12080182 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11431-IOLLYI-IEAD LN CONfRACR)R:AFFORDABLE WATER PF-RNIITNO; 12080182
II EATERS&
OWNhR'S NAME:
VALENCIA.CA 91355 PHONE NO:(661)259-7131
❑ LICENSf:D CONTRACTOR'S DECLARATION 13UILDING PERMIT INFO: BLDG r ELECT r PLUNIB r.—
License
License Class Lia N
NISCH r RESIDENTIAL r CONIDIERCLSL
Contractor Date
herebc affirm that Into licensed under We provisions of Chapter 9 JOB DESCRIPTION: RI?PLACE WATER HEATER,SAME LOCATION
(Coil] with Section 7000)of Division 3 of the Business&Professions
Code and that ON,license is in full force mid effect.
hereby affirm under penally of perjury one of the following two declarations:
I have and will maintain',)certificate Of consent tO self-insure Ibr Worker's
Compensation,as provided for by Section 3700 ol'the Labor Code,for the
performance of the work for which this permit is issued Sq,Ft Floor Area:0 Valuation:$2179
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the perfommnce of the work for which this
permit is issued. APN Number:36226019.00 Occuparity Type:
APPLICANT CERTI PICATION
I certify that I have read this application mud state that the above information is
correct.l agree to comply with all city and county ordinmucesand state laws relating pERn11T EMPIRES IF WORK ISNOT 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•ofCupertino against liabilides,judgment, 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 all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date:
9.18,
Signature Date
REI-ROOFS:
❑ OW'NER-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
hereby affirm that I am exempt from the Contractor's License Law for one Of inspection.
the following 1)%u reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contacting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETITR
construct the project(Sec.7044,Business&Professions Code).
hereby affirm under penaly of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: 1 have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California IIca11h&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 I Iea11h&
performance of work for which this permit is issued Safe(y Cuda Section 25532(x)should I store or handle hazardous material.
I have and will.maintain Worker's Compensation Insurance,ws provided fbr by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the perfornumcc Of the work for which this coulnminanls as defined by the Bay Area Air Quality Management Dis'riel 1 will
omit is issued. maintain compliance wilh the Cupertino Municipal Code,Chapter 9.12 and the
p
I certify that in the performance of the work for which this pennil is issued I shall Health&Safely Code,Seetions 25505.25533.and 25534.
not employ any person in Try mmamer so as to become subject to the Worker's Owner or authorized agent:
Compensation laws of California. IL after making this certificate of exemption,I Date:
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. CONS'TRIICI'ION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT'CERTIFICATION for which this permit is issued(Sec.3097,Civ Q
I certify that I have read this application and state that the above information is Lender's Name
correct.I agreeto comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ,V3CI11'I'ECI"S DECLARATION
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1143 11OLLYHEAD LN CONTRACTOR:AFFORDABLE WATER PERMIT NO: 12080182
HEATERS&
OWNER'S NAME:
VALENCIA,CA 91355 PHONEN'O:(66089-7131
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG C ELECT I_I PLUMB (_
License Class Lia N
M1I F.CII RESIDENTIAL J COMMERCIAL —�
Contractor Date
hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE WATER HEATER,SAME LOCATION
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two 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. Sq.Ft.Floor Area:0 Valuation:52179
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. ANN Number:36226019.00 Occupancy'rype:
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above information is
correct.l agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF 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 all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date:
9.18.
Signature Date
REI-ROOFS:
❑ OWNER-RUILDF,R DECLARATION All roofs shall be inspected prior to any roofing material being installed.Ira roof is
installed without first obtaining an inspection,I agree to remove all new materials for
hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
hereby affirm under penalty of perjury one of the following three IIA-LARDOUS\L\TF.RLU S DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Ilealth&Safety Code,Sections 25505,2.5533,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&
perfommnce of the work for which this permit is issued. Safely Code,Section 25532(x)should 1 store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should 1 use equipment or devices which emir hazardous air
Section 3700 of the Labor Code,for the perfommnce of the work for which this contaminants as defined by the Buy Area Air Quality Management District I will
ermit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
p
I certify that in the performance of doe work for which this permit is issued,I shall Ilealth&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's Owner or authorized agent:
Compensation laws of California. If,alter making[his certificate of exemption,I (late:
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. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANTCERTIFICATION 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 and state laws relating
to building construction,and hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ,\RCII I'I'FCI"S DECLARATIONcosts,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date