12030074 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18892 ARATA WAY CONTRACTOR:FAST WATER HEATER PERMIT,NO: 12030074
OWNER'SNAJIF.: CIIOPRAANGE'f ANDSIiIK11A 12601.132AVE NE DATE ISSUED:03/15/2012
O\\'NER'SSPOONF.: 4085611250 BIRKLAND,WA 98034 PlIONE NO:(800)454-8955
❑ INCENSED CONTRACTOR'S DECLARATION r r C,
BUILDING PERMIT INFO: BLDG � ELECT"-' PLUMB
License Class Lie.#
OIECFI r RESIDENTIAL r COMMERCIAL (-•
Contractor Date
I hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RI?MOVFIREPLACE GAS WATER IIEATER
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that niy license is in full force and effect.
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
Sy.FI Floor Arca:0 Valuation:$850
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of One work for which this
permit is.issued APN Number:37513004.00 Occupancy Type
AI'1'LIC.\N'I'CF.R'1'1PICA"I'ION
I certify that I have read(his application and state that the above information is
correct.lagree m comply with all city and county ordinances and slate laws relating PERMIT EXPIRES IF WORT{ IS NOT STARTED
to building construction,and herebyauthorize representatives ofthis city to enter
upon the above mentioned properly for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino 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 non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date:
9.18.
Signature Date
RE-ROOFS:
❑ OWNER-11111 LITER DE.CLA RATION All roofs shall be inspected prior to any roofing material beiig installed.If a roofis
installed withom first obtaining an inspection,1 agree to remove all new materials for
1 hereby affirm that 1 am exempt from the Contractor's License Lawfor one of inspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, Signature ol'ApplicrnC Date:
will do the work,laid the structure is not intended or offered for sale(Sce.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALI,ROOF COVERINGS TO BE CLASS'A"OR BE'T`TER
construct the project(Sec.7044,Business&Professions Code).
hereby affirm under penalty of perjury one of the following three IIA''/.ARDOIIS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements trader Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Ilealth&Safety Code.Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 ofthe Labor Code,for(he compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilealth&
performance of the work for which this permit is issued Safeh.Code,Section 25532(a)should I"store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit huardous air
Section 3700 of the Labor Code,for the perl'ammnce of the work for which this contaminants as defined by the Ray.Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
Health&Safety Code,Sections 25505,_5533,and_5534.
1 certifythat in the performance of the work for which this permit is issued,I shall
not employ any person in any mannenso as to become subject to the Worker's Owner or authorized agent:
Compensation laws o'California. If,alter making this certificate of exemption,I Date:
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRIICfION LENDING AGENCY
I hereby of inn that there is a construction lending agency for the performance of work's
APPLICANT CE,11TIFIC TION for which this permit is issued(Sec.3097,Civ C.)
Icertify that 1 have read this application and state that the above information is Lender's Name
correct. I agree to comply with all city and county ordinances mid state laws relating
to building construction,mid hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned properly for inspection purposes.(We)agree to save
indemnify and keep harmless the Ci(y of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECTS DECLARATIONgranting ofthis permit.Additionally,the applicant understands and will comply I understand my plmis shall be usedas public records.
with all non-point source regulations per(he Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date