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B-2016-1851CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1851 863 BETLIN AVE CUPERTINO, CA 95014-4546 (3 69 27 025) WATER BEATER SPECIALISTS FOSTER CITY, CA 94404 OWNER'S NAME: PONDER FRANCES OWNER'S PHONE: 408-252-8771 LICENSED CONTRACTOR'S DECLARATION License Class C-36 Lic. #741904 Contractor WATER HEATER SPECIALISTS Date 10/31/2017 I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: 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 erformance of the work for which this permit is issued. 4 I 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. 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 to building construction, and hereby 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 expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. gnaturei'./�� - t Date 4/28/2016 OViTNE-BUILDERDECLAMR-AT14 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: 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 performance of the work for which this permit is issued. 2. I 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. 3. I certify that in the performance of the work for which this permit is issued, I shall 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 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. 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 to building construction, and hereby 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 expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date 4/28/2016 DATE ISSUED: 04/28/2016 PHONE NO: (650) 525-9287 BUILDING PERMIT INFO: X BLDG —ELECT X PLUMB _ MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: REPLACE (E) WATER HEATER WITH (N) WATER HEATER IN GARAGE - 40 GALLONS Sq. Ft Floor Area: I Valuation: $1950.00 APN Number: Occupancy Type: 369 27 025 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Abby Ayende Date: 04/28/2016 RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: 4/28/2016 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & 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 I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections %2.555(J05, 25533, and 25534. ner or authorized agent: fl & Date: 4/28/2016 CONSTRUCTION LEND ANCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(a�cupertino.org E--rPLUMBING ❑ MECHANICAL ❑ ELECTRICAL ❑ I\CSCELLANEOUS PROJECT ADDRESS APN m OWNER NAME oJ PHOI\ v" ` E-MAIL V �J fry n� �� s Po ry ��..� v • 0 Z� STREET ADDRESS CITY, STATE, ZIP u ^� N� FAX CONTACT NAME VA TO-L - ��^r n� i�f �) } PHONE / ,T •.�-_` STREET ADDRESS ? � ( (� 7 CITY, STATE, ZIP j Cl ° vzi FAX 11OwNER EIOWNER-BUILDER❑ OWNER AGENT 1:1 CONTRACTOR El CONTRACTOR AGENT El ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTUS ME y �y ( L.ICEN L BFR Ie LICENSE TYPE BUS. LIC 1 COMPANY NAME (� E-MAIL FAX STREET IRESS,, CITY.ST 7J � , �/ ( PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER. BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF FD or DUPLEX ❑ MULTI-FAMI Y BUILDING: ❑ COMMERCIAL PROJECT IN ILDIAND ❑ YES URBAN INTERFACE AREA❑ PROTECT IN ❑ YES FLOOD ZONE E]NO IS THE BLDG AN ElYES EICHLER HOME? El NO pNO DESCRIPTION OF WLOORK l 6 (J� ( J O / -A r `� V W T� k.9-,tl TOTAL VALUATION: a1 RECEIVED BY 1 By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have rovided is correct. I have read the Description of Rork and verify it is accurate. I agree to comply with all applicable local ordinances and state laws re]ating to. I ding cons n. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent:/ ,�/�'�/ Date:Zz REQUIRED I _ : OFFICE USE ONL1 r tRGE AJOR MEPMiscApp_ 01 ].doe revised 06121/11