12080180 CITY OF CUPERTINO 13UILDING PERMIT
BUILDING ADDRESS: 8162 PARK VILLA CIR CONTRACTOR:AFFORDABLE WATER PERMITNO: 12080180
1-1EATERS&•
OWNFR'S NAME:
VALENCIA.CA 91355 PHONE NO:(661)259-7131
❑ LICENSED CON TRACTOR'S DECLARA'T'ION BUILDING PERMIT INFO: 13LDG r ELECT r PLUMB F-
License Class Lie.A
NIECII r RESIDENTIAL COD(IIERCIAL
Conimcnor Date
1 hereby affirm that I ani licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE WATER BEAM,SAME LOCATION
(commencing i,ilh Section 7000)of Ill%isiun 3 of the Business&PrufessionS
Code and that ruY license is in full force and effect.
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 Sq,Ft Floor Arca:0 Valuation:$2497
1 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. .\I;N Number:35610002.00 Occupancy"Il pe:
APPLICANT CERTI FICTION
I certify that I have read this application and state that the above infomonion is
correct.I agree to comply with all city and county ordinances mid state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,mid 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, 1811 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 bv: Date:
9.18.
Signature Dale
RF-ROOFS:
❑ OWNER-BUILDER DIiCLARA'TION All roofs shall be inspected prior to any roofing material being installed.If roof is
installed without first obtaining an inspection,I agree to remove all new materials for
I hereby affirm Ihm I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as owner of the property,or my emplopces with wages as their sole compensation, Signature of Applicain: 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 B1:CLASS"A"OR BE9-I'ER
construct the project(See.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three IIA%ARUOIIS 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 self-insure for Worker's California I lealth&Safety Code.Sections 25505,25533,and 2.5534. 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(lealth&
performance of the work for which this permit is issued. Safely 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 1 use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this conla ndnan Ls as defined by the Bay Area Air Quality Management District 1 will
permit is issued. maintain compliance with the Cuperlino Municipal5534.Code,Chapter 9.12 and the
I certify that in the performance of doe work for which this permit is issued 1 shall Iea11h&Safety Code.Sections 25505,25533.and_
not employ any person in any manner so as to become subject to the Worker's On ner or authorized agent:
Compensation laws of California. If.after making this certificate of exemption,I Date.
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 CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of work's
APPLIC\N F CERTI FIC TION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state thin the above information is Lender's Name
correct.I agree to comply with all city and county ordinances and slate Imus 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 Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCI11'I'IiCI"S DECLARATION
graining 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
BUILDINGADDRESS: 8162 PARK VILLA CIR CON"FRACFOR:AFFORDABLE WATER PERNIIT NO: 12080180
HEATERS&
OWNER'SNAME: FRANSON CARL 1 28372 CONSTELLATION RD DATE ISSUED:08/152012
OWNER'S PI IONF-: 4082550322 VALENCIA,CA 91355 PHONE NO:(661)759-7131
❑ LICENSED COKFRACFOR'S DECLARATION BUILDING PERMIT INFO: BLDG C ELECT r PLUMB Cl
License Class Lic.q r r1 C
N1EC11 RESIDENTIALCOMMERCIAL
Contractor Date
1 hereby affirm that 1 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 full force and effect.
I hereby affirm under penalty of perjury one orthe 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 die Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area:0 Valuation:$2497
1 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:35610002.00 Occupancy'Type:
APPLICA\FCERTIFIC TION
I certify that I have read this application and state that the above information is
correct.l agree to comply with all city and county ordinances and state 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. (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:
❑ OWNER-BUILDF-R DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,1 agree to remove all new materials for
hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following too 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(Sec.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BF,CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
hereby affirm under penalty of perjury one of the following three IIAZARDOUS NIATERIAIS 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 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 Code,Chapter 9.12 and the Ilealth&
performance of the work for which this permit 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 performance of the work for which this contaminams 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
F Ilealth&Safely Code,Sections 25505,25533,and_5534.
1 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 Owner or authorized agent:
Compensation Imes of Cali fomia. If,after making this certificate of exemption,I Date:
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—FION LENDING AGFNCY
I hereby affirm that there is a constmclionlending agency for the performance of work's
APPLICANTCERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I.certify that I have read this application mid state that the above information is Cinder's Name
correct.I agree to comply with all city and county ordumnces'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 hamdess the City of Cupertino against liabilities,judgments, A RCI I I'1'ISCT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the
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