10100147 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10385 MERRIMAN RD CON TRACTOR:JUST WATER HEATERS PERMIT NO: 10100147
INC
NER'S NAME: DAVID&STEPHANIA KANEDA 3400 INVESTMENT BLVD DATE ISSUED: 10/20/2010
OWNER'S PHONE: 4088630474 HAY WARD,CA 94545 PHONE NO:(510)293-9901
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB
License Class Lic.#
MECH r- RESIDENTIAL r COMMERCIAL
Contractor Date
JOB DESCRIPTION:REPLACE EXISTING 30 GALLON GAS 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 FOR
UNI7'B LOCATED IN LA UNDR Y ROOM
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.
I 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 Sq.I t Floor Area:0 Valuation:$1341
permit is issued.
APPLICANT CERTIFICATION APN Number:34229027.00 Occupancy Type:
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
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 liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. 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.
Issu zd by: Date:
r' -iture Date
❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All r)ofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspo ction.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Sign iture of Applicant: Date:
1,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 BETTER
I hereby affirm under penalty of perjury one of the following three —
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 I ha m read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. Cali Fornia Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by com�liance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
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 Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall mail utain 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 Heath&Safety Code,Sections 25505,25533,and 25534.
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 Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. — Date:
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is I hei eby affirm that there is a constriction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for i✓hich this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Len Jer's Name
the above mentioned property for inspection purposes.(We)agree to save
:mify and keep harmless the City of Cupertino against liabilities,judgments, Len Jer's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this 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 un ierstand my plans shall be used as public records.
Signature Date Lia nsed Professional