03090168 CITY OF CUPERTINO
BUILDING Dlvls)ory PERMIT y�CONTRAOTO INFORMATION
tA, 9:
Bl11LDINGADDRESS: NEIL .•HANG PERMIT N0.03090168
OWNER'S NAME: PERMITMUEDATE
INC: SANITARY NO. CONTROL N0.
HITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o o LICENSED CONTRACTOR'S DECLARATION CJ O O O
F 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
E?Nwith Section 7gkq of Division Sof the Business and Professions Cnde.and mylicensa is
in full force and effect. REPLACE WATER HEATER
st2Z Loeme Class Lk.k
�
ARCHITECTS k u atTECTS DECLARATION FINAL
M®
< 1 understand my planss shall used purecorecords ■moi
M1lic cn
s
JyU
a
Licensed Prnfcsximnel
OWNER-BUILDER DECLARATION
e Law for lM1e FEB 0 9 2004
<y 1 hereby affirm that)am exempt from the Contractors Licens
cac following reason.(Section 7031.5,Business and Prole:sions Code:Any city or county
<m which requites a permit to Comlmct,alter,improve.demolish,or repair any stmcture 1152
poor In its issuance.also myuires the applicant for such Permit o fileasigned statementloll
a that he is Him osed pursuant to the provisions of the Contradtor's License Law(Chapter 9 a Valuation
2Fo (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or
Nal he is exempt therefrom and de basis for the alleged exemption.Any violation of 36616037 . 00
Section 7031.5 by any applicant for a permit objects the applicant to a civil penalty of ccu ane APN Number OType
not more man five hundred dollars 01501B. P Y YP
1,as owner of the property,or my employees with wages at their sole compensation,
will do the work,and the swcture is not intended or offered for safe(Sm.7614.Business b02 _ L A7,TTMT]T]S7j"2 Gt RGI'
and Prolessiom Code:The Cmu etors License law does not apply man owner of lEC'1Tj'tHN nssF>C
property who builds or improves thereon.and who does such work himselforlhrough his 506 - GAS TES
own employcm,provided lhatauch impreemenciamoot inlendedmrmrfeted mrsale.B. 507 — FINAL PLUMBING
however,the building or improvement is scold within one year of completion,Ne owner.
Wild.,will have the burden of proving that he did not build or improve fur pulp..of
ole.).
❑1.as owner of the property,am exclusively contracting with licensed emmiaeUms to
construct the pmject(Sec.7014,Business and Professions Code:)The Contractor's Li. .
cense law dors not apply to an owner of propeny who builds or improves Notion.and
who contracts for such projects with a eontracmr(s)licensed pursuant o the Contractors
L.O.Law.
liq lam c/m�.pI under Secy/ � ,B&PCfmdtisreason
Own ./l wig l Z /l Data 7
7 WORKER'S COMPENSATION NDECf.ARATION
1 hereby affirm under penalty of perjury one or the following declarations:
I have and will mainuin a Certificate of Consent o self-insure for Worker's Comfit
n,as provided for by Section 37M of the labor Code,for the performance of the
for which this permit lammed.
1 have and will maintain Worker's CompensmlOn Insurance,as required by Section
37W of the Labor Code,for the Performance of the work for which this permit is issued
My Worker's Compentation Insurance carrier and Policy number art:
Canner: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not k completed if the Permit is for one hundrnd dollars(5180)
or less.)
1 dimity that in the performance of the work for which this permit is issued,l shall not
employ any person in any manner so as to become subject to the Workers'Compemadon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Ccnificam of Exemption,you should
become subject to the Worker's Compensation previsions of the Labor Code,you must
.J$ forthwith comply with such provisions or this Permit shall k deemed mvokcd.
Z'O CONSTRUCTION LENDING AGENCY
'f. 1 hereby affirm that there is a comtmction lending agency for the perfurmanee of
LL the walk for which to.permit it issued(Sec.3097.Ci,C.)
IA Q1"ender's Name
7gL. z lenders Address
U Q 1 certify Net I have read this application and stem that the above information is
d, f-' correct.1 agree to comply with all city and county ordinances and state laws¢lacing m
0 U building comwction,and hereby authosne representatives of this city to inter upon the
mad!
r d ahove-ms,judgme ts.Propertycosts
for ie penes Purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
N incoiucajuce Of the cosuand expomeermit, may inany way accord against saidCity
V z A APPLICANT
of DERST ingot this permit, '
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date .
SOURC RE ULATI
g 0 Re-roofs
m
igoarca ApplicanUConuacmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle haruduus material
*A�
ad defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
We.Secuon 25532(.)7 All�Nu roofs shall be inspected prior to any roofing material being installed.❑Yax
Will the applicant or future building occupant use equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
til havufdnps On, noumm.m.;as defined by the Bay Area Ail Quality Management all new materials for inspection.
vicR IK
cycs C o
I have read the havafdnusmaterialsmquimmenu under ChaPmrb.95 of the Califon
ria Health&Safety COM,Secuum 25585.25533 and 25534.1 understand thm if the building
does not currently hove a most,that it is my nespunsihility to wtily Ike occupant of the
.qui enLwhich unk clptortoissuan¢ raCcrurcamofucupaney.
9 �- v" Signa[ureofApplicant Dale
caner or whofirsd agent Dam I All roof coverings to be Class "B" or better
OWNER-BUILDER VERIFICATION
1. (Check one) I or/my immediate family (parent,spouse or child) will perform:
A. v All the work authorized by this permit
B. _ A portion of the work
C. None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
uc ' ua-vau,cu
i
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer(see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
_performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side).
Property Owners Signature: JA ` ate: q 0
Job Ad ess: k 6 3 Permit# U
AU changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
. .
City of Cupertino Building Departmen
CITY OF 10300 Torre Avenu
C 1 I P E kT I N O Phone: 408 777-3
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified.
For your protection you should be aware that as owner-builder you are the responsible party of record
on such a permit. Building permits are not required to be signed by property owners unless they are
personally performing their own work. If your work is being performed by someone other than yourself,you
may protect vourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license number on all
permits for which they apply.
If you plan to do your own work,with the exception of various trades that you plan to subcontract,you
should be aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work
(including materials and other costs) is$200 or more for the entire project, and such persons are not licensed as
contractors or subcontractors, then you may be an employer.
If you are an employer,you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding, federal social
security taxes,workers' compensation insurance,disability insurance costs,and unemployment compensation
contributions.
There may be financial risks for you if you do not cavy out these obligations, and these risks are
especially serious with respect to workers compensation insurance.
For more specific information about your obligations under federal law,contact the Internal Revenue
Service (and,if you wish,the U.S.Small Business Administration). For more specific information about your
obligations under state law,contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale,property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees,without a licensed contractor or
subcontractor,only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder
building permit,erroneously implying that the property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they are performing
their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors'State License
Board in your community or at 1020 N Street,Sacramento,California 95814.
Please complete and return the enclosed owner-builder verification form so that we can confine that
you are aware of these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
Building Department,
City of Cupertino
Printed on Recycled Paper
CITY OF CUPERTINO 53 07014s,
WATER HEATER
CUPE(�TiNq PERMIT APPLICATION FORM
API # Date:
Building Address:
Owner's Name: n C " CT Phone#: ?- -Z-2:1-7 3
Contractor: .� �� Phone: License #:
/ DWn(�2 N AA252-2 .-73
ef
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plu Mech ❑
Job Description: RC-f>LACC i EA K i iJ C6(
Residential ❑ Commercial ❑
Cost of Project:
Strapped ❑ Pn Platform ❑ Bonded ❑
New Location ❑ Re laceme
Qty
App&abl Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
2, �
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