B-2018-0080G
CITY OF CUPERTINO BUILDING PERMIT
13UILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2018-0080
20875 VALLEY GREEN DR CUPERTINO, CA 95014-1799 (326 09 064)
AMERICAN WATER
HEATER SERVICE INC
NEWARK, CA 94560
OWNER'S NAME: KORET VC I LP
DATE ISSUED: 01/22/2018
OWNER'S PHONE: 408-257-1060
PHONE NU: (51 D) 490-4411
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C36 C4 Lia #959436
Contractor AMERICAN WATER HEATER SERVICE INC Date 0 3/3 112 01 9
X BLDG —ELECT X PLUMB
MECH X RESIDENTIAL COMMERCIAL
1 hereby affirm that 1 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.
JOB DESCRIPTION:
BLDG# 298-309 - REPLACE 100 GAL WATER HEATER (SAME
I hereby affirm under penalty of perjury one of the following two declarations:
LOCATION)
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
per£arinancc of the work for which This permit is issued.
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 folwhich this
Sp. Ft Floor Arca:
Valuation: $6850.00
permit is issued
APPLICANT CERTIFICATION
I certify that I have read this application and slate that the above
information is correct. I agree to comply with all city and county ordinances
APN Number:
Occupancy Type.
and slate laws relating to building construction, and hereby authorize
326 09 064
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
PERMIT EXPIRES IF WORI{ IS NOT STARTED
may
I hereby affirm that I am exempt from ontracto's License Law for one of the
RE -ROOFS:
following two reasons:
All roofs shall be inspected prior to any nutting material being installed. If a roof is
n. 1, as owner of the property, or my employees with wages as their sole
installed without first obtaining an inspection, I agree to remove all new, materials for
compensation, will do the work, and the structure is not intended or offered for
inspection.
sale (Sec.7044, Business & Professions Code)
2. I, as owner' of die property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (See.7044, Business & Professions Cade),
Dale: 01-22-2018
1 hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
r. 1 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.
HAZARDOUS MATERIALS DISCLOSURE
2. 1 have and will maintain Worker's Compensation Insurance, as provided for by
I have read the hazardous materials regnfrementS under Chaplet 6.95 of the
Section 3700 of due Labor Cade, for the performance of the work for which this
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
a. 1 certify that in the performance of the work for which this permit is issued, I
Health & Safety Code, Section 25532(a) should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the
material. Additionally, should 1 use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California, If, after making this eerliptata of
exemption, I become subject to the Worker's Compensation of the
wft maintain compliance
APPLICANT CERTIFICATION
Date: 01-22-2018
I certify that I have read this application and state that the above information is
Co C
correct. I agree to comply with all city and county ordinances and state laws
I hereby affirm that there is a construction lending age cy for a performance
relating to building construction, and hereby authorize representatives of this city
of work's for which this permit is issued (Sec. 3097, Civ
to enter upon the above mentioned property for inspection purposes. (We) agree
Lender's Name
to save Indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
Lender's Address
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non -point source regulations per the Cupertino Municipal
ARCHITECT'S DECLARATION
Code, Section 9.18.
1 understand my plans shall be used as public records.
Licensed
Signature Date 01-22-2018
Professional