10080090 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20832 GREENLEAF DR CONTRACTOR:FAST WATER HEATER PERMIT NO: 10080090
OWNER'S NAME: CHARLES OLSON
12,i01 132 AVE NE DATE ISSUED:08/12/2010
dER'S PHONE: 4084463450
KI RKLAND,WA 98034 PHONE NO:(800)4548955
LICENSED CONTRACTOR'S D
License Class Lic.# ECLARATION
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
Contractor Date MECH r RESIDENTIAL r COMMERCIAL r
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE/REPLACE GAS WATER HEATER
(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.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq. Ft Floor Area:0 Valuation:$850
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION APP'Number:32630172.00 Occupancy
P Y 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 PERMIT EXPIRES IF WORK IS NOT STARTED
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 Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the 8O DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18• Issued by: Date:
Signature Date
V OWNER-BUILDER DECLARATION All RE-ROOFS:
ro its shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of instal]ed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspe(tion.
1,as owner of the property,or my employees with wages as their sole compensation,
Signal ure of Applicant:
will do the work,and the structure is not intended or offered for sale(Sec.7044, Date:
Business&Professions Code)
1,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).
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 I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the Califo•nia Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additi rnally,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 contan tinants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
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 must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereb)affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender s Name
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
-inify and keep harmless the City of Cupertino against liabilities,judgments,
4 and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will complyARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
License([Professional
Signature Date