12100126 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10511 DAVISON AVE CONI'RAC'FOR:FAST WATER HEATER PERMIT NO: 12100126
OWNER'S NAME: SINAR ALEXANDER AND ANETA 12601 132 AVE NE DATE ISSUED: 10/17/2012
OW'NER'S Pl IONE: 4087251602 KIRKLAND,WA 98034 PHONE NO:(800)45Y8955
❑ LICENSED CONTRACT'OR'S DECLARATION BUILDING PERMIT INFO: 13LDC C ELECT r PLURIB IJ
License Class Lie.t!
\IEC11 r RESIDENTIAL J COMMERCIAL 0-
Contractor Date
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 AOR DESCRIPTION:REMOVE AND REPLACE WATER BEATER IN SAME
(commencing with Section 7000)of Division 3 of the Business A:Professions LOCATION
Code and(hot my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following nvo 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 Sq.Ft Floor Area:0 Valualion:$1045
Section 3700 of the Labor Code,for the performance of the work far which this
permit is issued.
APN Number:36913055.00 Occupancy Type:
APPLICANT CERTIFICATION .
I certify that I have read this application and state(hal the above inlbnnation is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives oflhis city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands mrd will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. . Issued by: Date:
Signature Date t
❑ OWNER-RUIIAER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Low for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following mo reasons: inspection.
I,as owner of the property,or my employees with wages as their sole comp:nsa(ion,
will do the work,and the structure is not intended or offered for sale(Sce.7044, Signature of Applicant: Date:
Business&Professions Code)
1,as owner of the properly,mm exclusively contracting with licensed contractors to
contract the project(Sec.7044,Business R Professions Code). ALI•ROOF COVERINGS TO 13E CLASS"A"OR BETTER
hereby affirm under penalty of perjury one of the following three
declarations: ILAZARDOUS JIATERIAIS DISCLOSURE
1 have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Ilcalth d Safety Code,Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance with the Cupertino hlunicipal Code,Chapter 9.12 and the I Icalth 3
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25.532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of Ore work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued contaminants as defined by the Ray Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Cade.Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Rcalth S Safety Code,Sections 25505,'25533.and 25534.
not employ any person in any manner so as to become subject to the Worker's '
Compensation laws of California, If,after making this certificate ofexemption,1 Owner or authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
A PILI Cy\f CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may aceme against said City in consequence of die
granting of this permit.Additionally,the applicant understands and will comply ARCII Iq'FCI"S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section I undersumd my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date