12080274 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11672 VINEYARD SPRING CT CONTRACTOR:AFFORDABLE WATER PERMIT NO: 12080274
BEATERS&
OWNER'S NAME:
VALENCIA,CA 91355 PHONENO:(661)259-7131
❑ LICENSED CONTRACTOR'S DECLARA'T'ION BUILDING PERMIT INFO: BLDG [ ELECT I_t PLUMB rl
License Class Lie.b r Fj r�
MECH RESIDENTIAL COMMERCIAL
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 of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided fon by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area:0 Valuation:$2725
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for die performance of die work for which this
permit is issued. APN Number:36654010.00 Occupancy Type:
APPLICANTCERTIFICATION
I cenify that I have read this application mid state that the above information is
correct.I agree to comply with all city and county ordinances mid state laws relating PERMIT EMPIRES IF WORK [S 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 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 Issued by: Date:
9.18.
Signature Dale
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material beug installed.If a roof is
installed without first obtaining an inspection,1 agree to remove all new materials for
hereby affirm that 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(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR RETTER
construct the project(Sec.7044,Business&Professions Code).
hereby affirm under penalty of perjury one of the following three HAZARDOUS 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 Ilealth&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. Safely Code,Section 25532(a)should I store or handle hazardous material.
I have mid will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Day Arca Air Quality Management District I will
pcnnit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Ilenith&Safety Code,Sections 25505,25533,and 25534.
I certify that in the performance of the work forwhich this permit is issued,I shall
non employ any person in my manner so as to become subject to die Worker's Owner or authorized agent:
Compensation laws of California. If,a0er 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
APPLICANT CERTIFICATION - for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
correct. I agree to comply with all city and county ordinances and state laws relating
no 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, ,\RCIIITECf'S DECLARATIONcosts,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