12080181 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 10540 CI LACE DR CONTRACTOR:AFFORDABLE WATER PERMIT NO: 12080181
HEATERS&
OWNER'SNANIE:
VALENCIA,CA 91355 PHONE NO:(661)259-7131
❑ LICENSED CON'1'RACfOR'S IIISCLARATION
BUILDING PERMIT INFO: 13LDC ELECT PLUi\II3
License Class Lie.d
DIECH r RESIDENTIAL r COMMERCIAL
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 3013 DESCRIPTION: REPLACE WATER HEATER,SAME LOCATION
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that nrr license is in full force and effect.
I hereby affirm under penalty of perjury one of the following Hill 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. Sy. FI Floor.\rea:0 Valuation:$3103
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of Ole Work for which this
permit is issued. APN Number:32613027.00 Occupancy'I'ype:
.\PPL1cnN-r cEarurlc\'rl<)N
I certify that I have read this application'road state than the above information is
correct.l agree to comply with all city and courtly ordinances Enid stale laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (Wc)agrce to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indenmilvandkeepharmlesstheCityolCupertinoagainstliabilitics,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 UIRIM tads and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Dale.
9.18.
Signature Date
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed Without first obtaining an inspection,I agree to remove all new materials for
1 herchy affirm that 1 am exempt from the Contractor's License Lm, for one of inspection.
the following two reasons:
1,as owner of the property,or in),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(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting With licensed contractors to ALL ROOF COVERINGS TO 1117 CIASS"A"OR IIF;FITR
construct die project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three IIA%ARDOIIS NIAT iRIAIS DISCLOSURE
declarations: 1 have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-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 Coda Chapter 9.12 and the health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which snit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Aren Air Quality Management District I will
maintain compliance With the Cupertino Municipal Collor,Chapter 9.12 and the
permit is issued. llcalth&Safely Code,Sections 2550.5.25533,and 25534.
1 certify that in the performance of de work forwhich this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's Owner or authorized agent:
Compensation laws of California. If,,after making this certificate ofexcmption,I hale:
become subject to the Worker's Compensation provisions Of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUC-110N LEINDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
\I'I'I-IG\N'1'CFIfI'l1 IC,\'I'I(IN fonvhich this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and shoe that the above information is Leader's Name
correct.1 agree to comply with all city and county ordinancesand stale laws relating
to building construction,mid hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify mid keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence Of the ARCHITECI"S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply' 1 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