10080034 CITY OF CUPERTINO BUILDING PERMIT
UILDING ADDRESS: 11801 SIERRA SPRING CT CONTRA(TOR:ECONOMY ROOTER PERMIT NO: 10080034
WNER'S NAME: MARCUS BERBER
PO BOX 2:52 DATE ISSUED:08/04/2010
ER'S PHONE: 4082424776
SANTA CLARA,CA 95055 PHONE NO:(408)249-4922
] LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
icense Class Lic.# MECH RESIDENTIAL COMMERCIAL
Date-ontractor DaJOB DEQ CRIPTION:REPLACE A 40 GALLON WATER HEATER IN THE SAM
hereby affirm that I am licensed under the provisions of Chapter 9 LOCATIOTi
:ommencing with Section 7000)of Division 3 of the Business&Professions
'ode and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
have and will maintain a certificate of consent to self-insure for Worker's
'ompensation,as provided for by Section 3700 of the Labor Code,for the
erfonnance of the work for which this permit is issued. Valuation:$600
have and will maintain Worker's Compensation Insurance,as provided for by Sq,Ft Flow Area:0
section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. APN Nun ber:36653048.00 Occupancy Type:
APPLICANT CERTIFICATION
certify that I have read this application and state that the above information is
;orrect.I agree to comply with all city and county ordinances and state laws relating IT EXPIRES IF WORK IS NOT STARTED
o building construction,and hereby authorize representatives of this city to enter PEIMIT
.tpon the above mentioned property for inspection purposes. (We)agree to save WI THIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
,osts,and expenses which may accrue against said City in consequence of the 180 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 Date:
9.18.
Issued by:
Signature Date
V OWNER BUILDER DECLARATION RE-ROOFS:
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 Contractor's License Law for one of installed vithout first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspectio I.
1,as owner of the property,or my employees with wages as their sole compensation, Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signaturf of Applicant:
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 HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I have r sad the hazardous materials requirements under Chapter 6.95 oft e
Compensation,as provided for by Section 3700 of the Labor Code,for the Califorr is 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.
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Additio rally,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 contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintai n compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the perfonnance of the work for which this permit is issued,I shall Health &c 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:)r authorized agent: 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
APPLICANT CERTIFICATION I herebN 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 whi,:h 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
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
nnify and keep harmless the City of Cupertino against liabilities,judgments,
,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,Section I under stand my plans shall be used as public records.
9.18.
Licens'd Professional
Signature Date