12010166 CITY OF CUPERTINO BUILDING PERMIT
U[LU[NG ADDRESS: l l 136 LINDA VISTA DR CONTRACTOR:PAST WATER HEATER PERMIT NO: 12010166
OWNER'S NAME: ECKMAN CHARLES J AND CATHERINE
12601 132 AVE NE DATE ISSUED:01/27/2012
)WNER'S PHONE: 4085170967
KIRKLANB,WA 98034 PHONE NO:(800)454-8955
LICENSEn CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
,icense Class Lic.# MECH RESIDENTIAL COMMERCIAL '
_'ontractor Date JOB DESCRIPTION:REMOVE/REPLACE GAS NATER HEATER
[hereby affirm that I am licensed under the provisions of Chapter 9
,commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I 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 Valuation:$920
performance of the work for which this permit is issued. Sq.Ft Floor Area:0
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:3616017.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We)agree to save
indemnity 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 Date:
with all non-paint source regulations per the Cupertino Municipal Code,Section Issued by:
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 all inspection,I agree to remove all new materials for
I hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons: Date:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code).
HAZARDOUS hIATERI.AL5 DISCLOSURE
I hereby affirm under penalty of perjury one of the following three
I have read the hazardous materials requirements under Chapter 6.95 of the
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
municiCompensation.as provided for by Section 3700 of the Labor Code,for the Safety Code,with
Cupertino
should IsCode, t
compliance tore ohandlehazardous mer 9.12 and aterial.
Health&
al�
performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I have and will maintain Worker's Compensation Insurance,as provided for by contaminants as defined by the Bay Area Air Quality Management District I will
Section 3700 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
I certify that in the perti�rmance of the work for which this permit is issued,I shall
not employ ariy person in any manner so as to become subject to the Worker's Owner or authorized agent: Date
Compensation laws of California. if,after making this certificate of exemption,I
become subject to the W'orker's Compensation provisions of tiie Labor Code,I must CONSTRUCTION LENDING AGENCY comply with such provisions or this permit shall be deemed revoked.
I hereby aftinn that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I 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 and 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.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs.and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date