12080183CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10365 DEMISTER AVIS
C0N`f AC`f0R: EGOV
PERMITNO: 12080183
OWNER'SNAME:
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BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lie.H
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DIECII RESIDENTIAL CODIi\11ERCLU,
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: REPLACE WATER HEATER, SAME LOCATION
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in fall force and effect.
1 hereby affirm under penalty of perjury one of the following mo declarations:
I have and will maintain certificate of consent Io self -insure for Worker's
Compensation, as provided for by Section 3700 of Ilio Labor Code, for the
performance of [lie work for which this permit is issued
Sy. Ira Floor Area: 0
Valuation: $1856
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of die work for which this
permit is issued
APN Number: 32647078.00
Occupancy Type:
APPLICANT'CERTI FIC TION
I certify that I have read this application and slate that the above information is
correct. l agree to comply with all city and county ordinances and state lass relating
PERMIT EXPIRES IF WORK ISNOT STARTED
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (we) agree to save
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
180 DAYS FROM LAST CALLED INSPECTION.
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Issued by: Date:
9.18.
Signature Date
RF. -ROOFS:
❑ O\\'NER-I UILDER DECLARATION
All roofs shall be inspected prior EOMy roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all nese materials for
I hereby affirm ilial 1 am exempt from the Contractor's License Law for one of
inspection.
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
Signature of Applicant: Date:
will do the work, and the structure is not intended or offered for sale (Sce.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
A 1.1- ROOF COVERINGS TO BE CLASS "A" OR BETTER
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penally of perjury one of the following three
11A%ARDOIIS MATERIALS DISCLOSURE
declarations:
I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to sell' -insure for Worker's
California Health & Safety Code, Sections 25505. 25533. and 25534. 1 will maintain
Compensation, as provided for by Section 3700 of the Labor Code, for the
compliance with the Cupertino Municipal Code. Chapter 9.12 and the Health &
performance of the work for which this pemnit is issued
Safety Code, Section 25532(x) should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance, as provided for by
Additionally, should 1 use equipment or devices which emit hazardous air
Section 3700 of the Labor Code, for the pertonnanee of the work for which this
coutaminanis as defined by [lie Iia) Area Air Qualify Management District 1 will
maintain compliance with the Cupertino Municipal Cade. Chapter 9.12 and the
Permit is issued
Health & Safety Code, Sections 25505, 25533, and 25534.
1 certify that in the performance of Ilse %York IM whlCh this permit Is Issued, I shall
not employtiny person in any manner so as to become subject to the Worker's
Owner or authorized agent:
Compensation laws of Cali forma. 11; after making this certificate ofexemption, I
Date:
become subject to the Worker's Compensation provisions ofthe Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLIC\NTCFRT'I FICATIO,N
for which this permit is issued (Sec. 3097, Cir C.)
I certify that I have read this application and state than the above information is
Lender's Name
correct. I agree to complywith all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
Lender's Address
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupenino against liabilities -judgments.
costs, and expenses which may accrue against said City in consequence of the
AItCI l I'fECf'S DECLARATION
granting of this permit. Additionally, the applicant understands and will comply
I understand my plans shall be used as public records.
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10365 DEMPSTER AVE
O\VNER'SNAhIE:
❑ LICENSED CONTRACFOR'S DECLARATION
License Class Lic. H
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter!)
(commencing with Section 7000) of Division 3 of( he Business & Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following Iwo declarations:
I have and will maintain a certificate of consent to self-insurc 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
permit is issued.
APPLICANT' CERTIFICATION
I certify 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 slate 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
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.
Date
❑ OWNER -BUILDER DECLARATION
hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following three
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 perfommnce of the work for which this
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of Cali fomia. If, after making this certificate of exemption, 1
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this remit shall be deemed revoked,
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. 1 agree to comply with all city aril 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
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.
Date
CON'T'RACTOR: AFFORDABLE WATER PERMITNO: 12080183
HEATERS&
28372 CONSTELLA'T'ION RD DA'Z'E ISSUED: 08/152012
VALENCIA, CA 91355 PHONE NO: (661)259-7131
BUILDING PERMIT INFO: BLDG r ELECT I_I PLUMB r
DIECIH C RESIDENTIAL 0 COMMERCIAL
JOB DESCRIPTION: REPLACE WATER HEATER, SAME LOCATION
Sq. Ft Floor Area: 0 1 Valuation: $1856
APN Number: 32647078.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date.
RF: ROOFS:
All roofs shall be inspected prior to mty roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
TIA7.ARDOUS MATFRIAI S DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safely Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code. Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safey Code, Sections 25505, 25533, and 25534.
Owner or authorized agent:
Date:
CONSTRUCI-ION LENDINC AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
ARCIIFFECI"S DECLARATION
I understand my plans shall be used as public records.
Licensed