12030149 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10440 SERRA ST CONTRACTOR:AFFORDABLE WATER PERMIT NO: 12030149
HEATERS&
OWNER'S NAME: MIKE&APRIL GILLEY 24663 RAILROAD AVE DATE ISSUED:03/292012
OWNER'S PHONE: 6509682700 SANTA CLARITA,CA 91321 PHONE NO:(661)259-7131
❑ LICENSED CONTRACTOR'S DECLARATION r r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.p
MECH r RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVEIREPLACE STORAGE TYPE,GAS WATER
(commencing with Section 7000)of Division 3 of the Business&Professions HEATER-
Code and that my license is in full force and effect. SAME SIZE AND LOCATION
I hereby affirm under penally of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-inst re 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.
I 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 Sq.FI Floor Area:0 Valuation:$1895
permit is issued.
APPLICANT CERTIFICATION APN Number:34259014.00 Occupancy Type:
certify that I have read this application and stale that the above information is
correct.I agree to comply with all city and county ordinances and stale 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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Signature Date Issued by: Date:
❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
1 hereby affirm that l am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material berg installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the properly,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the properly,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of The following three
declarations: HAZARDOUS MATERIALS DISCLOSURE:
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 1 have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which thisSafety Code,Section 25532(a)should)store or handle hazardous material.
permit is issued. - Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of Califomia. If,after making this certificate of exemption,1
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Dale:
APPLICANT CERTIFICATION CONSTRUCTION[,ENDING AGENCY
I cenify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.1 agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned properly for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional