13080024 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10093 SENA,rE WAY CONTRACTOR:I'ASI'WATER HEATER PERMIT NO: 13080024
OWNER'S NANIE: ROBERT'WISER 11715 N CREEK PARKWAY STE C106 DATE ISSUED:08/05/2013
ff0),WNEESPHONE: 4086748435
BOTHELL,WA 98011 PHONE NO:(800)454-8955
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
Class Lic.4 MECH RESIDENTIAL COMMERCIAL
Contractor Date
JOB DESCRIPTION: REMOVE AND REPLACE WATER HEATER IN SAME
I hereby affirm that I am licensed under the provisions of Chapter 9 LOCATION
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
I have and will 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 of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq,Ft Floor Area:0 Valuation:$809
Section 3700 of the labor Code,for the performance of the work for which this
permit is issued. APN Number:32653049.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
,ranting ofthis 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
❑ OWNER-BUILDER DECLARATION
xE-Roor's:
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 without first obtaining an inspection,1 agree to remove all new materials for
the following two reasons: inspection.
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, Signature of Applicant:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALI,ROOF COVERINGS TO BE CLASS"A"OR BETTER
ER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 o the
I have and will maintain a Certificate of Consent to
Compensation,as provided for by Section 3700 of the Labor Code,for the Health complianceith the Cupertino Municipal Code, a
, Chapt r91h twin
2 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,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. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&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 or 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
APPI ICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
1 certify that I have read this application and state that the above information is for which this permit is issued(See.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
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,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 understand my plans shall be used as public records.
9.18. Licensed Professional
Signature Date