B-2018-1278 Permit Card CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2018-1278
7503 FALLENLEAF LN CUPERTINO,CA 95014-5843(359 28 033) WA'ITR HEATERS
ONLY INC
970 E MAIN ST GRASS
VALLEY,CA 95945
OWNER'S NAME: DATE ISSUED;07/30/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 Lic.#$t.4 3
Contractor WATER HEATERS ONLY INC Date 05/31/2019 X BLDG ELECT X PLUMB
I hereby affirm that I am licensed under the provisions of Clmpter 9(commencing —MECII X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license Is in fall force and effect. JOB DESCRIPTION:
REPLACE 40 GAL WATER HEATER(SAME LOCATION)
1 hereby ufllrm ander penalty of perjury one of the following two declarations:
1. I have and will unaintoin a certificate of consent to self-insure for Worker's
Compensation,as provided far by Section 3700 of the Labor Code,for the
have add will meintaiu Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work fm•which this
permit is issued Sq.Ft Floor Area: Vnluntion:$1679.00
APPLICANT CERTIFICATION -
I certify that I have read this application and state(hat the above
information is correct.I agree to comply with all city and county ordinances AIN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 35929 033
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 WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signatur -" �-- --- Data 7-30-2018 Issued by:Kim Dunbar
Date:07/30/2018 -
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of theRE-ROOFS:
following two reasons: All roofs shall be inspected prior to city roofing material being installed.If a roof is
1. 1,as owner of the property,or my employees with wages na 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)
z, I,as owner of the properly,am exclusively contracting with licensed Signal—ot'Applicanh
contractors to construct the project(Sec.7044,Business&Professions Code). Data:7-30-2018
I hereby affirm under penalty of perjury one of the following three declarations; ALL ROOF COVERINGS TO BE CLASS"A"OR BET'T'ER
1. 1 have and will maintain a Cerlifieste 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 permil 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 requirements order Chapter 6.95 or the
Section 3700 of the Labor Code,for the performance of die work for which this California Health&Safety Code,Sections 25505,25533,and 25534.I will
permit is issued maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and the
3. I certify that in the fork ca of the work for which this permit is issued,I Health&Safety Cade,Section 25532(x)should 1 store or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additimmlly,should I use equipment or devices which emit hazardous
nir contaminants as defined by the Buy Area Air Quality Management District 1
Worker's Compensation laws of Celifomia.If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,T become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,1 must forthwith comply with such provisions or this permil shall
be deemed revoked. Owner or authorized ages
APPLICANT CERTIFICATION Date:7-30-2018
1 certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there Is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Clv C.)
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 ARCIV5'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Data 7-30-2018 Licensed
Professional