B-2018-1785 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2018-1785
10169 S BLANEYAVE CUPERTINO, CA 95014-3158 (369 03 008) AMERICAN WATER
HEATER SERVICE INC
NEWARK, CA 94560
OWNER'S NAME: LAKE BILTMORE APARTMENTS DATE ISSUED: 10/19/2018
OWNER'S PHONE: PHONE NO: (
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class 959436 Lic. #959436
Contractor AMERICAN WATER HEATER SERVICE INC Date 03/31/2019 X BLDG — ELECT X PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing MECH X RESIDENTIAL _ COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
REMOVE & REPLACE 100 GAL WATER HEATER IN THE SAME
I hereby affirm under penalty of perjury one of the following two declarations: UTILITY ROOM 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
performance 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 for which this
permit is issued. Sq. Ft Floor Area: Valuation: $6650.00
APPLICANT CERTIFICATION
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 69 Number: Occupancy Type:
3
and state laws relating to building construction, and hereby authorize 369 03 008
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 der3tands dandy with all non-point
source r alt s per t "'C Mu
MSection 9.18. 180^DAYS FROM LAST CALLED INSPECTION.
,1gna
I hereby affirm that I am a pt fro the Con actor's License Law for one of the RE-ROOFS.-
following
E-:ROOFS:following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is
1. I, 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)
z. I, as owner of the property, am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project (Sec,7044, Business & Professions Code). Date: 10/19/2018
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
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance, as provided for by I have- read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor.. Code, for the performance of the work for which this California Health & Safety Code, Sections 25505, 25533, and 25534. I will
permit is issuedmaintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. I 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 I 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. Tf, after making this certificate of will maintain compliance with thy,-Gu-p tino Mu n fM 'p -C arr1E, hapter 9.1 ind°,
exemption, I become subject to the Workers Compensation provisions of the the Health & Safet >�
correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that the E s a construcji lending agency f r th perfo mance
relatingto building construction and hereby authorize representatives o of works for which this perms is issued (S 3097, Civ C.
g y p f this city
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. I understand my plans shall be used as public records.
Signature Date 10/19/2018 Licensed
Professional