11050052 CITY OF CUPERTINO BUILDING PERMIT
CONTRACTOR:WATER HEATERS ONLY PERMIT NO:11050052
BUILDING ADDRESS: 10186 MANN DR 970 E MAIN ST DATE ISSUED:05/09/2011
OWNER'S NAME: CAPENER CHRISTOPHER L AND LYNN PHONE NO:(800)835-5946
GRASS VALLEY,CA 95945
ov"."BR'S PHONE: 4084460333
LIC
ENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
0
Lic.# MECH r RESIDENTIAL r COMMERCIAL
License Class
Contractor
Date JOB DESCRIPTION:REPLACE EXISTING WATER HEATER
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I 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 Valuation:$1500
Sq.Ft Floor Area:0
performance of the work for which this permit is issued. provided for by
I have and will maintain Worker's Compensation Insurance,as p Occupancy Type:
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:32619010.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IFF PERMIT
I NOT DANCE OR
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS O
to building construction,and hereby
fort nspectiorize n purposes. of this city to(We)agree to saveenter
upon the above mentioned property 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Date with all non-point source regulations per the Cupertino Municipal Code,Section Issued by
9.18.
Date
Signature
RE_ Rte_
All roofs shall be inspected prior to any roofing material berg installed.If a roof is
[ OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for
I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. Date:
the following two reasons: their sole compensation, Signature of Applicant:
I,as owner of the property,or my employees with wages as
will do the work,and the structure is not intended or offered for sale(Sec.7044, ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE
I hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements under Chapter 6.95 of the
declarations: Chapter 9.12 and the Health&
I have and will maintain a Certificate of Consent to self-insure for Worker's compliancep Health
h the CupertinodMunicipal CodeSections , 25533�azardous material.and 25534. 1 will maintain
Safety Code,Section 25532(a)should I store or handle h
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I have and will maintain Worker's Compensation Insurance,as provided for by contaminants as defined by the Bay Area Air Quality Management District I will
the Cupertino Municipal Section 3700 of the Labor Code,for the performance of the work for which this H alt i&S compliance
Code,Sections 25505,25533,and 25534e�Chapter 9.12 and the
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall
to the Worker's Owner or authorized agent:
not employ any person in any manner so as to become subject Date:___
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must CONSTRUCTION LENDING AGENCY
forthwith comply with such provisions or this permit shall be deemed revoked.
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
hat the abve infoation is I certify that I have read this application and state to duianes and state Lender's Name
laws relating
correct.I agree to comply with all city and county
to building construction,and hereby authorize representatives of this agree to saveer Lender's Address
upon the above mentioned property for inspection purposes.(We)agr
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments, fans shall be used as public records.
co, nd expenses which may accrue against said City in consequence of the
g, of this permit.Additionally,the applicant understands and will comply I understand my p
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Date
Signature