13060158 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20650 GARDENSIDE CIR CONTRACTOR:STREET PLUMBING& PERMIT NO: 13060158
ROOTER
OWNER'S NAME: OSWALD&VIRINDA D'SA 2293 WALNUT GROVE AVE DATE ISSUED:06/19/2013
OWNER'S PI ZONE: 4086897158 SAN JOSE,CA 95128 PHONE NO:(408)496-1155
❑ LICENSED CONTRACTOR'S DECLARATION f- I—BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:WATER HEATER REMOVAL AND REPLACEMENT IN THE
(comm encine,,ith Section 7000)of Division 3 of the Business&Professions SAME
Code and that my license is in full force and effect. LOCATION
I hereby affirm under penalty of perjury one of the following two declarations:
I have and\\i!I 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 I he work for which this permit is issued.
I have and N\I'i r,iintain Worker's Compensation Insurance,as provided for by
Sectinn 170 c Labor Code,for the performance of the work for which this Sq.Ft Floor Area:0 Valuation:$500
permit is
APPLICANT CERTIFICATION APN Number:36232034.00 Occupancy Type:
I certil`v that I h;rvc read this application and state that the above information is
correct.I agr to comply with all city and county ordinances and state laws relating
to building co isn action,and hereby authorize representatives of this city to enter
upon tl�::ib, _.rationed property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indene I:w:, ,harmless the City of Cupertino against liabilities,judgments,
costs.:::: \hick may accrue against said City inconsequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
gran Ii:,,_ r,uit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Date Issued by: Date:
Signature____
❑ It-BUILDER DECLARATION
RE-ROOFS:
I hrrel. I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed. If a roof is
the Ibllw, in.: n :,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 he !:i;!the structure is not intended or offered for sale(Sec.7044,
B LIS i:.. ,;s Code) Signature of Applicant: Date:
I,as —crty,am exclusively contracting with licensed contractors to
const: -c.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I florcl r rrnalty of perjury one of the following three
`lHAZARDOUS MATERIALS DISCLOSURE
I have and Im a Certificate of Consent to self-insure for Worker's
Colli!--:.!; , --d for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
Pei! for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I ho• ,Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Sec. Code,for the performance of the work for which this Safety Code,Section 25532(a)should 1 store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
1 c.r i, mance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I:;any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
C(-);11;v! ...:i -'i lbrnia. If,after making this certificate of exemption,I
be, leer's Compensation provisions of the Labor Code,I must Owner or authorized agent:
1..:. ,h provisions or this permit shall be deemed revoked. Date:
!'PLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I c.: is application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
c %ith all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
d hereby authorize representatives of this city to enter Lender's Name
ul property for inspection purposes.(We)agree to save
i,, ss the City of Cupertino against liabilities,judgments, Lender's Address
C may accrue against said City in consequence of the
ar: _ditionally,the applicant understands and will comply ARCHITECT'S DECLARATION
per the Cupertino Municipal Code,Section
I understand my plans shall be used as public records.
Date Licensed Professional