B-2018-1885 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS; CONTRACTOR: PERMIT NO: B-2018-1885
10121 EMPIRE AVE CUPERTINO, CA 95014-1204 (326 24 057) AFFORDABLE WATER
HEATERS AND
PLUMBING INC
28358
CONSTELLATION RD
VALENCIA, CA 91355
OWNER'S NAME: DATE ISSUED: 11/02/2018
OWNER'S PHONE: PHONE NO: (855) 345-9087
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 Lic. #627368
Contractor AFFORDABLE WATER HEATERS AND PLUMBING INC Date X BLDG — ELECT X PLUMB
09/30/2020 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 .TOB DESCRIPTION:
license is in full force and effect. REPLACE 50 GAL WATER HEATER (SAME LOCATION)
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.
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 326 24 057
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 WORD 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 regul&
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 re : 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: 11-2-201.8
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 I use equipment or devices which emit hazardous
air contaminants as defined by th Bay Area Air Quality Management District I
shall not employ any person in any manner so as to become subject to the will maintain compliance with t CuRfffi"Dj Municipal Code, Chapter 9.12 and
Worker's Compensation laws of California, If, after making this certificate ofthe Health & Saf'etyod
APPLICANT CERTIFICATION
CONSTRUTIO LENDING AGENCY
certify that I have read this application and state that the above information is I hereby affirm that there is a c, nstru tion 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 'ssu d (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.