12090237 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21085 LAURETTA DR CON'"1'RACTOR:FAST WATER HEATER PERMIT NO: 12090237
OWNER'S NAM F,: RICHARD BOGART&MIRIAM ACOSTA 12601 132 AVE NF DATE ISSUED:09127/2012
OWNER'S Pl IONE: 4086749431 KIRKLANIL\1'A 98034 PBONENO:(800)4S1-89.55
❑ LICENSED CON'TRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT rI PLUMB(-t
License Class Lie.N
1'IEC11 r RESIDENTIAL r COMMERCIAL r
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DE SCRI PTION: REMOVE AND REPLACE GAS WATER[WATER IN
(commencing with Section 7000)of Division 3 of the Business&Professions EXISTING
Code and that my license is in full force and effect. LOCATION
herebyaffirm tinder penally'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 lire Labor Code,Ibr the
performance of flic 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 Sq.Ft Floor Area:0 Valuation:$1045
permit is issued.
APPLICANT CERTIFICATION APN Number:32655009.00 Occupancy Type:
1 certify that I have read this application mid state that the above information is
correct.I agree to comply with all city and county ordinances:old state law's retail ng
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting ofthis permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Sectiai
9.18.
Issued bv: Date:
Signature Date
❑ O\VNF.R-BUILDER DECLARATION
RI ROOFS:
hereby affirm that Iam exempt from the Contractor's License Law for(tire(If All roofs shalt be inspected prior toany roofing material berg installed.Ira roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sce.7044,
Business&Professions Code) Signmure of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed conlmcurs to
construct the project(See.7044,Business R Professions Cade). ALI,ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm tinder penally of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's 11,\7.,\RDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements tinder Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code.Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided Ibr by compliance yvith the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,tar the performance of the work for which this Safety Code,Section 25532(11)should I store or handle hazardous material.
Additionally,should 1 use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
not employ any person in any manner so as to become subject to the p'orker's Ilealth&Safety Code.Sections 25505.25533,and 25534.
Compensation law's of Cali fomia. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,t must Owner or authorized agent:
forthwith comply with such provisions or this permil shall be deemed revoked. hare:
CONSTRIICIJON LFNDfNG AGENCY
APPLICAN"1'CERTIFICATION
I certify that I have read this application and state that the above information is I hereby aff ren that there is a construction lending agency for the performance of work's
correct. 1 agree to comply with all city and county ordinances ad state Imus relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to cater Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino againstIiabililies,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCIIITECT'S DECLARATION
with all non-point source regulatiaus per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature Date Licensed Professional