12080145 CITY OF CUPGRTINO 13UILDING PGRMIT
13UILDING ADDRI:SS: I I58 ELMSPORD DR CON'I'R,\CPOR:6L'TTf:R R'ATGR IIEATERS PF.R�II'I'NO: 12080145
OR'\ER'S\AJIF.:
SAN.IOSIi.G� i5133 PIIONF,\O:N�S)250-6671
❑ LICIS\SIiD CONI'RACfOR'ti DIiCI..\R.\'IION QUII.DWC PERi�I1T INFO: BLDC r ELECT r PLUbB r
License Class I.ic.q
MECH r RESIDENTIAL r COAIDIERCIAL r
Comracmr Daie
Ihereb��alTirm�hullumlicemeJundenhrprurisiunsofChapler'/ �013DFSCRIPTION;REMOVALANDREPLACEMENTOF40GALR'ATLR
(commcncing e'i�h Scc�ion 7000)�f Uirisinn 3 of�hc Bu.rinczs S 1'rnfessinns li&\TER IN
CuJe und Ihul mv licrnse is in full force unJ effecl. SAhIH LOCATION
1 hcreby affinn unJer penalty uf perjury onr uf Ihe fullue'in�n�'o Jrclnra�iunr
I hace and will mainmin a certificale of consenl to self-insurc for N'orkcr's
Compensation,az prorided(or by Section 3700 o(thc Labor Code,lor the
performance of ihe�rork for which this pemiit is issued.
I have and�eill maintain N'orker's Compcnsation Insurance,as providcd(or b�•
Seciion 3700 ofthe Labor Code,(or tlie per(onnance o(tlic�eork fonvhich ihis tiy.FI I�loor.\rrn:0 �'aluntion:$1398
�ermi�is issued.
.U'PLICAN"fCEN'I'IPIC.�'I'10\ ,\I'\\umber:36?09013.00 Occupancy9}�pe:
1 certify that 1 have read this applicaiion a��J slalc that thc abocc infomiaiion is
corzecL I agree m wmply wiih all ciry�anJ counry�arJin:uices:md smte laws rclaling
to builJing cons�runion,and hcreb�•au�horizc represcmmi�•es of this ciry�io cmcr
upontheabovementionedpropem�forinspcclionpurposes. (N'c)agrectosave �'EIiMIT E\PIRES IF WORK IS NOT STARTEll
indemni(y and Acep harmlcss thc Ci�y o(Cupcnino againsl IiuAililies,judgmcnts,
costs,andeapense5�chichmayaccrueagainstsnidCityinconscyucnceo(the �VITHIN 180 DAYS OF PERMIT ISSUANCC OR
gnnting of tliis pemiiL Additionally,tlie applicmu undersl.wJs and�eill comply �$U �)AYS F�2��� LAST CALL�D INSPECT�Q�i.
with all non-point sourec regulatims per thc Cupertino Municipal Codc,Scetiai
9.18.
Issucd by: Date:
Signa�ure Dntc �
❑ O��'NISH-BUILUI?N UIiCI.,\R,\'110,\
� RP:KOOI�S:
I hrrr6c affirm llm�I am cccmpl 1'rum Ihr Cunlractor's I,iccnse I.:nr fur unc uf p�l«w(s sh�ill be iny�ccted prior to v�y roofin�material bei�g installed.If a roof is
ihe follo.ving.le�o rr.uais: insialled wilhoia first obtaining vi inspection,1 agrtt to remove all new materinls for
I,as owner of Ihcpropert}•,or my emplo}'ecs H�i�h wugcs ns Ihcir cole comR��s������� inspcction.
�eill do ihc�cork,and thc slrucmre is not intcndcJ or alfcreJ for s:dc(Scc.7044,
f3usiness K Pro(essions Code) Si6naturc of ApplirvnC Date:
I,u owner of the propeny,am esclusiccly contracting�eith licenred contnctors�o
Con5lruCt lhC pmjcct(SeC.70�i4,I3usinc55 d Prolasions Codc). ,��,�,{tOOI�COVIikINGS'1'O UE CLASS".\"OR RE7'I'F R
I hrreby:diirm unJer pcnally n(pery'urp unc uf Ihc follurring thrcc
declarulions: 11.\%ARDOUS NA9�F.HIAIS DISCLOSUHE
I have and�eill mainminm Cenificme of Consenllo selGinsure for Worker's
Compcnsalioq at provided(or by Sec�ion 3700 of thc labor Codc,lor Ihc 1 hnre reud Ihe huznrJous matcrials reyuiremenls undcr Chapler G.95 of Ihr
per(ortnance o(the worA for�chich tliis permil is issucd. Califnrnia llrahh S Safrly CoJe.Seclinns?5505,?Si33,and?Si3J. I aill muinmin
I have nnd will maintain 11'orker'S COmpensnlion Insurance,ns provided for Ay compliancr nilh the Cupertino Aluniripal Code.Chap�er 9.1?anJ Ihe Ikalth fi
Section 3700 o(the Labor Code,for lhe perfonnance of the�vork I'or�chich this Safeq�CoJr.Serlion 25i3'_(u).houlJ I store or handle ha>nrdous ma�erial.
.\JJilimmlly,shoulJ I use equipment or decices e�hich emit hnzarJuus air
pemiil is issucJ. coniumin:inls as defined b���he Iiay.\rea Air Quali[���lanagemenl Districl I�vill
I tertify that in the performance o(Ihe�cork fonrhich this permit is issucd,I shall mainuiin cnmpliance��'i�h�hc Cupcnino Jlunicipul CoJe.Chapler 9.12 unJ Ihe
nol emplo}'any person in any manner so as Io bccoinc subjcet to thc\\'orAcr's ❑rulih S Sufery�Codr,Scc�ions 25{O5,25533,nnd 25531.
Compensation laws ofCali(omia. If,ulter maAing this ceniticate o(e�emption,I
become subject to the WorAer's Compensation pro��isions of lhc labor Codc,I musl �����ner or aulhorizeJ aga�L
(onhwith camply wiih such prorisions or this pcnnit shall be dccmcJ rcrokcd. Da�e:
nrri.ic.�nrcr•.irru=icrrio� co�sreucrio�i.r,�onc.�ce�cv
1 cenify lhat I hare read this applicaiion anJ swte that the above infomimion is I hemby a�7imi thm there is o conswetion lending aee��•for the performance of�wrA's
cortecL I agree m compl�•with all cii}•ard count}•orJinyues and state la�rs relating for�vhich thi5 permil i5 issued(Sec.3097,Cic C.)
lo builJing conswetion,and hereby authorize represenln�ices of thi5 cily Io enter �.ender's\omr
upon Ihe above mentioned propert}'for inspcclion purposcs.(���e)agrec io save
indemnifi�andAeepharmlesslheCiiyo(CupeninongtinsiliaAililies,judgments, I.cndrr's.\JJres�
wsts,and e.�penses��'hich ma}�accrue aeainst said City in consequenee o(the
granting of this pertniL Additionall}•,tlic applicwn undcrsmnJs Und will comply ARCIIPI'PCI"ti DPCI..U2A7'10\
with all�non-poini source re�ulatiais per Iht Cupenino Municipal Code,Scctiai
9.18. I undcrsWnd my plans shall bc uscd as public rccorJs.
Signnturc Datc LicaiseJ I'rofrssional �