12030110CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22605 SALEM AVE
OWNER'S NAME: ALTh1AIER RICI LARD C AND PAULL—IT
OWNER'S PIIO,NE: 4085823506
❑ LICENSED fON l'R,\CfOR'S DISCLARA'I'ION
License Class Lie. 4
Contractor Date
hereby ofrm that I our licensed under the provisions of Chapter 9
(commencing with Section 701111) of Division 3 (if the Business & Professions
Code and that in)- license is in full force and effect.
hereby affirm under penalty (if perjury fine of the following two declarations:
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
pertbmtance of the work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of die work for which This
permit is issued.
.U'I'LICAN'I' CIiR'I'I FIC.\'PION
I certify that I have read this application :rad 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 ol'Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regularities per the Cupertino Municipal Code, Section
9.18.
Signature Dale
❑ OWNEWBUILDER DECLARATION
1 herebyalfnrin that 1 run cxcnnpt from the Contractor's License Lae' for one of
the folinw'ing two reasons:
I, as owner of the properly, or my employees with wages as their sole compensation,
will do the work, and the structure isnot intended or offered forsake (Sce.7044,
Business & Professions Code)
1• as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, 13uxiness R Pr0fcSSi0aS Code).
hereby affirm wader penalty of perjury one of the following three
declarations:
Ihave and will maintain a Certificate ol'Consent to self -insure for Worker's
Compensation, as provided fix by Section 3700 of the Labor Code, for the
performance of One 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 penornance of the work for which this
permit is issued.
1 eenify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to die Worker's
Compensation Imus of California. If, after making this certificate of exemption, 1
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. 1 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 abovementioned properly for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against Iiabilities,judgaents,
costs, and expenses which may accrue against said City in consequence of tire
granting of this permit. Additionally, the applicant understands and will comply
with all nun -point source regulaii(ns per the Cupertino Municipal Code, Section
9.18.
CONIRACI'OR: STREl f PLUMBING & PERNI IT NO: 12030110
ROOTER
2293 RSU.NUFGROVFAVE- DATE ISSUED: 03121/2012
SAN JOSE. CA 95128 1 PHONE NO: (408) 496-1155
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
NIECII r RESIDENTIAL r COMMERCIAL r
.1013 DESCRIPTION: WA'1'17R HEATER REPLACEMENT
Sq. Ft Floor Area: 0 1 Valuation: $500
AI'N Number: 34212062.00 1 Occupancy'lype:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of
Date:
ALI, ROOF COVERINGS TO 13F, CLASS "A" OR BF; ITER
IL\%ARDOIIS MATERIALS DISCLOSURE:
have read the hazardous materials requirements under Chapter 6.95 of the
California Iladth & Safety Code. Sections 25505, 25533, and 25534. 1 will mainain
compliance with the Cupertino, Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25.532(x) should 1 store fir 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
Ilealth & Safety Code. Sections 25505. 25533, and 25534.
Owner or authorized agent:
Date:
CONSTRUCTION LENDING AGENCY
I hereby affnrn that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCIIITECT"S DECLARA'T'ION
I understand my plans shall be used as public records.
Licensed