BLD-2020-2097F -1
2
BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Tone Avenue a Cupertino, CA 95014-3255
PHONE 408-777-3228
W W W.CUPERTINO.,ORG
BUILDING ADDRESS:
—�`
OWNER'S PHONE: 5743397523
CONTRACTOR: WATER HEATERS ONLY INC. 970 E MAIN STREET #2D0 GRASS VALLEY
I CONTRACTOR PHONE:
DATE ISSUED 12/17/202D 10:42:32 AM E311E I BY: JASMINE ARCHBOLD
VALUATION: j2534
REPLACE 50 GALLON GAS WATER HEATER SAME LOCATION
LICENSED CONTRACTOR DECLARATION
CONRACTOR: WATER HEATERS ONLY INC
LICENSED CLASS:
C36 PLUMBING
LICENSED NO: 374573
ED DATE
05/31/2021
I hereby affirm that I am licensed under the provisions of Chanter 9 (cammenc*no with Section 70001 of Division 3 of the Business & Professions Code and that my license is in full
force and effect.
1 hereby affirm under penalty of perjury one of the following three declarations:
1 have and Will maintain a certificate of consent to selfAnsure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this pewit is issued.
911 have and will maintain Workers Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the perfoiffnance of the work for which this permit is
issued.
1 certify that in the performance of the work for which this permit B issued, I stall not employ any person in any manner so as to become subject to the Workers
Compensation laws of California. If, after making this certificate of exemption, I become subject to the Workers Compensation provisions of the Labor Code. I must forthwith
comply with such provisions or this permit shot be deemed revoked.
QI have read the hazardous materials requirements under Chapter 6.95 of the California Heath a Safety Code, Sections 95SQ5. 25533, and 25534, 1 will maintain compliance
with the Cupertino Municioal Code. Chanter 9.12 and the Heath & Safety Code. Section 25532(a) should I store or handle hazardous material. Additionally, should I use
equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino
Municipal Code, Chapter 9.12 and the Health & Safety Code. Sections 25505. 25533, and 25534.
EPA LEAD -SAFE DISCLOSURE
An EPA Lead -Safe Certfied Renovator wig be responsible for this project.
Certified Fran Name:
Firm Certification No: n/a
No EPA Lead -Safe Certified Firm is required for this project. j
CONSTRUCTION LENDING AGENCY
1 hereby affirm under penalty of perjury that there is a construction tending agency for the performance of the work which this permit is issued (Section 3097. Civil Code). 1
oYesFV]No
Lenders Name: n/a i
Lender's Address: n/a
I 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 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 City of Cupertino against liabilities. judgements, cosh. and expenses which may accrue a said C" in consequence
the applicant understands and sal corn with oil n �a Per 9 l ltYn.1A-of the granting of this permit. Addtionaly,
ply non -point source regulations Cupertino M � ' load Section 9 1 B
Signature:
�y Ot�seltI,_" *AS Maenr• rmarA mleo IM vek m the We authorfmd by such p di b comaaaced weNn US do 01tM irk bwance. W r the wort aum .d m M. sire by such p—ii Is suspended w ab—i—d far a pesbd
af3U dop dilikebrreIII. —k u cmmesnced.
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