hereby mithorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnity and keep harmless(lie City ofCupertino against liabilities.judgments. 180 DAYS FROM LAST CALLED INSPECTION.
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 nom-point source regulations per the Cupertino Municipal Code,Section Issued by: Date:
9.18.
Signature Date
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION 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
hereby affirm that 1 am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I.as owner of the prop",,or my employees with wages as their sole compensation, Signature of Applicant Date:
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(See.7044.Business&Professions Code).
hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Cole.Sections 25505,25533,and 25534. 1 will maintain
Compensation.as provided for by Section 3700 of die labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the wort:for which this pemtit is issued. Safety Code,Section 25532(a)should t store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additimmlly,should 1 use equipment or devices which colt hazardous an,
Section 3700 of the Labor Code,for the performance of the work for which this contaminant as defined by the Bay Area Air Quality Management Dish let I will
permit is issued, maintain compliance with(he Cupertino Municipal Code,Chapter 9.12 and the
Lleallh&Safety Code,Sections 25505.25533.and 25534.
1 certify that in the performance of die work for which this permit is issued,I shall
nut employ any person in any manner so as to become subject to the Worker's Owner or authorized agent:
Compensation laws of California. If,after making this certificate of exemption,I Date:
become subject to the Worker's Compensation provisions of die Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
I hereby aRinn that there is a construction lending agency for the performance of work's
APPLICANT CF.RTI FICATION for which dais permit is issued(Sec.3097,Civ C.)
1 certifv that I have read this application mid state that the above infomation is Lender's Name
correct.I agree to comply with all city anJ county ordinances mid state laws relating
to building construction,and hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes,(11'e)agree to save
indemnify and keep harmless the City of Cupertino against liabilitiesJudgments. ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the
granting of this perink.Additionally,the applicant understands mid will comply I understand my plans shall be used as public records.
with all non-point source regulmicns per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date