10080123CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 10810 PENINSULAR AVE
rr`rNER'S NAME: FARRER DAVID J
�- ,rNER'S PHONE: 4087731847
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor
Date
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 license is in full force and effect.
I hereby affirm under penalty of perjury one 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
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.
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
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, 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 regulations per the Cupertino Municipal Code, Section
9.18.
;^nature
Date
❑ OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
COr TRACTOR: JUST WATER HEATERSI PERMIT NO: 10080123
INC
3400 INVESTMENT BLVD
DATE ISSUED: 08/18/2010
HA) -WARD, CA 94545
PHONE NO: (510)293-9901
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB
MECH r RESIDENTIAL r COMMERCIAL
JOI t DESCRIPTION: REPLACE EXISTING 50 GAL WATER HEATER
Sq. Ft Floor Area: 0
Valuation: $1583
4 Number: 32603047.00
Occupancy Type:
I hereby affirm under penalty of perjury one of the following three
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
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.
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
Compensation laws of California. If, after making this certificate of exemption, I
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. 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
the above mentioned property for inspection purposes. (We) agree to save
mify and keep harmless the City of Cupertino against liabilities, judgments,
cues, 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 regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date.
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Iss Lied 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
ins lection.
SiI nature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I I ave read the hazardous materials requirements under Chapter 6.95 of the
Ci lifornia Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
So fety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
C
as defined by the Bay Area Air Quality Management District I will
m iintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
H Wth & Safety Code, Sections 25505, 25533, and 25534.
O Jvner or authorized agent:
Date
CONSTRUCTION LENDING AGENCY
I ) iereby affirm that there is a construction lending agency for the performance of work's
fc r which this permit is issued (Sec. 3097, Civ C.)
L miler's Name
Lender's Address
ARCHITECT'S DECLARATION
I .mderstand my plans shall be used as public records.
L icensed Professional