12060164 CITY OF CUPERTINO BUILDING PERMIT
BIIILDINC ADDRESS: 10193 TONI CT CONTRACTOR:FAST WAT'GR I WATER PERMIT NO: 12060164
OWNER'S NAME: WESLEY JOIiN J AND BARBARA A 12601 132 AVE NF- DATE ISSUED:0627/2012
OWNER'S PHONE: 4085066924 KIRKLAND,WA 98034 P]]ONE NO:(800)45 8955
❑ LICENSED CONT'RACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic b r r r
MECH RESIDENTIAL COMMERCIAL
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE/REPLACE GAS WATER I IEATFR
(commencing with Section 7000)of Division 3 of the Business&Professions SEF NOTES"
Code and that my license is in full force and effect.
I hereby affirm under penally 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 Sq.Ft Floor Area:0 Valualion:$1115
Section 3700 of the Labor Code,for the performance of(he work for which this
permit is issued
.\PN Number:31623108.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and stale laws relating
to budding construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City ofCupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of This permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: Date:
Signature Date
❑ OWNER-RIIILOF.R DECLARATION RF:ROOFS:
All roofs shall be inspected prior to any roofing material bcug installed.If a roof is
hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
I,as owner of the property,or illy employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applivanu Date
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sce.7044,Business&Professions Code). ALL ROOF'COVERINGS TO RF:CI 'b\"OR BETI CLASS
1 hereby affirm under penalty of perjury one of the following three
declarations: IIA%ARDOIIS M.\'fF:R1A1.S DISCLOSURE
I have and will maintain a Ccniticaic of Consent to self-insure for Worker's 1 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 Ilealth&Safely Code,Sections 25505,25533,and 25534. 1 will maintain
perfomnance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ileallb&
I have and will maintain Worker's Compensation Insurance,as provided for by Safely Cade,Section 25532(a)should 1 store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should 1 use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance 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 Cali foria. If,after making this certificate of exemption,I Owner or authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Dale:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANI-CF-RTIFIC\TION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that 1 have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C-)
cored. I agree to comply with all city and county 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 save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all nun-poinl source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Dale,