12030042 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10305 EL PRADO WAY CONTRACTOR:FAST WATER HEATER PERMIT NO: 12030042
OWNER'S NAME: JACKMAN ERNA B TRUSTEE 12601 132 AVE NE DATE ISSUED:03!032012
OW'NER'S PHONE: 7035692627 KIRKLAND,WA 98034 PHONE NO:plOm 4M-8955
❑ LICENSED CON'TRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Chess Lie.N
MEGH r RESIDENTIAL r' COMMERCIAL —
Contractor Date
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVEIREPLACE GAS WATER HEATER IN UNIT A.
(commencing with Section 7000(of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
hereby affirm under penalty of perjury one Of the following two declarations:
I have and will nmaimain a cerliticaw of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for dee
performance of the work for which this permit is issued. Sq.Ft Fluor Area:0 Valuation:.$935
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 ofthe Labor Code,for die perfommoce of the work for which this
permit is issued. APN Number:34230015.00 Occupancy Type:
APPLICANT CERTIFICATION
1 certify film 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 [F 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, 180 DAYS FROM LAST CALLED INSPECTION.
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 allnom-point source regulations per the Cupertino Nlunieipal Code,Section Issued bv: Date:
9,13,
Signature Date
RE-ROOFS:
❑ OAVNER-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
1 hereby affirm flint 1 am exempt from the Contractor's License Law for one of inspection.
11te following two reasons:
Las;owner of the property,or my employees with wages as their sole compensation, Siunmure of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1,as Owner of the propelly,am exclusively COauaeling with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Se0.7044.Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 orthe
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&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 Health&
performance of the wort:for which this pennit is issued. Safety Code,Section 25532(a)should 1 store or handle hazardous materiel.
I have and will maintain Worker's Compensation Insurance,as:provided for by Additionally,should I use equipment or devices which emR hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District 1 will
pennit is issued. maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
Health&Safety Code,Sections 25505,25533.and 25534.
1 certify flint in the performance of die work for which this permit is issued,I shall
nut employ any person in any manner so as to become subject to the Worker's Owner or authorized agent:
Compensation laws of California. If,ager making this certificate of exemption,I Date:
become subject to tine Worker's Compensation provisions of the labor Code,1 must
forthwith comply with such provisions or this pennit shall'be deemed revoked. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of works
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
correct.I agree to comply with all city and county ordinances mid stale laws relating
in building construction,and hereby authorize representatives of this city to enter Lender's Address
upon the above memioned propery for inspection purposes.(We)agree to save
indemnify and keep hamless the City of Cupertino against liabilities,judgments. ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the
granting of this pennit.Additionally,the applicant understands and will complyI understand nay plums shall be used as public records.
with all non-point source regulaticiis per time Cupertino Municipal Cotte,Section
9.18. Licensed Professional
Signature Date