03120116 CITY OF COPEICHNO '"" �' 'mal t� .a'l' '� '• ''- r<=
BUILDING DIVISION PERMIT CONTRACTOR INFORMATN
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ftU ILDING ADDRESS: HAK KIM PERMITNO 031201.16
OW NER'S NAME: PERMS ISSUE DATE
HAK KIM 19 /92 /2nn-�
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMS MECH
0 0 0
uoo LICENSED CONTRACTOR'S DECLARATION Job Description
y V u I hereby affirm Ibat I am licensed under provisions of Chapter 9(commencing P
_Zm with Seed.,700(unf Division Bof the Rom nessand Professions Codeffnd my licence is
Limuefarm Class den"` REPALCE WATER HEATER
o�Z
License Class Lk.a
nF W Dale COnlDECL
Zj As 0.11 x use DECLARATION
1 understand my plans shall he used az public records
,,FU
l o s Licensed Professional JAN 2 1
OWNER-BUILDER DECLARATION 2004
ia Y 1 hereby affirm that I am exempt from the Cromaaor's License Law for(be
00 fallowing mason.(Section](111.5,Business and Professions Code:Any city or county
K m which requires a Proah to construct,alter,improve.JcmOlmli,m repair any structure
prior to its issuance.also acquires the applicant!orsuch permit to file aligned statement
i< that he is licensed pursuant o the provisions of the Contractor's Liccnu Liw(Chapter 9 Sq. Ft. Floor Area
(commencing with Section WKXB o(Divieion 3 of the Business and Professions Crate)or
y _
that he is exempt therefrom and the basis for the alleged exemption,Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 38 )4I`IDIAT&er00 Occupancy Type
not mom Wan five hundred dollars(5500). P Y YP
❑I,az owner critic property,or my employees with wages as their sole compensation.
will do the work,and the Struma is not intended or offered for sale(Sec.RWa,Business
and Professions Cade:The Contractors License law does not apply to an owner of Required Inspections
progeny who builds or improves Ihemon,and who doessuch work himself orthmugh his
tun employees,provided that such improvements are not intended oroRered for sale.It,
however.Ne building or improvement is sob within one year of completion,the owner-
builder will have the burden of proving that he did not build or impmse for pufpose of
sale.).
1,as her of the property,am emotively contracting with licensed contractors to
construct the projm(Sec.]Bra,Business and Pmfesslam Code:)The Contractor;Li-
come law does not apply On an owner of property who Wilds or improves themon,and.
who contracts for such projects with a contractoos)licensed pursuant o the Contractor's
eau Law,
1 am caempr under Sec. .B&P C far this moon
�i
Ow r �".i�- i a r� ii a Dam
//WORKERSrSO�ATION�DIIPA-ARATION
I hercbyaflirm under penalty of perjury am of the following declarations:
I have and will maintain a certificate of Consent o self-insure for Worker's Compcm
ration.az provided for by Section 37Mof the Labor th
Code,for e performarec of the
work fm which this permit is issued
❑ I have and will maintain Workers Compensation Insurance,az required by Section
nof the Labor Code,for the pef(ormarim of the work for which this permit is issued.
y Worker's Compensation Insurance carrier and Policy number art:
Carrier: Policy No.: _
CERTIFICATE OF EKEM MON MOM WORKERS'
COMPENSATION INSURANCE
(This Section need not he completed if the Permit is for one hundred dollars(,IIA))
or les.)
I ccnify that ice he perfonnancc of the work for which this permit is issued.I shall nm
employ nypes manncrsn asmbecome subjem9lhc Workcrs'Cnmpensatinn
laws fCalif I
Appl�t%ryry✓✓ 6/ r
NOTme sor, APPLI ANT:If.after making this Certificau of Exemption.you shrub
We hject to the Worker's Compensation provisions of the Labor Code.you mus
.,Z forthwith comply with such Provisions of this permit shall W deemed mvokcd.
Z O CONSTRUCTION LENDING AGENCY
[-+ I hereby affirm that Nett is a construction lending agency for the performance of
CC the work cur which this permit is issued sec.5091,Civ.C.)
W Q Lender,Name
O+
z Lenders Address
]
t.)Q 1 ccnify that 1 have read this application and sure that the above information is
0 U e Wilding
Iagreectcomply withal!city and courtlyoNinantta this city
laws
rupong e
QU .1how-gconstrul propend herfor ms,uthorim representatives of thiscitymcnterupnn the
� 4 above-meat)agree 1.Saw,rty for adpurpmear ,r
F
(We)agree to case,indemnity and tech harmless the City of against S id City
N incoitieajudgmcnh,granand eapcmcrmit. may in any way accmc against said City
V z A APPLICANT
of the UNDERSandTANDS
of this permit.
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date f
SOURCE REGULATIONS.
i�
of AilCmumRe-roofs
of, pplca ate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant sore or handle hazardous material
az defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
101.Lodi SCction 25532(a)?
C] NAll roofs shall be inspected prior to any roofing material being installed.
Will the apldicantor future building occupant me egnipmenl or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants defined by the Bay Area Air Quality Management all new materials for inspection.
ismer?
0Yes No
1 have mal the hammous materials mquirenni under Chapter 6.95 of the Califor-
niaHcalthhSofcty COdc,SccuomJ M.35533and2 5Ja.lundcrsundthui0hr Wilding
docs not morenlly have a tenant,that it is my reaponsihility to notify the occupant of the
myuimmcns which mus Mmes prior to issuance ofa Ccnifreau of Occup y.
12 Signature of Applicant Date
owner nrLed agent 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. -fi/ 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
be performed
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 Owner's Signature:
2 r Date:1 �2 22
Job Address: 11. _32- /iJt"_Y;x 52n�� f
6L Permit# I " /
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
City of Cupertino Building Department
CITY OF 10300 Torre Avenuqft
C O P E IST I N O Phone (406)777-3
Dear Property Owner.
An application fora 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 yourself 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 carry 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 confirm 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
aua WATER HEATER o3 t z " l l b
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
32 & S t C
Owner's Name: Phone#:
f J 410 P — .2 2— 7/ 7 2
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg l Elect ❑ Plumb ❑ Mech ❑
Job Description:
P n�
Residential Commercial ❑
Cost of Project:
Strapped ❑ On PlaifofEl
p� Bonded ❑
r� New Location ❑ Replacement
QtY. .
A c 1 e Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING