12030120 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRI?SS: 7557 NEWCASTLE DR CON'I'R,%CI'OR:MOOMAU PLUMBINC. PERMITNO: 12030120
OWNER'S NAME: JOIi NSON JUDY M AND LARS E TRUSTHE 1177 BRANDADI 1,N UNIT 152 DATE ISSUED:03832012
OWNER'S PHONE: 4082529047 SANdOSE.CA 95118 PBONF,NO:(408)396-3837
❑ LICENSED CONTRACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG I- ELECT r, PLUMB M
License Class Lic.q
NIF,CH r RESIDENTIAL rl COMMERCIAL(-
Contractor Date
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE WM ER HEATER
(commencing with Section 7000)of Division 3 of the Business S Professions "SEE NOTES'•
Code and that my license is in full force and effect.
I hereb) affirm under penalty of perjury(,lie of the following two declarations:
I haveand nd will maintain a certificate of consent to self-insure for Worker's
C0mpensali0a,ars provided for by Section 3700 of the lahor Code,for the
perl'onnance of the work lin which this permil is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.171 Floor Area:0 Vnlumina:$600
Section 3700 of the labor Code,for[he performance of Ore work for which this
permit is issued.
APN Number:36617073.00 Ocetgrancy Type:
APPLICANT CERTIFICA'T'ION
I certify that 1 have read this application and slate that the above infommtion is
correct. I agree to comply with all city and County Ordinances and slate laws relating
to building construction,and hereby authorize representatives of this city In enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the aboyc mentioned properly for inspection purposes. (We)agree to save
indamni ly and keep harmless the City of Cupertino against l iabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of flit 180 DAYS FROM LAST CALLED INSPECTION.
granting ollhis permit. Additionally,[he applicant understands mrd will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: Date:
Signature Date
❑ OWNER-BUILDER DECLARATION' RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed If a roof is
I hereby affirm that 1 am exengrl from the Conlractor's License Lase for(,lie of installed without first obtaining an inspection,I agree to remove all new materials for
[tie following two reasons: inspection.
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 salt(Sce.7044, Signature of Appliount: Date:
Business&.Professions Code)
1,as owner of the property,run exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&•Professions Code). ALL ROOF COVERINGS•1'O 111;CLASS"A"OR BE I-1'ER
hereby affirm under penally of perjury one of the following three
declarations: IIA%ARDOIIS MATERLVS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Iteal[h&Safety Code,Sections 25505.25533,and 25534. 1 will maintain
performance of[he work for which this permit is issued compliance with the Cupertino Municipal Code.Chapter 9.12 and[he health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safely Code.Section 25532(x)should I store or handle hazardous material.
Section 3700 ofthe Labor Code,for the performance of the work for which this Additionally,should 1 use equipment or devices which emit hazardous air
co ntaminunis as defined by the Bay Area Air Quality Management District I will
Permit is issued. mainntin compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the perf0rnnanee of the work for which this permit is issued.I shall health&Safety Code.Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,ager making this certificate of exemption,1 Owner or authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Mata
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTR11CHON LENDING AGENCY
APPLICANT Cf:RTIFICx-1'ION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and cooly ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to sive Lender's Address
indemnify laid keep harmless the City of Cupertino against liabilities,Judgments,
costs,and expenses which may accrue against said City in consequence of flic
granting of this permit.Additionally,the applicant understands and will comply ARCUI.1'ECI"S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code.Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date