12090236 CITY OF CUPERTINO BUILDING PERMIT
BUILDINC ADDRESS: 22414 RIVERSIDE DR COI 'TRACTOR:PAST WATER IIEATER PERMITNO: 12090236
OWNER'S NAME: ALLIIN MINOR 12601132 AVE NF. DATE ISSUED:09272012
OWNER'SPBONI:: 4082533061 KIRKLAND,WA 98034 PHONE NO:(800)454-8955
❑ LICENSED CON'I'RACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG (_ ELECT r PLUMB
License Class Lic.q
M ECII - RESIDENTIAL '1 COMMERCIAL —7
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE AND REPLACE GAS WATER BEATER IN
(commencing with Section 7000)of Division 3 of the Business&Professions EXISTING
Code and that my license is in full force and effect. LOCATION
hereby affirm under penally of perjury one of the following two declarations:
1 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 pemtit 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:$849
permit is issued.
A PPLI CANT CERTI FICATION APN Number:35602006.00 OccupancyType:
I certify[hat I have read this application and state that the above information is
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
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 Iiabilities,judgments,
costs,and expenses which may accrue against said City in consequence ofthe WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this pcnnit. 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: Date:
Signature Date
❑ OWNER-RIALDER DECLARATION
RF-ROOFS:
1 hereby nffirm that 1 am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material beug installed.If a roof is
the following two reasons: installed without first obtaining an inspection,1 agree to remove all new materials for
I,as owner of the property,or my employees with wages as[heir 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:
I,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 BErITER
I hereby affirm under penally of perjury one of the following three
declarations:
I have and will maintain a Cenificate of Consent to self insure for Worker's IIA'LARDOUS BLATERIAI S DISCLOSURE.
Compensation,as provided for by Section 3700 of the Labor Code,for the 1 hive read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Ilndth&Safety Code.Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code.Chapter 9.12 and the I lealth&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code.Section 25532(a)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 Ray Area Air Quality planagement District I will
I certify that in the performance of the work forwhich this permit is issued,I shall maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
not employ any person.in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation Imus of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or authorized agent:
forthwith comply with such provisions or this pennit shall be deemed revoked. Dale:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
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 Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertinoagainst liabilities.judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of[his 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