12070168 CITY OF CUPERTINO BUILDING PERMIT
BIIILDINGADDRESS: 10122ADELIIEIDCT CO\"1'RACI'OR:tliKECOUNSILPLUMBING PERMITNO: 12070168
INC
OWNER'S NAME: BROOKS FISHER 191507OOLE WAY DATE ISSUED:07232012
OWNER'S PIIONF-: 4082559352 SAN JOSE,CA 95131 P110Nf7 NO:(408)272-4900
❑ LICENSED CONTRACfOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r. PLUMB r
License Class Lie.N
DIECII RESIDENTIAL COAIDIERCLU.
Contractor Date
hereby affirm that I not licensed trader the provisions of Chapter 9 JOB DESCRIPTION:REPLACE WATER SERVICE FROM HOUSETO STREET
(commencing with Section 7000)of Division 3 of the Business S Professions **SEE NOTES"
Code and that my licenw•is in full force and effect.
1 hereby affirm under penally of perjury one of the following two declarations:
I have and will maintain a certificate of consent in self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Cade,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 Valuation:$4500
Section 3700 of the Labor Code,for the performance of die work for which this
permit is issued.
MIN Number:35709025.00 Occupancy'I'ypc:
.u'rl.lcw"r c1•:R ru�IC,YrI<rN
I certify that I hnvc read this application and suite that the above information is
correct.I agree m comply with all city and comity ordinances and state laws relating
to building construction,mid 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 of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said Cily 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 regulatims per the Cupertino Municipal Code,Section
9.18. Issued by: Date:
Signature Date
❑ OWNER-BUILDER DECLARATION RE-ROOFS:
4 All roofs shall be inspected prior to any roofing material being installed.If a roof is
hereby'affirm that I am exempt front 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.
1,as owner of the property;or my employees with w'age's as their sole compensalloil.
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date:
Business fi Professions Code)
I,as owner of the properly,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business d Professions Code). ALI-ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three
declarations: IIA-/.ARDOUS MATERIALS DISCLOSURE
I have and will maintain a Cenificate of Consent to self insure for Worker's I 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 Health S Safety Code.Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued, compliance with the Cupertino;Municipal Code,Chapter 9.12 and the Health S
I hive and will maintain Worker's Compensation Insurance,as provided for by Safety Code.Section 25532(x)should I store or handle luvnrdous material.
Section 3700 of the Labor Code,for the performance of the work lot which this Additionally'should I use equipment or devices which emit hazardous air
omit is issued. contaminants as defined by the Bay Area Air Quality Management District 1 will
F maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
I certify that in the performance of die work fonmich(his permit is issued,I shall I Iealth S Safety Code.Sections 25505.25533.and 25534.
not employ any person in an)-manner so as to become subject to the Worker's
Compensation laws of Cali fomin. If,after making this cer iftcale of exemption,I Owner or authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,1 must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRIICPION LENDING AGENCY
APPLICANT CERTI FICATION I hereby affirm than there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state Imes 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 Leader's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply AI2CIIITF.Cf'S DIiCI..\R.ITION
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Dme