12050150 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 2187613YRN13CI' CON'FRAC1'Oil:A PPORDABLE WA I 11 1 ERNII'I'N'0: 12050150
I IFA"I'I:RS&
OWNER'S NAME: III:NRY DAVID G AND I31'VI:RI.Y S 24663 RAILROAD AVE DAIE ISSU W OS212012
OWNER'S PHONE: 4084460144 S,\N-I'A CLARITA,CA 91321 PIIONE NO:16602594131
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT (— PLUMB r
License Class Lia p
MECII r RESIDENTIAL r COMMERCIAL
Contractor DalC
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRI I''I'ION: RIiPL,1Gli 5o GALLON wn'I'liR 111in'f1Slt,SnNn:LOCn noN
N
(commencing with Section 71100)of Division 3 of the Business&Professions GARAGE
Code and that my license is in full force and effect.
1 hereby affirm under penally or 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 I.abor Code,for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,its provided for by
Section 3700 of the labor Code,fix the performance of the work for which this Sq.Ft Floor Arrc 0 Valuation:S2700
permit is issued.
API'I.ICANI'CER'I'IFIC,\'1'10', APN Number:357 16142 00 occupancy fype:
I certify that I have read this application and stale that the nbove information is
correct I agree m comply with all city and county ordinances and state Imus relating
In 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 Uty of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Igo DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: Date:
Signature Datc
❑ OWNER-BUILDER DECLARATION
RF-ROOFS:
1 hereby affirm that I am exempt from the Contractor's License Laefor ane of All roofs shn11 be inspected prior to any tooling material being installed, If a ruul'is
the following two reasons: installed wilhom lint ohmining an inspection. I agree to remove all new materials lox
L as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,laid the structure is not intended or offered for sale(Sec 7044,
I3usinesS&Pr0JcSSi01lS Code) Signature of Applicant: lyase:
L as owner of the property.am exclusively contracting with licensed contractors 10
construct the project(Sce.7044.Business&Professions Code). ALL 1(001'COVERINC.S'f0 ISN:CLASS"A"011 IIETIEll
I hereby affirm under penally of perjury one of the following three
declarations: IIA%ARDOUS MATERIALS UISCLOSIiRF:
I have and will maintain a Certlheate of Consent to self-insure for Worker's
Compcnsalion,as provided for by Section 3700 of the labor Code,for the I have read the hazardous materials requirements under Chapter 695 of the
California Ileallh&Safely Code,Sections 25505,2,533.and 25534. 1 will maintain
performance ofthe work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.122 and the Ileallh&
Safety Code,Section 25532(x)should I store or handle haz:wdouc material.
Section 3700 of the Labor Code.for the performance of the work for which this ,additionally,should I use equipment or devices which emit hazardous air
permit is issued. eommilimutls as delined by the Bay Area Air Qualil Management District l ei11
I certify that in the performance ofthe work for which this permit is issued,I shall maintain compliance eOlh 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 Iladlh&Safely Code,Sections 25505,25533,and 25534.
Compensation laws of Calitoxnia, If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code.I must Owner or authorized agent:
Dale:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONS IRUC.'IION LENDING AGENCI'
APPLICANT CERTIFICAVION
I certifi that I have read this application and state that the above information is I hereby allirm Ih;a there is a construction lending agency for the performance of work's
correct. I agree to comply with all city and county ordimmees and stale laws relating for which this perinil is issued(Sec.3097.Car C.)
to building construction,and hereby authorize representatives Of this city to enter Lender's Name
upon the above mentioned property for inspection purposes,(We)agree to save
indenmily and keep harmless the City of Cuperlmo against liabilities,judgments. Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting o1'this permit Additionally.the applicant understands and will comply :%RCIIITF.CI'S DEC1,%RA""PION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.1 R. I understand illy plans shall be used as public records,
Signature Date Licensed Professional