01050205 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGADIIRESS: PERMIT NO.
148E HOLLY OAK DR HOT WATER INC *' -- 0105020
OWNER'S NAME: - APPLICATION SUB DATE
JUNG HENRY H AND MI—YIIXI M 2531, GRACELAND AVE 05/31/2001
IONS: SANITARY NO. - CONTROL NO.
_.(650)298x8494 .
u�i O O
ARCHITECT/ENGINEER: BUILDING PERMIT INTO
wUZ E FILED ELECT PLUMB - MECH
aFia 6 a IC CI LJ CI
Z y Z LICENSED CONT'RACTOR'S DECLARATION 10b Description
O Z-p 1 Immhy afFinn IMI 1 am IleensW under'provisinna of Chap¢r Y(coamnencing - P
pv, ce wiih Sec,ion]fN10)ol'llivixion3 of the Buainexa and Pmfcwinne Gnle,and my Bcmtae -
aiammll tome ane ermm.
„Ise Class REPLACE WATER HEATER'.
S!3 ar V Date Contractor
[[JJ ARCHITECT'S DECLARATION
O 1 unecrstunA my plans shall he aced as public reainls
E }
OO Isccreed Pmlessmall
i6s e•� OWNER-BUILDER DECLARATION
w=m 1 hereby affirm dint 1 an,exempt front the Gmo-adir's Licenw Law for the
Z< following maim.(Section 711315,nosiness and Professions Code:Any cityor county
Fx❑ wh I r coni permit t c i t Iter,a tprove.de nil rep y structure
a = pr rt t s it1 theapplicant for such porno II :'g dI foment
that he is licensedp t to the marViSiterSofineContracti License La (Chapter9 S Ft. Floor Area Valuation
(cunmcncing with Secton]00)of Division 3 of the Business and Pmfcion,Code) q'
it In.,he is exempt thercrmm and the hosts fill the alleged exemption.Any vo.lmoa^
of Section 9031.5 by any applicant ora pemiit auhjena Me application,a civil porgy ..'
of nw m,reman Five handl d,Bara($500). APN Number Occupancy Type
❑I,is owner ofthe pinpeny,carry employees with wage.Its their sale u,mperemian, 3620e^^029. 00
will dothe wick,and mo wouemre is no,intended or offered tot sale(See.WILL
Business d pro f Code The Court L nae Law deal al apply to nn Required Inspections
w fp pay Whoh Id p.. thermal, ad who d Inh cm himself
'
.nice through his own employees,provided that such' prove t intended or 502 — FINAL .PLUMBINGENERGY"
oflercd for aide.If,how,ser,the building or nnpmvemem is sold wimtn one year,of
lindrn,n,the owneirledfder will have the Auden oprovng te did not build or
fihat h 506 — GAS TEST
i�npreyeforpurposeofsale.). 507 — FINAL' PLUMBING'
131,as covacr,nne property,ant esclus,vely eomramtng with Ittccowd ewnmcun.to .
tnsinmt the project(Sec]04Each-4,Eh—and Professional CW 's
c:)The Creurn '
License Law does not apply nes in owner of property who builds or improves thereon,
and who contracts for such projects with v•conapac¢,rG)licensed pursunnl ,d the
G napanely License Law. -
❑Inmexentp,undo,See. ,B&P C for this re:uon
Owner Date
' WORKER'S COMPENSATION DECLARATION -
I hereby offinn under penalty of perjury one if the fallowing declarations: �,n n -
7 1 have and will mnimvin a Ccrificate of Conrem ,o self-itchfor Worker's v- .�V/� D
Compensadurd as provided fm by Section 3]0,1 of the Labor Code, for the
performance of the work for which this permil is issued
❑ O 2001
1 have add will mnimnio Work,,*,Compensation heamce
d ,as mqulred by ScOid. JUL
3700 of the I.nbir Code,lot the performance of the work for which this perno,j, t.
sued.My Wocah'i Csnnpensmion Imurunce caner and Policy number Ire_: -
Carrier Pill,No: BUILDING
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be eindicted if the permit Ix Toro..hundred dollars
($1110)or less.). -
1 certify that in the parromwnce of the work for which this permit Is issued.1
shall not empty any person is any manner son ax to become subject to loo W..kery - ^
Compeouniin Laws of California.Date q
Applicant -
-NOTICE TOAPPLICAN 1:If,afiermakagmis Cedilicvmof Exemption,you should
Q Oobeansubject to the Workers Compensation provisions of the LahrCode,younnta
forthwith cnalf,with such proviainns or this worm,shall be deemed mvokud -
F .fin
CONS em is a c(INLENDINO AGENCY ,
a 1 hereby kfor affirm that them ass roued(Sol, lending C agency for performance
W Of theLoohdo work for whicM1 this permil is issued(Sec.309],Cie CI -
z Lender's Nume
Q' Lenders Addmss '-
U 0 1 certify 0th 1 hove read this application bad ante that do curve information a -
WT tti correct.I agree to comply with hall city and county ordinances and state laws relating '
0 U to huilding ennsmmtina.und hereby nuthorwe mpre,ofilives if this city to inner upon `
i4. rW the above-mentioned property for inspection purposes. .
(� p. (W)al.It, e indemnity ad k cp lai the City of Cupertino,ag lost
fir m liabilities.judgments,costs and-expenses soIF tell troy in any as iy rearne agad not slid
U � City ill consequence of the granting of has remit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS, Issued by: - Date
Stgnmumpf Applicant/Cnolonel - Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE '
Will the applicant or future building(occupant store or handl,anomalous materiel Type of Roof
as defined by the CuplaNno Municipal Code,Chapter 9.12,and the Health and Solely '
Code,Seddon 2553200? -
area EJ No All roofs shall be inspected prior to any roofing material being installed.
Wid the vppluout future building oAtivnt ase ,manual or devices which If a roof is installed without first obtainingan inspection, I agree to remove
mil havudoux air contaminants as refund by the Bay Area Air Quality Management P g
DiatritaoY a Cl No all new materials for inspection. Applicant understands and will comply with
all.non-point:source regulations.
1 Mrve read the an,andous nedleals regnirmems under Plot 6.95 of the
California Health&Safety Cn 1,Sections 25505,25533 and 25534.I understand that
if the build,or does not currently Its,,a natural, I'll,it is my responsibid i,y,,he tfy the -
occupant of the rcyuiremems wtied bout he,tet prior to issuance of a C,mi of
Occupaimy.
Signature of Applicant Date
Owneror:mthori:ed agent Da,e All roof coverings to be Class `B" or better
OFFICE _. _.