12100080 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23694 BLACK OAK WAY CONI'RACI'OR:AFFORDABLE WATER PERMITNO: 12100080
HEATERS&
OWNER'SNAME: TOOMEY CHRISTOPHER N AND LORI O TRU 28372 CONSTEELATIONRD DATE ISSUED: 10/102012
OWNER'S PDONE: 6502794918 VALENCIA.CA 91355 PHONF-NO:(661)259-7131
❑ INCENSED CON I'RACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT rl PLUMB r
License Class Lie.N r_ r
M ECH RESIDENTIAL C011i11ERC1AL -J
Contractor Dale
hereby affirm that I am licensed under the provisions of Chapter') 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.
hereby affirm under penaltyof 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:$2662
I have mid 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:34256012.00 Occupancy Type:
APPLICANT CF,RTI FICATION
1 certify that I have read this application and slate 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:
❑ OWN'ER-RUILDF-R DECLARATION All roofs shall be inspected prior to my roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
1 hereby affirm that 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 employees with wages as their sole compensation, Signature of Applicuit 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 AI,h ROOT'COVERINGS'I'O BF CLASS"A"OR BF:FI'ER
construct the project(Sce.7044,Business&Professions Code).
1 hereby affirm under penalty of perjury one of the following three ILA'/,.ARI1011S d1A"1'ERLUS 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&Safely Code,Sections 25505,25533,and 25534. I 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&
perfomance of the work for which this permit is issued Safely Code,Section 25532(x)should 1 store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700:017 the Labor Code,for the performance of the work for which this contaminants as defined by the Ray Arca Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Ilealth&Safety'Code,Sections 25505,25533,and 25534.
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 laws of Cal denim. If,after making this cenilicme of exemption,I Dale:
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. CONSTRIICI'ION[,ENDING AGENCY
I hereby affirm thin there is a construction lending agency for the perfomance of work's
APPLICANTCF,RT1 FICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above infomalion is Lender's Name
correct.1 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 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, ARCI II'1'FCf'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 Dale