B-2016-1279CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:.
CONTRACTOR:
PERMIT NO: B -2016 -1279
10159 S 13LANEYAVE UNIT 96B CUPERTINO, CA 95014 -3116 (369 03 008)
(AMERICAN WATER
HEATER SERVICE INC)
NEWARK, CA 94560
OWNER'S NAME:. LAKE BILTMORE APARTMENTS
DATE ISSUED: 01/28/2016
OWNER'S PHONE: 408 -255 -8787
PHONE NO: 510- 490 -4411
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lic. #959436
Contractor ( AMERICAN WATER HEATER SERVICE INC) Date
X BLDG —ELECT —PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing .
_ MECH X RESIDENTIAL _ COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
UNIT 9613- REPLACEMENT OF A 40 GALLON GAS WATER HEATER
I hereby affirm under penalty of perjury one of the following two declarations:
WITH THE SAME SIZE IN THE SAME LOCATION (WATER HEATER
1. I have and will maintain a certificate of consent to self - insure for Worker's
CLOSET).
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
2. 1 have and will maintain Worker's Compensation Insurance, as provided for
by Section 3700 of the Labor Code, for the performance of the work for which
this permit is issued.
Sq. Ft Floor Area:
Valuation: $1167.00
APPLICANT CERTIFICATION
certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
APN Number:
Occupancy Type:
ordinances and state laws relating to building construction, and hereby
369 03 008
authorize representatives of this city to enter upon the above mentioned
property for inspection purposes. (We) agree to save indemnify and keep
harmless the City of Cupertino against liabilities, judgments, costs, and
PERMIT EXPIRES IF WORK IS NOT STARTED
expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will
comply with all non -point source regulations per the Cupertino Municipal
180 DAYS FROM LAST CALLED INSPECTION.
Code, Section 9.18.
Issued by: Susan Winslow
Signature Date
Date:
OWNER- BUILDER DECLARATION
RE- ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
1. 1, as owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered
for sale (Sec.7044, Business & Professions Code)
Signature of Applicant:
2. I, as owner of the property, am exclusively contracting with licensed
Date:
contractors to construct the project (See.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS' "A" OR BETTER
1. 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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance, as provided for
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will'
by Section 3700 of the Labor Code, for the performance of the work for which
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
this permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
3. 1 certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
shall not employ any person in any manner so as to become subject to the
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Worker's Compensation laws of California. If, after making this certificate of
the Health & Safety Code, Sections 25505, 25533, and 25534.
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
Owner or authorized agent:
be deemed revoked.
Date:
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant
ARCHITECT'S DECLARATION
understands- and will comply with all non -point source regulations per the
I understand my plans shall be used as public records.
Cupertino Municipal Code, Section 9.18,
Licensed
Professional
Signature Date
GENERAL PERMIT APPLICATION
COMMUNITYDEVELOPMENT DEPARTMENT- f3UILDING DIVISION MEP
10300,TORRE AVENUE - CUPERTIN0, CA 95014-3255
CUPERTINO (408) 777-3228 • FAX (408) 777-3333 - buildinqacuoertino.oro misc
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