13080048 CITY OF CUPERTINO BUILDING PERMIT
Bl ILDI\G ADDRESS: 21871 COLUMBUS AV6 CON"1'RAC"1'OR:ALL VALLEY PLUMI3ING PERMI'f NO: 13080048
OW\r;R'S\'AME: F161LMAN JOHN J AND PAUSTENE V 3345 SF.LDON CT S'CE B DATF, [SSUED:08/07/2013
OW�ER'S PFIONF,: 4089738098 FRENION7',CA 94539 PHONE NO:(510)376-4816
❑ I,acFNSEll CON'Ck2ACTOR�s Dk CLARA'I�Iov BUILDING PERMIT INFO: BLDG � ELECT � PLUMB �
I.iccnsc Class Lic.# MECH � RESIDENT]AL � COMMERCIAL �
Coi�tractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE 50 GALLON GAS WA'CER HGA'CGR LIKE FOR
(commencing with Section 7000)of'Division 3 of the Business&Professions
LIKE
C'ode and that my license is in full force and effect.
1 hereby affirm under pcnalty of perjury one of the fbllowing two declarations:
1 havc and will maintain a certiticate of consent to self insure for Worker's
Compcnsation,as provided for by Section 3700 of the Labor Code,for thc
performance of the work for which this permit is issued.
I havc and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor r�rea:0 Valuation:$750
Scction 3700 0l thc l,abor Code,for the performance of the work for which this
permit is issucd.
APN Numbcr:35614030.00 Occupancy 1'ypc:
APPLICANT CER1'IFICAI'ION
1 ccrtify that 1 have rcad this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter pERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioncd property for inspection purposes. (We)agree ro save
indemnity and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the �g0 DAYS FROM LAST CALLED INSPECTION.
,rantin�of this permit. Additionally,the applicant understands and will comply
with 111 non-point sourcc regulations per the Cupertino Municipal Code,Section
9.�g. Issued by: Date:
Signaturc Date
❑ OWNER-BUILDF,R DECLARATION RF,-ROOFS:
1111 roofs shall be inspected prior to any roofing material being installed.If a rooY is
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of insYalled without first obtaining an inspection,1 agree to remove all new materials for
thc following two reasons: inspcction.
I.as owner of the property,or my cmployees with wages as their sole compensation,
will do thc work,and the sfructure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date:
13usincss&Professions Codc)
I,as owncr oYthc property,am exclusively contracting with licensed contractors to pLl,ROOF COVF,RINGS TO BE CLASS"A"OR BETTER
construct lhe project(Sec.7044,f3usiness&Professions Code).
1 hcrcby affirm undcr penalty of perjury one of the following three IIAZARDOUS N1A'CERIALS DISCLOSURF.
declarations:
I havc and will maintain a Certificate of Consent to self-insure forWorker's I havc read thc hazardous materials requirements under Chaptcr 6.95 of the
Compcnsation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
perfonnance of the work for which this permit is issued. compliance with the Cupertino Munieipal Code,Chapter 9.12 and the Health&
1 havc and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I storc or handlc harardous material.
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 eontaminants as defined by the Bay Area Air Quality�lanagement Distriet I will
permit is issucd. maintain compliance with the Cupertino Municipal Code,Chaptcr 9.12 and the
1 ccrtit'y 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
Compcnsation laws of California. If,after making this certificate of exemption,I Owner or authorized agent:
become subject to the Worker's Compensation provisions ofthe Labor Code,I must
Date:
lorthwith comply with such provisions or this permit shall be deemed revoked.
('ONS"IRUCTJON LENDING AGENCY
APPLICANT CERTIFICATION I hereby aftirm that there is a construction lending agency for the performance of work's
1 certify that 1 have read Ihis application and state that the above information is for which 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 representativcs of this city to entcr
upon the abovc mentioned property(or 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 ARCHITEC"C'S DECLARA'I'ION
granting o1'this permit.ndditionally,the applicant understands and will comply
with all non-point sourcc regulations per the Cupertino Municipal Code,Section 1 understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date