10010148CITY OF CU
PERTINO BUILDING PERMIT
CONTRACTOR: EGOV
BUILDING ADDRESS: 10480 SERRA ST ON LINE PERMIT
IIWNER'S NAME: JAY & HARITA PATEL CUPERTINO, CA 95014
.JWN PHONE: 6509678295
n LICENSED CONTRACTOR'S DECLARATION
,icense Class Lic. #
BUILDING PERMIT INFO:
PERMIT NO' 10010148
DATE ISSUED- 01/27/2010
PHONE NO:
BLDG ELECT PLUMB
rl-
MECH RESIDENTIAL
COMMERCIAL
JOB DESCRIPTION: REMOVE AND REPLACE 75 GAL WATER HEATER
Date
.ontractor the provisions of Chapter 9
[ hereby affirm that I am licensed under
'nwith Section 7000) of Division 3 of the Business &Professions
(commencing
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
for Worker's
and will maintain a certificate of consent to self -insure Code, for the
I have
a
Compensation, as provided for by Section 3700 of the
performance of the work for which this Pep Compensation
Insis urance, as provided for by
I have and will maintain Worker's Compcation of the work for which this
Section 3700 of the Labor Code, for the performance
permit is issued.
APPLICANT CERTIFICATION
I have read this application and state that the °ve information is
and state laws relating
I certify that 1 with all city and county ordinances
correct. I agree to comply authorize representatives of this city to enter
agree to save
to building construction, and hereby for inspection purposes. (We) g
upon the above mentioned property against liabilities, judgments,
indemnify and keep harmless the City of Cupertino
Psa d City in consequence of the
costs, and expenses which may accrue againstlicant understands and will comply
granting this per eguilataons,the per the Cupertino Municipal Code, Section
with all no
n-point s ource
9.18.
Date
";nature
1 OWNER -BUILDER DECLARATION Law for one of
affirm that I am exempt from the Contractor's License
hereby
he following two reasons: e to ees with wages as their sole compensation,
n,
as owner of the property, or my mp Y
k and the structure is not intended or offered for sale (Sec.7044,
vill do the wor ,
3usiness & Professions Code) with licensed contractors to
as owner of the property, am exclusively contracting
construct the project (Sec.7044, Business & Professions Code).
one of the following three
I hereby affirm under penalty of perjury
declarations:
and will maintain a Certificate of Consent to self -insure Code, the Worker's
I have a Section 3700 of the Lab
Compensation, as provided for by
ermit is issued.
performance of the work for whichthis Perm
.on Insurance, as provided for by
I have and will maintain Worker's Comp
f the Labor Code, for the performance of the work for which this
Section 3700 0
permit is issued.ermit is issued, I shall
I certify that in the performance of the work for which this ect to the Worker's
not employ any person in any manner so as to become subj
law of California. If, after making this certificate Of
Code, must
Compensation la provisions of the La
become subject to the Worker's v °o pens this permit shall be deemed revoked.
forthwith comply with such pro
Valuation: $1965
Sq. Ft Floor Area: 0
Occupancy Type:
APN Number, 34259010.00
PERMIT EXAIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Date:
Issued by,
RE -ROOFS:
roofing material bebg installed. If a roof is
All roofs shall be inspected prior to any
ut first obtaining an inspection, I agree to remove all new materials or
installed witho
inspection.
Date:
Signature of Applicant:
ER
L ROOF COVERINGS TO BE CLASS "A" OR B
ALETT
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirement525533r andChapter 6.95 of the
25534. I will
California Health &Safety Code, Sections 25505
hap
9.12
maintain comp
he with the Cupertino Municipal Code, nd ethazard an the
Health &Safety Code, Section 25532(a) should I store or
Additionally, should I use equipment or devices hichitDistrict I
material. Add the Bay Area Air QualityManagementter ist and
air contaminants a 1 defined
with the Cupertino Municipal Code, Chap
will maintain comp
the Health & Safety Code, Sections 25505, 25533, and 25534.
Date•
APPLICANT CERTIFICATION
have read this application and state that the above i State laws relating
ormation is
1 certify that I y ordinances correct. I agree to comply with all cit and county
authorize representatives of this city to enter
to building construction, and hereby (We) agree to save
�n the above mentioned property for in purposes. ud ments,
i and keep harmless the City of CupertinoCgnntconsequence of the
emn fy accrue against said y
costs, and expenses which may
of this pill Comply
ermit. Additionally, the applicant unn e uri C . I Code, Section
s and wi
granting
with all non -point source regulations per the Cupert
9.18.
Date
Signature
Owner or authorized agent:
CONSTRUCTION LENDING AGENCY erformance of
I hereby affirm that there is a construction lending agency for the p
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional