BLD-2021-00129Permit.pdfBUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 21746 COLLINGSWORTH ST Cupertino
APN: 356 17 050
PERMIT NO: BLD-2021-00129
OWNER'S NAME: FOX JEROME M AND RONNIE E TRUSTEE
OWNER'S PHONE: Not Provided
CONTRACTOR: MOOMAU PLUMBING, 1 177 BRANHAM LANE 152 SAN JOSE
CONTRACTOR PHONE:
DATE ISSUED 1/19/2021 4:05:33 PM
ISSUED BY:
VALUATION: $2750
JOB DESCRIPTION
REPLACE EXISTING WATER HEATER TANK
LICENSED CONTRACTOR INFORMATION
CONTRACTOR: MOOMAU PLUMBING
LICENSED CLASS: C36 PLUMBING
LICENSED NO: 792821
EXP DATE: 08/31/2022
I hereby
force
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
and effect.
affirm under penatiy of perjury one of the following three declarations:
I have and will maintain a certificate of consent to self -insure for
for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided
I certify that in the performance of the work for which this permit
laws of California. If, after making this certificate of exemption,
with such provisions or this permit shall be deemed revoked.
and agree that I am electronically signing and filing this application
that I have the option of filing a paper copy of this application
Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the
1
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
is issued, I shall not employ any person in any manner so as to become subject to the Worker's
I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith
and that checking the box below has the same legal effect as manual signature. I also
with a manual signature but have chosen instead to file this application electronically.
work
2
issued.
3
Compensation
comply
I understand
understand