10090247 CITY OF CUPERTINO BUILDING PERMIT 7
CONTRACTOR:AFFORDABLE WATER PERMIT NO: 10090247
BUILDING ADDRESS: 10546 GASCOIGNE DR E[EATERS&
'.4663 RAILROAD AVE DATE ISSUED:09/27/2010
F( ER'S NAME: JUDITH MALONE PHONE NO:(661)259-7131
SANTA CLARITA,CA 91321
OWNER'S PHONE: 4082522245
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r PLUMB
❑ RESIDENTIAL F COMMERCIAL
License Class Lic.# MECH
Date ATER HEATS
Contractor
JOB DESCRIPTION:REPLACE STORAGE TYPE,NAT.CAS W
I hereby affirm that I am licensed under the provisions of Chapter 9 -SAME
(commencing with Section 7000)of Division 3 of the Business&Professions SIZE AND LOCATION
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 Valuation:$1800
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area:0
permit is issued. Occupancy Type:
APPLICANT CERTIFICATION
APN Number:37523008.00
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, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
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
Date:
9.18. Issued by:
Date_
S* 'ure
OWNER BUILDER DECLARATION RE-ROOFS:
Contractor's License Law for one o
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the
installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensatior,, inspection.
ection.
will do the work,and the structure is not intended or offered for sale(Sec.7044, Date:
Signature of Applicant:
Business&Professions Code)
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 BETTER
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's
California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 o the
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
ation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compens
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shal 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 laws of California. If,after making this certificate of exemption,I Owner or authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I m.rst Date:_
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
and state laws rela ing for ewhich this reby affinn there issued(Sec 3097 Civ C.)
agency for the performance of wor s
correct.I agree to comply with all city and county ordinance
to b»lding construction,and hereby authorize representatives of thiscity to e Lender's Name
r 're above mentioned property for inspection purposes.(We)agree to sant
in- ..nify and keep harmless the City of Cupertino against liabilities,judgment,,, Lender's Address
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Sectior I understand my plans shall be used as public records.
9.18.
Date _— Licensed Professional
Signature