11010034CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1087 S STELLING RD
CONTRACTOR: AMERICAN RESIDENTIAL
PERMIT NO: 11010034
SERVICES OF CA
OWNER'S NAME: MARY RAW
965 RIDGE LAKE BLVD STE 201
DATE ISSUED: 01/06/2011
d ER'S PHONE: 4082539900
MEMPHIS, TN 38120
PHONE NO: (408) 982-0405
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG r r ELECT PLUMB
License Class Lic. #
MECH r RESIDENTIAL r COMMERCIAL
Contractor Date
JOB DESCRIPTION: REPLACING 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
performance of the work for which this permit is issued.
Sq. Ft Floor Area: 0 Valuation: $4545
1 have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
APN Number: 36222002.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
PERMIT EXPIRES IF WORK IS NOT STARTED
to building constriction, and hereby authorize representatives of this city to enter
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We) agree to save
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
`L.
RE -ROOFS:
OWNER -BUILDER 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
I 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 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 TO BE CLASS "A" OR BETTER
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:
I have and will maintain a Certificate of Consent to self -insure for Worker's
for
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
the Cupertino Municipal Code, Chapter 9.12 and the Health &
Compensation, as provided for by Section 3700 of the Labor Code, the
compliance with
Safety Code, Section 25532(a) should I store or handle hazardous material.
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Additionally, should I use equipment or devices which emit hazardous air
as defined by the Bay Area Air Quality Management District I will
Section 3700 of the Labor Code, for the performance of the work for which this
contaminants
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
Health & 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 California. If, after making this certificate of exemption, I
Date:
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.
CONSTRUCTION LENDING AGENCY
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.)
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 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
' -mnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
R and expenses which may accrue against said City in consequence of the
,
gidnting 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