06010147 CITY OF CUPERTINO '_�_• a +' '�' �' W
BUILDING DIVISION PERMIT CUNTRACv': UR.�TIVFOMA' IO.1�I �;
BUILDING AD00.ESS: PERMIT N0.06010147
1.1 MIRA VISTA AV
NER'S NAME: PERMIT ISSUE DATE
TSAI TSAO-TUNG AND CHIHUI 01/26/2006
NE: SANITARY NO. CONTROL No.
ARCHInCT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB PARCH
r�oo LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that 1 am licensed under provisions of CMpler 9(commencing
i wthScam,orceAn 7110l Division non3afumBuatnwmdPro(s onaCode,atMmylicemcia REPLACE WATER HEATER
'+ In full force end GGMt.P _Z6 999
;a2 LkeamClat'_6vr . �U`l _ - CONTRACTOR: GREAT WESTERN RLUMBING.13n
Dam !/ L Commewr •�
ARCHITECTS DECLARATION
1 understand my plans Shell be used as r public records I l` —7-
2006
k rats Licensed Pmfeaimal •�f.•^ L
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am esempl from the Contractor's License Law for the s
0 0 folbw1 mean.(Section 7031],Business and Fmfeaslum Cade:M ail or count �1r'pI' �rrJJJ tt't
$ which requlrea a permit In comma,alter,improve,demolish,or repair any structure t I I_ rI Il `i
_ Prior to its iauanew alae acquires the Applicant(orsuch permit to file a sigiontumment
ii
that Wto;licensed pursuant hat dim provision ofUmCommu'sLicenaLaw(Chapter 9 Sq.Ft. Floor Area Valuati - 5
$ (commncing with Sccdon7000)of Division 3 oftha Bualnessmd Profcaiam CO,I
— that WO u"•-rpt tomorrow and the Much for dm allcZal exemption.My violation of
secdon 7031.5 by any applicant for a permit Subjects the applom In a civil penalty ofpA um b r Occupancy Type
not mom tion fin hundred dolless(s300k 3 7��u 4 T. 00
❑1,u awns of that property,a my mnployees wIN cages u thew sole mmpewtion,
will do Ne work and thatimmum isnotlmmuded oroRered far ale(Sec.IDN,Business Required Inspections
and Pmfe sus.Code:The Conuacmr's License Law does not apply man awns of q P
property who Wilda at impmvuthereon,and who doessuch work himselforduough his
own employes.provided that such improvements are nothrended aroRmnd for We IC
however.the building or improvement Is mid within one year of completion,the owner
bander will have the burden of proving that M did not Wild or improve for purpose of
am.).
Q I.AS owner of the property,am selusively canuaNng with licensed comrmmss m
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Lt•
came law dos not pply in an owner of propenywim Wilds or improves dtemon.red,
who comas,for each projects with a cora ter(S)licensed pursuant an the Cmannu fa
License Law.
Q l am esempt under See .B k P C for this mason
Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury aro of thus following declarations:
I have and will malnsatn•CeAfim¢of Consent he SelFlmure for Wench Camper
satiun,As provided far by Section 370D of the tabus Cade,toe dm performance of that
MASS:for which this permit is issued.
[141mve and will mainuin Waftes Compensation IruWance,As required by Section
3700 of the Labor Cade.fur the performance or the work fm which this permit is issued.
My Worker's Computation Imtmnce/artier and Policy number are;
— E � `Polry No.:Caller. 5f!FI0HP ION
PROM WORKERS'
COMPENSATION INSURANCE '
(This ad.reed rust becompleted lfdm permit 4 forces hundred call.($1011) -
mmaa.)
1 certify that in the performance of the work for which this Permit 4 issued,l Shall not
employ any Perron in my Manor AS At Wcome mbjat to the Workma'Compemtion
taws of Califomla.Dam
Applicant
NOTICE TO APPLICANT:If.After making Nis Cenlrraam of Esemptian,you should
become subject in the Worker's Compensation provisions of that Labor Cade.you must
.,O foMwith comply with such previsions or this permit Mall be deemed revoked.
Z► CONSTRUCTION LENDING AGENCY
[—i I hereby arrm that them iso construction tending agency for the performance of
!Yi 7 the work for which this permit 4 issued(Sec 3097.Civ.C.)
GQ Lendae:Name
Z Lender's AAdrw
U 0 1 cenily that 1 haw rad this application and sum that the aWve infomatiun 4
V corms,1 agrte to comply with all city and county onlinanees and Sum IoW!relating to
0 building construction.and Wmby authodxe repmxenmiws ofthis city mcmer upon the
W abovmmemioned pmpeny for Inspection purposes.
a (We)Agree to an,Indemnify and keep harmless the City Of Cupertino against
cj liabilities,judgments.costs and expenses which may In my My amus al Wit City ' /I
r^ ^ "D
U In consequence of the Sroll.&of this permit. Q
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON•POINf Issued by: Date
SOURCEREGULATIONS
y• � i%� z--lv 6 Re-roofs
slgnatum of Applicm✓Conummr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum Wilding occupant store or handle haurdous material
turned by dm Cup"no Municipal Code.Chapter 9.11,and the Health ad Safety
de.Seman 15531(.)? All roofs shall be inspected prior to any roofing material being installed.
Oyu 13,W
Will the applicant or future building=upon(Im equipment or devima which If a roof is installed without first obtaining an inspection,I agree to remove
It hgardaus air conuminanot As defined by the Bey Area Air Quality Management all new materials for inspection.
Ionia?
Q Yes QNo'
I have mad the Wardous mamrials requirements underompter6.95 of the Califon
nice Health d:SafetirCede.Sectimu 15505,25533 aW25534.I understood one true Wilding
does not currently how a moan,than It h my womomihility,m notify the occupant ar the
requirements w�most Wryypriar a ate ar.camrre.mafoyxapamy/ Signature of Applicant Dale
Owner ar,atn`o aagem(fy % /ZED All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
allo
Cupertino CA 95014
Telephone(408) 777-3228
Fax(408)777-3333
�
jUPEI�TINO ,
Building De artment
JOB ADDRESS: PERMIT#
0 '-2�. 9 (q /11 i 0 A V i s rA A v 1. . C50/1-/ U�,"/ oI
OWNER'SNAME: Sv,j)v 7-AS1 PHONE # yCg X17 &-967L
GENERAL CONTRACTOR: 08 A y/ -F/ods �/ FAX # o y S.z - 9 i 7
I am not using any subcontractors:
Signature— Date
Please check applicable subcontractors and complete the following information
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing (;2F T WC5rE2.v cuh�n
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
• % /z�/oma
Owner/Contracto Si a Date
1r
CITY OF CUPERTINO
WATER HEATERD
CUPEkTINO PERMIT APPLICATION FORM
APN# 3 ,S7 Date: / Z /0
Building Address:
/ 03 M i2A V, rA Avg L) CA %5�/h'
Owner's Name: Phone#:
T S 1 ob 873- 7Z
Contractor: I I License#:
Cii1 CL It /e S e r✓ ✓t of 7
Contact: A y Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb IF Mech ❑
Job Description:
tie 19/.Ac.E WArE,tHE rr-4
Residential Rf Commercial ❑
Cost of Project: 175v .0
r
ed On Platform Bondedocation ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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