12080086CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 811 ALDERBROOK LN
OWNER'S NAME: KHAN SFIABBIR A ANDTAHEREH R
OWNER'S PHONE: 4082575481
LICENSED COM'RAC'OR'S DECLARATION
icense
Class � ��rG4� Lie.4
(n�
Contractor IbA Fy� � Date
1 hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business S Professions
Code and that my 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 cenificate of consent bn self -insure for Worker's
Compensation, as provided for by Section 3700 ollhe Labor Code, for the
pert'onnance 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 ille work for which this
permit is issued.
. \I'I'I- ICAN'I' CIiR'I'I FIC.\'I'I(IN
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 state 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 aceme against said Ciq• 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. i
Date��2
❑ OWNER- BUILDER DECLARATION
hereby affirm that I am exempt from the Contractor's License Tar for one of
the following two reasons:
I, as owner of the property, or niy employees with wages as their sole compensation,
will do the work, and the structure is not intended or ollered for sale (Sec.7044,
Business & professions Code)
I, as owner of the properly, am exclusively contracting with licensed contractors to
construct the project(Sec.7044,13usiness R Professions Code).
I herehy affirm under penalty of perjury one of the following three
declarations:
1 have and will maintain a Certificate of Conscnt 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.
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.
I certify that in the performance of the work for which this permit is issued, 1 shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of Cali fornia. 11, after making this certificate ofesemption, I
become subject to the Worker's Compensation provisions of the Labor Code, 1 must
tonhwith comply with such provisions or this permit shall be deemed revoked.
.dl'I'LICAN'I' CI92'I'IFIC, \'1'Il1,N
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 atdsate laws relating
to building construction, and hereby aphorize 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 aceme 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
CONTRACTOR: AAA 17URNACC K AIR
PERMIT NO: 12080086
CONDITIONING
1712 STONE AVE
DATE ISSUED: 08/082012
SAN JOSE, CA 95125
PlIONE NO: (408)293 -1717
.TOR DESCRIPTION: RESIDFNTlAL LJ
COMMERCIALS]
REMOVE AND REPLACE 40 GALLON
WATER HEATER IN
SAME
LOCATION
Sy: FL Floor Area: I Valuation: $1151
AI'N Number: 36916015.00 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:
RE-ROOFS:
All roofs shall be inspected prior many roofing material being installed. If a roof is
installed without fast obtaining an inspection, I agree to remove all new materials for
Inspection.
Signature of
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
IL\•LARDOUS ML\TERIAI S DISCLOSURE
have read the hazardous materials requirements under Chapter 6.95 of the
California llcaldt S Safety Code. Seclimas 25505.25533. and 25534. I will
maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and the
Dealth S Safety Code, Section 25532(u) 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
Will maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and
the Ilealth S Safety Code, Seel) is 25505.'_5533 and 25534.
Owner or authorized agent: Date:
CONSfRI1C1'ION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for die performance of
work's far Which this permit is issued (Sec. 3097, Cie C.)
Lender's Name
ARCHITECT`S DECLARA'T'ION
I understand my plans shall be used as public records.
Licensed