B-2016-2814 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2016-2814
20690 RODRIGUES AVE CUPERTINO,CA 95014-2965(359 11013) AFFORDABLE WATER
HEATERS AND
PLUMBING INC
28358
CONSTELLATION RD
VALENCIA,CA 91355
OWNER'S NAME: HANSENMARILYNATRUSTEE DATE ISSUED:10/05/2016
OWNER'S PHONE:408-253-4117 PHONE NO:(855)345-9087
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class CC-36 Lic.#627368
Contractor AFFORDABLE WATER HEATERS AND PLUMBING INC Date X BLDG —ELECT X PLUMB
09/30/2018 _MECH X RESIDENTIAL_COMMERCIAL
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 JOB DESCRIPTION:
license is in full force and effect. REPLACE 40 GAL WATER HEATER(INSIDE,CLOSET)
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
,performance of the work for which this permit is issued.
z_ 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
Sq.Ft Floor Area: Valuation:$979.00.
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above APN Number: Occupancy Type:
information is correct.I agree to comply with all city and county ordinances 359 11013
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 PERMIT EXPIRES IF WORK IS NOT STARTED
City of Cupertino against liabilities,judgments,costs,and expenses which WITHIN 180 DAYS OF PERMIT ISSUANCE OR
may accrue against said City in consequence of the granting of this permit.
Additionally,the applicant understands and will comply with all non-point 180 DAYS FROM LAST CALLED INSPECTION.
source regulations per the Cupertino Municipal Code,Section 9.18.
r'l Issued by:Abby Ayende
Signature Date 10/5/2016 Date: 10/05/2016
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. I,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:10/5/2016
contractors to construct the project(Sec.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 by California Health&Safety Code,Sections 25505,25533,and 25534. I will
Section 3700 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Health&Safety Code,Section 25532(a)should I store or handle hazardous
permit is issued.
s. I 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 airthe 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 t
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 de,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:10/5/2016
APPLICANT CERTIFICATION CONSTRUCTION LE 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 understands ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records.
Code,Section 9.18.
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GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION I.
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTIN0 (408)777-3228--FAX(408)777-3333•building(@cuaertino.mg MISC
dPLUMDING QMECTIANICAL QELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESSAPNB `
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OWNERNAME I'I10N'- E-MAIL - -
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STREF,TADDRESS. CITY,STA-;i ZIP • ITAX
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CONTACTNAME - E•MAIL - -
S 1 o u - -j-
STREE I'ADDRESS CITY,STATE,ZIP FAX
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❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR VhCQ.TRACTOR AGENT ❑ ARCHITECT '❑ENGINEER ❑ DEVELOPER ❑ TENANT -
CON ACTOR NAM' LICENSE•NUMBER. 7CFNSFTYPE BUS.LIit� NAa erO
COMPANYNAME E-MAIL _ -!• X
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STREET ADDRESS - CITY,STATE,ZIP PHONE
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ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC it
COMPANY NAME E-MATI. FAX
STREETADDRESS CITY,STATE,ZIP PHONE
USE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJE(71NWILDLAND ❑ YES PROJECTIN ❑YES IS TILE BLDG AN ❑YES
BUILDING: COMMERCIAL URBAN INTERFACE.AREA ❑ NO FLOODLONE ❑NO EICIILER HOME? ❑NO
DESCRIPTION OF WORK
KPOOrfiD a e
sa c a
TOTAL ._....._......< .-.. ............._..._.. -
0 VALUATION: � •-R --:-•;: �...._.:.-:::;__:-_�:...----...............:_._....:.:........................_
By my signature below,l certify to each of the following:. I am the property owner or authorized agent to act on the property Owners behalf 1 have read this
application and the information I Have provided is correct. I have read the Description of Work and verify itis accurate. 1 agree to comply with all applicable local
ordinances and state laws relating to buildin OnstTuction. 1 authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of ApplicanUAgent: Date:
SUPPLEMENTAL INFORMATION R13QU1RED
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MLPMiscApp_2011.doc revised 06/21/11