12100002 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 10209 NILE DR CONTRACTOR:IIOFFMAN ALBERTA ET PERMITNO: 12100002
AL
OWNER'SNAME: HOFFMAN ALBERTA ETAL 10209 NILE DR DATF, ISSUED: 101012012
OWNER'S PlIONE: 4089738348 CUPER'TINO,C\ 95014-2143 PHONE NO:
❑ LICENSED CON'URACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG (- ELECT r. PLUMB C-
License Class Lic.N
p1EC11 C. RESIDENTIAL(-1 COMMERCIAL (-
Contractor Date
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE ELECTRIC WATER HEATER WITH SAME.
(commencing w'ilh Section 7000)of Di%isinn 3 of the Business S Professions
Code and that my license is in fall force and effect.
I hereby affirm under penalty of perjury one of the following Iwo 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 Vnlualion:$1000
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of die work for which this
permit is issued. APN Number:36950030.00 Occupancy Type:
,%I'I'LICA,N 1'Cl?R't'IPICATIO\
I 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 harmlessthe6tyofCupertinoagainstliabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of die
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: Dale:
9.18.
Signature Dale
RE-ROOFS:
❑ O\YNER-111111DER DIsCLARATION 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 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 S Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO RE CLASS"A"Oil BETTER
construct die project(Sec.7044,Business K Prol''essions Code).
I hereby affirm under penalty of perjury one of the following three IIA'/.ARDOU3 NIATERLO 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 Ilenith S Safely 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 Cuperlino plunicipal Code,Chapter 9.12 and the Ilcalth S
performance of the work for which this permit is issued. Surety Code,Section 25532(a)should I store or handle hazardous material.
Ihave and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the perfomance of the work for which this contaminants as defined by the tiny Area Air Quality;Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.1_and the
Ilcalth S Safety Code,Sections 25505,25533,and_5534.
1 certify that in the performance of the work for which this permit is issued.I shall
not employ any person in any manner so as to become subject to the Worker's Owner or authorized agent:
Compensation laws ofCalifomia. If,after making this certificate of exemption,I Date.
become subject to the Worker's Compensation provisions of the labor Code,1 must
forthwith comply with such provisions or this permit shall be deemed revoked. CONS'IRHCTION LENDING AGENCY
1 hereby alTmn that there is a construction lending agency for the performance of work's
,\I'PLIC\N'T'CT,R'1'I1:IC 'I'ION for which this permit is issued(See.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 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,
costs,and expenses which may accrue against said City in consequence of the ,U2CIII'I'IiCC'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply I understand my phis shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date