12050149 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21617 ROSARIO AVE CONTRAC FOR:AFFORDABLE WATER PERNI I"1NO: 12050149
11 HA'ITRS&
OWNF.R'SNANIE: JAMIS110 24663 RAILROAD AVE DATE ISSUED:052112012
OWNER'S PIIONF.i 4082190558 SANTA CLARE"I'A.CA 91321 PHONE NO:(661)259-7I31
❑ LICENSED CON FRACFOWS DECLARA'T'ION BUILDING PF.RNIIT INFO: BLDG r ELECT (— PLUMB r
License Class Lic,N r r
N7 ECII RESIDENTIAL COMMERCIALContractor Date.
hereby affirm that I am licensed under the provisions of Chnpter 9 JOB DESCRIPTION: REPLACE 50 GAI.I.ON WA'I ER I II-A 11`.R.SAMI:LOCA PION
IN
(commencing with Section 7000)of Division 3 of the Business&Professions GARAGE
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
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 Fluor Arca:0 Valuation:51500
permit is issued.
APPLIC\NTCERTIFICATION APN Number:35619034.00 Occupancy']}pe:
I cenify 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 Imus 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. WITHIN ISO DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said Cit'in consequence of the
"ranting oflhis permit. Additionally.the applicant understands and Will comply I80 DAYS FROM LASE CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code.Section
9,18,
Issued by: Date:
Signature Date
❑ OWNER-BUILDER DECLARATION
RF:-ROOFS:
I hereby affirm that 1 am exempt from the Contractor's License Law for one or All roofs shall he inspected prior to any rooline material being installed. If a root"is
the following two reasons: installed without first obtaining an inspection.I agree R,remewe all new materials fur
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.
Date:
Slg
Business&Professions Code) namn oI Appllcanf.
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec,7044.Business&Professions Code). ,%LI.ROOp COVERINGS TO BE CLASS"A"OR BE ffER
I hereby affirm under penalty of perjury one of the following three
declarations: II:\%:%RDOUS MA1 ERIAI S DISCLOSURE
I have and will maintain it Certifeate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code.for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work lot which this permit is issued California Health&Safe. Code,Sections 255115,25533.:md?553J. I will maintain have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Nlunicipal Code,Chapter) I_vand the IEcalth&
Sal"etv Code.Section 25532(a)should 1 store or handle hazardous material.
Section 3700 of the Labor Codc,for the performance ollhe work for which this Additionally,should 1 use equipment or devices which emit hazardous air
permit is issued contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work lir which this permit is issued.I shall maintain compliance with the Cupertino Municipal Code,Chapter 7.12 and the
not ennploy any person in any manner so as to become subject to the Worker's Ilealth&Safet, Cade.Sections 255115,25533,and 25534.
Compensation laws of California. 11;alter making this certificate of excnnption;I
become subject to the Worker's Compensation provisions'of the Labor Code,I must (honer or authorized agent:
Date:
tiuthscilh comply with such provisions or this permit shall be deemed revoked.
CONS"I'RUC'1'ION LENDING AGF.NC1'
APPLICANT CERTIFICATION
I certify(hat I have read this application and state that the above information is I hereby affirm that there is a construction lending agency lot the performance of work's
correct.I agree to comply with all city and county ordinances mid state laws relating for which this permit is issued(Sec.3097.Cis'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
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 AR( Ill fE("1'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code.Section
9 1, 1 understand m)'plans shall he used as public records.
Signature Dane Licensed Professional