10010149 III O BUILDING PENT E0149
CITY OF CUPWII
ERTI11 N PERMIT N011411561
CONTRACTOR:EGOV
CT DATE ISSU /27/2010
NG ADDRESS' 10517 MANZANITA ON LINE PERMIT PHONE NO:
BUILDING PH
'S NAME:
MIT INFO: BLDG
ELECT PLUMB
'W N TION
BUILDING PER CpMMERCIAL
LICENSED CONTRACTOR'S DECLARA MECH RESIDENTIAL
0REMOVE AND REPLACE 75 GA WATER HEATER
Lic.# JOB DESCRIPTION.•
License Class
Date
Contractor provisions of Chapter 9
I hereby affirm that I ction 7000)am licensed under the
of Division 3 of the Business 81 Pro
(commencing with Sefessions
Code and that my license is in full force and effect. o declarations:
I hereby affirm
under penalty of perjury one of the following
lfo two
Valuation:$1965
. 3700 of the Labor Code,for the
I have and will maintain a certificate f consent to self-insure Sq,Ft Floor Area:0
Compensation,as provided for by Section
ancy Type:
permit is issued. provided for by Occup
performance of the work for which
Co pensation Insurance,as p for which this
will maintain W° ance of the work pPN Number:34261018.00
I have and performance
Section 3700 of the Labor Code,for the p WORK IS NOT STARTED
permit is issued. PERMIT EXPIRES IF PERMIT ISSUANCE OR
APPLICANT CE a eltChaThOa ove information is
THIN 180 DAYS OF P INSPECTION.
application and WI LAST CALLED
1 certify that I have read this app and county ordinances and state laws r 180 DAYS FROM
agree to comply with all city representatives of this city to enter
correct.I ag d hereby authorize rep ur oses. (We)agree to save
to building construction, ro erty for inspection p P Date:
of Cupertino against liabilities,judgments,
upon the above menthane harmless the City in consequence of the Issued by'
indemnify and keep accrue against said City
costs,and expenses which may the applicant understands and will comply
ermit. Additionally, er the Cupertino Municipal Code, RE-ROOFS. Installed.If a roof is
granting of this P ulations p
with all non-point source reg prior to any roofing material berg
9.18. All roofs shall be inspected p inspection,I agree to remove all new materials for
Date installed without first obtaining a"► P
Signature inspection. Date:
TION Signature of Applicant:
pWNER-BUILDER DECLARA ,s License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
� t from the Contractor A
I hereby affirm that I am exemp nsation,
the following two reasons: employees with wages as their sole compe
or my
I as owner of the property, is not intended or offered for sale(Sec-7044, ter 6.95 of the
HAZARDOUS MATERIALS DISCLOSURE
will do the work,and the structurerequire under Chap
mess&Professions Code) 1 contracting with licensed contractors to ha ter 9.12 and tl
Code,Sections 25505,25533,and 25534• I will
Bus exclusive y I have read the hazardousSafety materials req I Code, p
I,as owner of the property,am California Health& Cupertino Municipaazardous
ro ect(Sec. maintain Business&Professions Code). maintain compliance with the Cup should I store or handle emit hazard
construct the p J three Code,Section 25532(x)
of perjury one of the following Health&Safety useequipment or devices wh ement Distril
penalty p Area Air Quality Manag
hereby affirm under p Worker's material. Additions defined by the Bay Code,Chapter 9.12
Ih y
declarations: air contaminants a Cupertino Municipal
aintain a Certificate of Consent to self bar Code,for the will maintain compliance with the Cup
I have and will m Section 3700 of the Safety Code,Sections 25505,25533,and 25534.
Compensation,as provided for by the Health& y Date*____ —
issued. rovided for by
performance of the work for Worker's
his Permit's ensati°n Insurance,asp agent'
I have and will maintain Worker'fo ihe performance of the work for which this
Owner or authorized
Section 3700 of the Labor Code, Perm* is issued,I shall CONSTRUCTION LENDING AGENCY
permit is issued. CONSTRU for the per
c
that in the performance of the work fobe om this
to the Worker's nstructIon lending agency
1 certify t manner so as to this certificate of exemption,I affirm that there is a co Sec.3097,Civ C.)
not employ any person in any I must I hereby
work's for which this permit is issued
nsation provisions of the Labor Code,ked. e
laws of California. If,after making k 1
Compensation
ermit shall be deemed revo Lender's Nam
become subject to the
Worker's Comp
forthwith comply with such provisions or this p
Lender's Address
ON
APPLICANT CERTate ltharthee above information ielahng
that I have read this application and s
I certify with all city and county ordinances and state laws
enter
to comply e resentatives of this city ARCHITECT'S DECLARATION
correct.1 agree and hereby authorize r p ur oses.(We)agree to save
to building construction, property for inspection p P public records.
ertino against liabilities,judgments, I understand my plans shall be used as
�)n the above mentioned prop y. °f Cup in consequence of the
;mnify and keep harmless the City st said City
expenses which may accrue again
,,osts,and exp Additionally,the applicant understands and will comply
granting of this Perm A per the Cupertino Municipal Code,Section Licensed Professional
with all non-point source regulations p
9.18. Date
Signature