13060181 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20652 CLEO AVE CONTRACTOR:BENJAMIN FRANKLIN PERMIT NO: 13060181
PLUMBING
OWNER'S NAME: BURROW BRADLEY J AND JUANITA S 22 DIGITAL DR DATE ISSUED:06/21/2013
OWNER'S PHONE: 4083661531 NOVATO,CA 94949 PHONE NO:(415)506-0400
❑ LICENSED CONTRACTOR'S DECLARATIONr f—
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH r RESIDENTIAL r– COMMERCIAL�
Contractor Date
I hereby aff-irm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVAL AND REPLACEMENT OF 50 GAL WATER
(common t i n �l(h Section 7000)of Division 3 of the Business&Professions HEATER IN
Code and ih:t uta license is in full force and effect. SAME LOCATION
I hereby affirm under penalty of perjury one of the following two declarations:
I have and •i'! 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 ol'the work for which this permit is issued.
I have and\\I:1 ,,.Intain Worker's Compensation Insurance,as provided for by
Section ,70 Labor Code,for the performance of the work for which this Sq.Ft Floor Area:0 Valuation:$3074
permit i;is:. ...
APPLICANT CERTIFICATION APN Number:36231002.00 Occupancy Type:
I certify flint I h;rve read this application and state that the above information is
correct. I a,Lr: comply with all city and county ordinances and state laws relating
to building co:i;.:.;:tion,and hereby authorize representatives of this city to enter
upon th,:,bi,. :: :tioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indenuu , harmless the City of Cupertino against liabilities,judgments,
costs,a which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
arantin, ::nit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: Date:
Sianaturr Date
❑ !'NER-BUILDER DECLARATION
RE-ROOFS:
I here t I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the follu reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner o i'du;property,or my employees with wages as their sole compensation, inspection.
will do!!,: ,d the structure is not intended or offered for sale(Sec.7044,
13U,11j, ons Code) Signature of Applicant: Date:
I,as o. --operty,am exclusively contracting with licensed contractors to
collsln. th (Sec.7044,Business&Professions Code).
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
ler penalty of perjury one of the following three
1 have an,!v n, l itain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Comp,,i ovided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
ork for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I ho tain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
abor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District 1 will
rformancc of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
on in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
f California. If,after making this certificate of exemption,I
Worker's Compensation provisions of the Labor Code,I must Owner or authorized agent:
h such provisions or this permit shall be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I cer; read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
torr tply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to bu., on,and hereby authorize representatives of this city to enter Lender's Name
upa oned property for inspection purposes.(We)agree to save
i nd armless the City of Cupertino against liabilities,judgments, Lender's Address
o> hich may accrue against said City in consequence of the
gra:.: it.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with urce regulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Sign: Date Licensed Professional