12090102 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10351 IiENEY CREEK 1'L CON'I'BACfOR:FAST WATER HEATER PERMITNO: 12090102
OWNF.R'SNA01E: OMALLEYRAPIIAELM 12601132AVF-NE DA'Z'E ISSUED:09/12/2012
O\1'NF,R'S PRONE: 4085694782 KIRKI.AND•N'A 98034 PIION6No:(800)45+8955
❑ LICENSED CON I'RACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB I_
License Class Lie.g
t11ECH (_ RESIDENTIAL r COAIDIERCIAL r
Contractor Date
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:.REMOVE AND REPLACE WATER HEATER IN EXISTING
(commencing with Section 7000)of Division 3 of the Business&Professions LOCATION
Code and that my license is in full force and effect.
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 for by Section 3700 of the 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 die work for which this Sq.Ft Floor Area:0 Valuation:$1332
permit is issued.
APPI,ICAN'1'CER'I'IFIC.\TION APN Number:34248029.00 Occupangy Type:
1 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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accme against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: Dole:
Signature Data
❑ O\VNF,R-BIIII,DI?R I)ECLARA'I'ION
RE-ROOFS:
I hereby affirm that 1 am exempt from the Contractor's License Law for One of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Ih\'l,ARDOIIS 51.\"PERh\IS DISChOSl1RE
Compensation,as provided for by Section 3700 of the Labor Code,for the 1 have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Iladth&Safety Code,Sections 25505,25533,and 25534. 1 pill maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertirm Municip l Code.Chapter 9.12 and the Ilealth&
Section 3700 of the Labor Code,.for the performance of the work for which this Safety Code,Section 25532(x)should_I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
1 certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any personin any manner so as to become subject to the Worker's Ilealth&Safeh Code.Sections 25505,25533,and 25534.
Compensation laws of Califnmia. If,after making this ceniBcate of exemption,I
become subject to the Workers Compensation provisions of the Labor Code,I must Owner or authorized ageme
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
CONSTRUCTION LENDING AGENCY
APPLICANTCERTIFICATION
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Nome
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accme against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional
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Signature Date Licensed Professional