10080126 CITY OF CUPERTINO BUILDING PERMIT
LDING ADDRESS: 21131 GRENOLA DR CONTRACTOR:FAST WATER HEATER PERMIT NO:10080126
12601 132 AN E NE DATE ISSUED:08/18/2010
14ER'S NAME: BILLIE BADNERMANN PHONE NO:(80014548955
KIRKLAND,WA 98034
ER'S PHONE: 4089969352
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB r
rise Class Lic.# MECH r RESIDENTIAL[- COMMERCIAL r
tractor Date
JOB DESCRIPTION:REMOVE/REPLACE GAS WATER HEATER
reby affirm that I am licensed under the provisions of Chapter 9
nmencing with Section 7000)of Division 3 of the Business&Professions
le and that my license is in full force and effect.
:reby affirm under penalty of perjury one of the following two declarations:
eve and will maintain a certificate of consent to self-insure for Worker's
npensation,as provided for by Section 3700 of the Labor Code,for the Valuation:$1055
formance of the work for which this permit is issued. FAPN
t Floor Area:0
ive and will maintain Worker's Compensation Insurance,as provided for by
:tion 3700 of the Labor Code,for the performance of the work for which this Numb'r:32628013.00 Occupancy Type:
mit is issued.
APPLICANT CERTIFICATION
ratify that I have read this application and state that the above information is
rrect.I agree to comply with all city and county ordinances and state laws relatingFPERIdIT EXPIRES IF WORK IS NOT STARTED
building construction,and hereby authorize representatives of this city to enterHIN 180 DAYS OF PERMIT ISSUANCE OR
on the above mentioned property for inspection purposes. (We)agree to savedemnify and keep harmless the City of Cupertino against liabilities,judgments, DAYS FROM LAST CALLED INSPECTION.
sts,and expenses which may accrue against said City in consequence of the
anting of this permit. Additionally,the applicant understands and will comply Date:
ith all non-point source regulations per the Cupertino Municipal Code,Section Issued by
18.
ignature Date____
RE-ROOFS:
OWNER-BUILDER DECLARATION All roofs A kall be inspected prior to any roofing material being installed.If a roof is
installed w thout first obtaining an inspection,I agree to remove all new materials for
hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
he following two reasons: Date:
,as owner of the property,or my employees with wages as their sole compensation, Signature�.f Applicant:
All do the work,and the structure is not intended or offered for sale(Sec.7044,
Wsiness&Professions Code) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
,as owner of the property,am exclusively contracting with licensed contractors to
*nstmct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE
l hereby affirm under penalty of perjury one of the following three
declarations: I have re:,d the hazardous materials requirements under Chapter 6.95 of the
e,Sections
,25533,and 25534. 1 will
l have and will maintain a Certificate cion Consent
t self
aborre for Worker's
hes Califo complian ni i He h the CupertinoSafety dMunialth& cipal Code,Chapter 9.12 and the Health&air
Compensation,as provided for by Sec Safety Code,Section 25532(a)should I store or handle hazardous material.
performance of the work for which this permit is issued. Addition illy,should I use equipment or devices which emit hazardous air
I have and will maintain Worker's Compensation Insurance,as provided for by contamir ants 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 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health 8 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: 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 whic i this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state at the above information is Lender':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 he above mentioned property for inspection purposes.(We)agree to save
nnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
and expenses which may accrue against said City in consequence of he
gi..ting of this permit.Additionally,the applicant understands and will comply I under tand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section Licensc d Professional
9.18.
Signature Date