10010007 IN O BUILDING PERMIT O:10010007
CITY OF CUPE11
RT ST WATER HEATER PERMIT N
CONTRACTOR.FA
DATE ISSUED:01/04/2010
BUILDING ADDRESS: 21532 REGNART RD 12601 132 AVE NE
PHONE NO:(800)454-8955
OWNER'S NAME: CANAVAN TERRY J AND PATRICIA KIRKLAND,WA 98034 �.,
4082575365 ELECT PLUMB
BIER'S PHONE.•
DECLARATION BUILDING PERMIT INFO: BLD •— COMMERCIAL
� LICENSED CONTRACTORS RESIDENTIAL COMM
MECH
#
License Class Lic. PLACE GAS WATER HEATS
Date JOB DESCRIPTION:REMOVE/RE
Contractor provisions of Chapter 9
I hereby affirm that I am licensed00) under the
(commencing with Section of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
affirm under penalty of perjury one of the following
two declarations:
I hereby Valuation:$850
maintain a certificate of consent to self-insure Code,foor wor the
I have and will m provided for by Section 3700 of the Lab Sq,Ft Floor Area.0
Compensation,as p permit is issued.
performance of the work for which this p provided for by Occupancy Type,
Compensation Insurance,as p
I have and will maintain WC de,for the performance of the work for which this APN Number:35623041.00
Section 3700 of the Labo
permit is issued. `7`10RK IS NOT STARTED
APPLICANT CERTIFICATIONation is
T EXPIRES IF NCE OR
this application and state that the above d state laws relating PERMIT PERMIT ISSUA
I certify that I have read WITHIN l80 DAYS OF PERM INSPECTION
1 with all city and county ordinance to enter
correct.I agree to comply authorize representatives of this city WIT T CALLED INS
construction,and hereby We a ree to save YS FROM LAS
to building for inspection purposes. ( ) g
upon the above mentioned property' of Cupertino against liabilities,judgments,the 180 DA
p and keep harmless the city in consequence Date:
indemnify accrue against said City
costs,and expenses which may the applicant understands and will comply Issued by:
granting of this permit. Additionally,the
Cupertino Municipal Code,Section
with all non-point source regulations p
9.18. Date
RE-ROOFS: installed.If a roof is
Signature prior to any roofing material being
All roofs shall be inspected p I agree to remove all new materials for
TION
installed without first obtaining an inspection,
OWNER-BUILDER DECLARA ,s License Law for one of inspection.
t from the Contractor Date:
I hereby affirm that I am exempt ensation, Signature of Applicant:
the following two reasons: es as their sole comp g
I,as owner of the property,
or my employees with wag "All OR BETTER
structure is not intended or offered for sale(Sec.704 L ROOF COVERINGS TO BE CLASS A
will do the work,and theAL
Business&Professions Code)m exclusively contracting with licensed contractors to
I as owner of the property, s&professions Code). HAZARDOUS MATERIALS DISCLOSURE •95 of the
(Sec.7044,Business ter 6
construct the project three
f the following 25505,25533,and 25534. I will mai&s
ap
one have read the hazardous materials requirements ements under Health
of perjury o I ha Code,Sec ter and
and the
I hereby affirm under penalty p J y
' nce with the Cupertino Municipal Code,Chap
to self-insure for Worker's California Health&Safeh' or handle hazardous material.
declarations: compliance should I store
I have and will maintain a Certificate of Consent Safety Code,Section 25532 q
for b Section 3700 of the Labor Code,for the should I use equipment or devices whichlVianagement District I wil
Compensation,as provided y Additionally,sho Area Air Quality
pe is issued. PT for by the Bay al Code,Chapter 9.12 and the
performance of the work for which this pensation Insurance,asp contaminants as defined by ertino Municipal
maintain compliance with the Cup
I have and will maintain Worker's Comp h&Safety
for the performance of the work for which this t Code,Sections 25505,25533,and 2553 .
Section 3700 of the Labor Code, Heal
permit is issued. permit is issued,I shall agent:
erformance of the work for which this p Date:
---------
I that in the p become subject to the Worker's Owner or authorize ag
Ice certify manner so as to tion,I
not employ any person in any this certificate of exemption,
I must
om ensation laws of California. If,after making visions of the Labor Code, CONSTRUCTION LENDING AGENC erformance of w
C P Compensation p
become subject to the Worker s Comp Permit shall be deemed revoked. agency for the p
with such provisions or this p I hereby affirm that there is a construction097,Cndin g y
forthwith comply permit is issued(Sec
for which this p
APPLICANT CERTIFICATIONation is
Lender's Name
this application and state that the above i t a laws relating dress
I certify that I have read p and county ordinances to enter Lenders Ad
correct.I agree to comply with all city representatives of this city
construction,and hereby authorize rep agree to save
to building for inspection purposes.(We) g •ud ments, ARCHITECT'S DECLARATION
upon the above mentioned property of Cupertino against liabilities, g public records.
;. ' unify and keep harmless the City in consequence of the plans shall be used as p
end expenses which may accrue against said City l I understand my
permit.Additionally,the applicant understands and will comply
g....ang of this pe per the Cupertino Municipal Code,Section Licensed Professional
with all non-point source regulations
9.18. Date
Signature