12060044 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18480 CII ELMSFORD DR CONTRACTOR:PAST WATER I WATER PERMIT NO: 12060044
OWNER'S NAME: GOLDBERG STEVE If AND RANES-GOLDBE 12601 132 AVE NE DATE ISSUED:06/072012
OWNER'S PHONE.: 4084465367 KIRKLAND,WA 98034 PI[ONE NO:(800)4518955
❑ LICENSED CONTRACT'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.q
M ECH r RESIDENTIAL r COMMERCIAL
Contractor Date
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RLfvfovr EPLACE GAS WATER I(LATER
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penally of perjury one of the following two declarations:
I have and will maintain a cenificale of consent to self-insure for Worker's
Compensation,as provided I-or by Section 3700 of the Labor Code,for the
performance of the work far which this permit is issued. Sq.Ft Floor Area:0 Valuation:S1215
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. APN Number:37522071.00 Occupancy Type:
APPLICANT CERTIFICATION
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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments. ]g0 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of this pemmil. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date:
9.18.
Signature Date
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION 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
hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044.
Business&Professions Code)
L as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec 7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three ILC%ARDOUS MATERIALS DISCLOSURE:
declarations: 1 have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate ofConsenl to self-insure for Worker's California Ileallh&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ileallh&
performance of the work for which this permit is issued. Safety Code,Section 25532(x)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance.as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,f'or the performance of the work for which this contaminants as defined by the Ray Area Air Quality Management District 1 will
permit is issued- maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Health&Safely Code,Sections 25505,2.5.533,and 25534.
I certify 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 the Worker's Owner or authorized agent:
Compensation Imus of Calif lmia If,after making this certificate of exemption,I Date:
become subject to the Worker's Compensation provisions of the Labor Code,1 must
forthwilh comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING.AGENCY
I hereby affrn that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and stale that the above information is Lender's Name
cored. I agree to comply with all city and county ordinances and state laws relating
to building construction,mrd hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, .ARCIIITF:(7"S DECLARATION
costs,and expenses which may accrue against said City in consequence of the
granting of this pertitL Additionally,the applicant understands and will comply I understand my plans shall be used as public records_
%%all all non-point source regulations per the Cupertino Municipal Code,Section
418. Licensed Professional
Signature Date