12110030 CITY OF CUPERTINO BUILDING PERMIT
BUILDINC ADDRFSS: 21163 PATRIOT WAY CO\1'RACI'OR:AFFORDABLE WATER I'IiRMITNO: 12110030
I lEATERS&
OW�NFR'S NAME: A BECKET SUZANNE 28372 CONS"I'FLLATION RD DA'Z'E ISSUED: 11/05/2012
OWNER'S PHONE: 4089739162 VALENCIA.CA 91355 PDONE NO:(661)259-7131
❑ LICENSED CO\TRACTOR'S DECLARA'T'ION BUILDING PERNnT INFO: BLDG r ELECT r PLUMB r
License Class Lic.N
P1ECH r RESIDENTIAL r COMMERCIAL J
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE WA"I'ER I'IFATER SAMF 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 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. Sq.Ft Fluor Area:0 Valuation:$1500
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of Ole work for which this
permit is issued. APN Number:32653060.00 OccupancyType:
APPLICANT CERT'I FICATION
I certify that I have read this application and stale that the above information is
correct.l agree to comply with all city mrd 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 bv: Date:
9.18.
Signature Date
RE-ROOFS:
❑ OWNER-FTUFI,DER DECLARATION All roofs shall be inspected prior to any roofing material being installed If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
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 comrensation, 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 T'O BE CLASS"A"OIt 11F:ITEIR
construct the project(Sec.7044,Business&Professions Code),
hereby affirm under penalty of perjury one of the following three 1IAZARD0IIS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements tinder Chaplcr 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Ilenhil&Safety 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&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle ha7mrdous 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 of the Labor Code,for the performance of the work for which this contaminanls as defined M the tiny Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
icakh&Safety Code,Sections 25515,25533,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 became subject to the Worker's Owner or authorized agent:
Compensation laws of California. If,after making this certificate of exemption,I Date.
become subject to the Worker's Compensation provisions of the Labor Code,1 must
forthwith comply with such provisions or this pernin shall be deemed revoked. CONSTRII(71'ION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
API'LIC,AN'f CER'1'IFICA"PION 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 stile 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,
costs,and expenses which ran),accrue against said City in consequence of the ARCIIIT'ECI"S DECLARATION
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