B-2017-1077w`
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1077
19967 PEAR TREE CT CUPERTINO, CA 95014-2318 (316 30 085)
AFFORDABLE WATER
HEATERS AND
PLUMBING INC
28358
CONSTELLATION RD
VALENCIA, CA 91355
OWNER'S NAME: MOORE RONALD J SR AND RUTH C TRUSTEE
DATE ISSUED: 07/06/2017
OWNER'S PHONE: 408-253-1197
PHONE NO: (855) 345-9087
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C-36 Lic. #62736$
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.
(N) 40 GAL WATER HEATER - GARAGE
I hereby affirm under penalty of perjury one of the following two declarations:
t. 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
Sq. Ft Floor Area:
Valuation: $2670.00
permit is issued.
APPLICANT CERTIFICATION
certi that I have read this application and state that the above
APN Number:
Occupancy Type:
,ibformation is correct. I agree to comply with all city and county ordinances
316 30 085
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.
Addition icant understands and will comply with all non -point
180 DAYS FROM LAST CALLED INSPECTION.
source r I r the Cupertino Municipal Code, Section 9.18.
Issued by: Kim Dunbar
Signature Date 07-06-2017
Date: 07/06/2017
ARATION -
I hereby affirmat I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two rems:
installed without first obtaining an inspection, I agree to remove all new materials for
2. 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: 07-06-2017
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
permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
3. I certify that in the performance of the work for which this permit is issued, I
material. Additionally, should a eqm ent or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the
air contaminants as defined by a Ar Air Quality Management District I
will maintain compliance with up o Municipal Code, Chapter 9.12 and
Worker's Compensation laws of California. If, after making this certificate of
the Health & Safety de, ec 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 authorizJagbe
deemed revoked.
Date: 07-06-2017
APPLICANT CERTIFICATION
D AGENCYI
certify that I have read this application and state that the above information is
I hereby affrm thatnstructioi lending agency far the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which issued ( ec. 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.
i
GUPERTI 0
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildino(d�cupertino.org
& -20
PLUI,�BING ❑MECHAI\ICAL ❑ELECTRICAL ❑.V1ISCELLANEOLS
PROTECT ADDRESS /? e� APN 12 J( i o Q —
01-k NER NA? E for ) q l e P x E-! LkIL
STREET.IDDRESS iiiVVV eCA
CIT S E TaP/ �S0)FAX
CONTACT NAME (\ rgf, /J r PHO' % , J /) � / j E- 4AIL n J� ✓
SS lJY 1 �L� ��/� ��' STA E, ZIP 'j v
❑ 0-W?SER ❑ 0'A`N t -BL=, ER ❑ 01'I,ER.AGD,7, CONTRACTOR ❑ COXIRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSt NIfB LICr 'SE P I BL'S. LIC nV r1V / C
L IpJ
CO I` E-DZAIL FAX
SIRE ✓ d (./I/' fS �i� I CITY, ST. 7 �n C/w �` A I2[ S P O. l� 7 /I
ARCHITECT/ENGL\EERNAME LICENSE NUMBER C1 � JJ BUS.LIC' S 'JL1
COMPANY NAME E-MAIL FAY,
STREET ADDRESS CITY, STATE, ZIP PHONE
USE OF SFD or DLIPL; -X ❑ NTULTI-FAMILY PROJECT IN, WILDLAOND i Es PROJECT PJ ❑ YES IS THE BLDG AN ❑ �ZS
BUII.DN-G: COM,4ERCLAL MAN L.TERFACF. AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
MASIN
TOTAL VALUATION: Q0 v I D
By my signature below, I &ertffy to each of oIlowing: I ain the property owner or authorized a_ent to act on the property owner's behalf. I have read this
application and the information I have p ed s correct. I have read the Description of Work and verify it is accurate. l gree o comply with all applicable local
ordinances and state laws relating to _ struction. I authorize representatives of Cupertino to enter the ab id if] perty inspection purposes.
Signature of Applicant%Agent: Date: 3 1 —
AL P -\`FORMATION REQUIRED
< ❑ LARGE,
�, TLAJOR.
A1EPkfisc,9pp_2011.doc revised 05/21;11