12070152 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10122 ADELI IFID CT CO,NTRACI'OR:MIKE COUNSIL PLUMBING PERMIT NO: 12070152
INC
O\VNRR'SNAME: BROOKS FISHER 19150"POOLE WAV DATE, ISSUE11):07/192012
OWNER'S PIIONE: 4082559352 SAN.IOSE,CA 95131 PHONE NO:(408)272-4900
❑ LICENSED CON"I'RACfoR'S DECLARATION BUILDING PERNIIT INFO: BLDG r ELECT 1— PLUMB 1—'
License Class Lie.#
pIECII r RESIDENTIAL r_—; COMMERCIAL
Contractor Date
hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RENIOVE40GALLON WATER HEATER AND REPLACE IT
(Commencing with Section 7000)of Division 3 of the Business S Profexions WITII
Code and that my license is in full force and effect. A 50 GALLON WATER I[RATER.
hereby affirm under penalty of perjury one of the following iwu 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 Sq. Et Eloor Area:0 Valuation:$2500
APPLICANT CF.RTI FI CATION
I certify that 1 have read this application and state that the above information is AU.N N umber:35709025.00 Occupancy'1)'pe:
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, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date Issued by: Date:
❑ OWNER-BUILDER DECLARATION
hereby affirm that 1 am exempt from the Contractor's License Law formic of RF-ROOFS:
the fullowing two reasons All roofs shall be inspected prior to any roofing material being installed If a roof is
I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection.I agree to remove all new materials for
will do the work,mid the structure is nor intended or offered for sale(Sec.7044, inspection.
Business k Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to Signature ol'Applicant: Date:
construct the project(Sec.7044,Business R Professions Code).
hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"012 BE'1"I'FR
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's 11A7.ARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,I'or the
performance of the work for which this permit is issued I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided I'or b) California Health S Safety Code,Sections 25505,25533,and 25534. I will maintain
Section 3700 of the Labor Code,for the erformance of the work for which this compliance with the Cupertino Municipal Code.Chapter 9.12 and the Ileallh S
p Safely Code,Section 25532(x)should I store or handle hazardous material.
permit is issued. Additionally.should 1 use equipment or devices which emit hazardous air
I certify that in the performance of the work forvvhich this permit is issued.I shall contaminants as defined by the Bay Area Air Quality Managemem District 1 will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Nunicipal Code,Chapter 9.12 and the
Compensation laws of California. If,alter making this certificate ofexemption,I Ilealth S Safely Code,Sections 25505,25533,and 25534.
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 O"'tier or amhorized agent'
Date:
A PPLICANI'CEITI FICAT'ION CONSTRU711ON LENDING AGENCY
I certify that I have read this application mid stale that the above information is
correct. I agree to comply with all city and county ordinances mid state I:nvS relating I hereby affirm that there is a construction lending agency for the performance of work's
to building construction,mid hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Cie C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemmnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCII ITFCI"S DECLARATION'
9.18.
I understand my plans shall be used as public records.
Signature Date
Licensed Professional