10010147 UPERTINO BUILDING PERMIT
CITY OFC PERMIT NO: 10010 147
CONTRACTOR:EGOV
PRESS; 11080 SANTA TERESA DR IT DATE ISSUED:01/27/2010
BUILDING AD ON LINE PERM
'S NAME: SCHLICHTEMEIER RONALD F AND JO p CA 95014 PHONE NO:
OWNER CUPERTIN ,
89969276 COMMERCIAL ❑
BIER'S PHONE: 40JOB DESCRIPTION, RESIDENTIAL ❑
❑ LICENSED CONTRACTOR'S DECLARATION REMOVE AND REPLACE 50 GAL WATER HEATER
License Class
Lic.#
Date
Contractor ter 9
affirm that I am licensed under the provisions of Chap
I hereby of Division 3 of the Business&Professions Valuation:$1700
(commencing with Section 7000) Sq.Ft Floor Area:0
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury
one of the following two declarations: Occupancy Type:
APN Number:35617030.0
1. l have
and will maintain a certificate of consent to self-insure for ,foWorker's
Compensation,as provided for by Section 3700 of the La STARTED
permit is issued.
performance will
the work for which this p provided for by MIT EXPIRES IF WORK IS NOT OR
2. 1 have and will maintain Worker's Compensation Insurance,asp PER IT ISSUANCE
0 of the Labor Code,for the performance of the work for which this INSPECTION.
• 7o WITHIN 180 DAYS OF PERM
Section 3
it is issued. DAYS FROM LAST CALLED
perm 180
APPLICANT CERTIFICATION
t I have read this application and state that the above infonnation is Date:
I certify that Issued by:
agree to comply with all city and county ordinances
of dhistc city to entering
correct.i agr representatives
to building construction,and hereby authorize rep We agree to save
upon the above in property for inspection
no against liabilities judgments,
P consequence of the RE-ROOFS:
and keep harmless the City of Cupertino
riot to any roofing maternal being installed.if a roof i�
accrue against said City r conseq with All roofs shall be inspected p
costs,and expenses which may licant understands and will comply agree to remove all new materials for
granting of this permit. Additionally,the app an ins ection,1 ag "
installed without first obtaining P
source regulations per the Cupertino Municipal Code,Section 9.18• . section.
all non-point s inspection.
Date Date:------- - - ____ ------
Signature Signature of Applicant-._ — -----
TION
ALL ROOF COVERINGS TO BE CLASS'
OR BETTER
OWNER-BUILDER DECLARA
firm t
hat I am exempt from the Contractor's License Law for one of HAZARDOUS MATERIALS DISCLOSURE
1 hereby af
the following two reasons: with wages as their sole requirements under Chapter 6.91 oft e
or my employees25533 and 25534. 1 will maintain
�. 1 as owner of the property, lth&Safety Code,Sections 25505, ' 9,12 and the Health&
tore is not intended or offered for 1 have read the hazardous materials req er
compensation,will do the work,and the structure California He
Professions Code) compliance with the Cupertino Municipal Code,Chapt
Sec.7044,Business& with licensed contractors to a Section 25532(a)should I store or handle hazardous
ha ardous ai material
sale( Safety Cod ,
am exclusively contracting ui ment or devices which
2. 1,as owner of the property, Additionally,should 1 use eghe Ba Area Air Quality Management District I will
construct the project(Sec.7044,Business&Professions Code). contaminants as defined by ee with the Bay
Municipal Code,Chapter 9.12 and the
r penalty of perjury maintain co fP l�Code,Sections 25505,25533,and 25534.
m under pone of the folio self-insure foreW rkerrs tions: Health&Sa y
1 hereby affir
1. 1 have and will maintain a Certificate ti Consent
of the Labor Code,for the t.
Compensation,as provided for by Sectnon
Owner or authorize agen pate:
performance of the work for which this permainoissued.tiurance,as provided for by
2. 1 have and will maintain Worker's Compe NSTRUCTION LENDING AGENCY
Section 3700 of the Labor Code,for the performance of the work for which this CO Hance of work's
b affirm that there is a construction lending agency for the perton
permit is issued. 1 hereby
performance of the work for which this permit is issued, it is issued(Sec.3097,Civ C.)
3. I certify that to thep for which this perm
t employ any person in any manner so as to becomefor
certificate of exemption, bender's Name
no P
Compensation laws of California. If,after making t
ct to the Worker's Compensation provisions of the ll b deemed Code,I Lender's Address
become subject rovisions or this permit shall
must forthwith comply with such p
revoked. ARCHITECT'S DECLARATION
I ation isunderstand my plans shall be used as public records.
APPLICANT CERTIFICATION -_
1 have read this application and state that theo and state laws relating Licensed Professional
1 certify that 1y with all city and county ordinances
correct.I agree to Comply
' 'n construction,and hereby authorize representatives of this city to enter
to building ro ert for inspection purposes.(We)agree to save
upon the above mentioned p P y Cupertino against liabilities,judgments,
indemnify and keep harmless the Cry of Cup consequence of the
accrue against said City�nn 1 with
and expenses which may licant understands and will comp y
ng of this permit.Additionally,the aP ertino Municipal Code,Section 9.18.
a,,►ion-point source regulations per the Cup
Date
Signature