01090017 CI OF BUILDING mviSiONNDPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21682 OLIVE AV HOT WATER INC 01090017
OWNER'S NAME: APPLICATION SUB DATE
�hgQIANG XU 2531 GRACELAND AVE 09/05/2001
141"HONE: (650) 298-8494 SANITARY NO. CONTROL NO.
C s z ARCHITEC iENGiNEER: BUILDING PERMIT INTO
z O O BLDG ELECT PLUMB MECH
yi�
=yi i LICENSED CONTRACTOR'S DECLARATION Job Description
I z v_C I hereby affirm rho I am licensed under provixions of Chapter 9(commencing
,aF; with Section]0001 of Division3 ofthe Business and Professioro Code.and myliceam E
' rs in full force and effect.
z z a License Class Lic.p
LL0 n V Date CO EKAor
e0.ri ARCHITF.Cr'SDECLARATION
I underxwnd my plans shall he used oo public remNs a'
�i p
I 6 p p Licensed Professional
Oan I it,B mole In DECLARATION
1 nereny alBr�n than 1 am eannpl rron,me cammamr'x license Law
Z C following mnxmt.ISecrinn]Ol LS.Busincse and Professions Cntle:Any city or county $500
SZ❑ which ry rc pant to construct. Im p demolish, repair' ysmcture
s.e:3pm•-P 9 applicant fin tiff fleesigned statement -
not t issuance,alwre arc thine IIs nt r such rn
(cooth4sltt wahSe l6lt !hepo wits of the t t dor Lc La (Chapter9 r.. C a , Valuation
or
gwkhgecuonoman the ba n3 ftp l sine dion. ions Code) .3�T'L S'�V4 ,'lTV ts�• ' s
or that be¢exempt(heirloom dm and the basis for bj cts th A applicant to Any violation
—of Section]031:5 by any applicant for a permit subjects the applicant to a civil penalty
ofnot'morethanfivehundreddouars(sso0). 502�PN'9'�tt4 PLUMBIN ENERGl'OccupancyType
D 1,as owner of the progeny,Or my emplayces w ith wages as their sale compensation.
"will-da the'work,and the s«uctuu is not intended or offered for sale(Sec.7044,
Business and Professions Code:The Contractor's License Law does not apply to an 507 — FINAL PBRlafi$Mspeetions
owner of popeny Who Wilds or improves thereon,and who docs such work himself
or throw h his o_wn employees.provided that such improvements are not intended or
,or
or idle If.however the building e I improvement is that he
one year of .,
improve for purpose
ofW it.).will have the burden of proving that he did not Wild or
improve far purpose of ale.). '
O 1.as owntt of Ne pmpeny,am Business and
Part it with licensed a Cimmmrs to
7-1 anstrvn tM1e project(Sec. to a Business and Property
who
Cotler)The improves
ffe on. _
License Law does not apply m an owner of progeny who builds or improves d¢rton.
and
.who"Lho ts.focwch pmjccu.with o commnogs)licenxd.purwam to the - . . _ ... .. -. .._. - _.-.
C 1 mncoes License law.
- ❑1 em exempt under Sk.. :B&P,Qfor this rtawn
0.1 Date' _
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penahy or perjury one of the following declarations:
❑ 1 have ead will maintain w Coilifictim of Cucsenr rb self-insure for Worker's
Compensation, as,provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
_ ❑i have and will malntnin Worker i Cnntpensminn,lniuri as'icgmr by Section
37W of the Labor Code,for the paannance of the work for which this permit is
issued.My Worker's Comps Policy number art:
., .,_ ,•• nsmion'Insumnce carrier and � _ ,. ^ _ ,y.�•, _ ...., .. ..
Comer._ Policy No.:
it"t'CERTIFICATION OF EXEMPTION FROM WORKERS'; ' •`
•rn *-'r:.- COMPENSATIONINSURANCE , .. . .._ .--__,. -. ......... ._..__..,._.. ._ .. . -_ _... .._.... .__.__.
'�This section rieeJ mol be completed if the permit is for drat hundred dollars
n 100)or lay.) „I
issued.
a .. _ -... .- ..�-... . _ ..... .. ..
amply iM1at in the performance,not of the work for which this permit a issued,1
shill snot employ any pawn in any manner.w vs m became object to tfic Workers
Compensation lag"of Caiifomia.Dae
IN come subject
APPLhe ANT.Work If.is after Compensation
this Ccnin s of of Labor Eatontown. .youou ould
most
Wcomccom the Worker's Compensation provisions of the labor Code,you must
z O forthwith comply 2.with such provisions or this permit shall be deemed revoked.
F`7 CONSTRUCTION LENDING AGENCY-
•'- °'I he i:by affirm that there is a construction lending agency for the Ferranti.e
all of the warkfor which this permit is ivuma(Sec.31197,Civt C.)
Q 'Lender's Name".
S Lnidm's Adds'
VYZ •p n -
.Q 1I agree that I have rend this application and orate that the above information is
coma.Ig con to comply with all city and county ordinances and site laws relating
the 0wingcontimisdan,and fiercinspectionpepre.umarives of this city to enter upon
+�s<r� the abo(We) m.to property far inspection kepurposes.,
�y 6s
(We)agree ro save,indemnify and keep harmlces the City of Cupertino against
Fro'W liabilities,judgments,coxes and expenses which ars,in any w"y acerve against said
G; City in consequence i rhe gmming D this permit. /,,ff1/Iy)� '
APPLICANT UNDGkSTpNDSAND WILL COMPLY WITH ALL
NO ISSLLed by: "� Date
SOURCE'REGULATIONS:.I I I'' ' '.
Sigppq,rcornpgre.hocant,ucm.:,.. .pate '- Re-roofs
HAZARDOUSMATERIALS DISCLOSURE
W'll the applicam or futbrcbIlding p4ntreorh dl hvmdous maerial _'I)rpe Of Roofi
as refined by the Corgartirs,Mun mpul,Code Chapter 9.12.and the Health and Safety
Cade.Section 35532(a)rl,'r, .. I.e r R,a:.. .. ,: ,.. . i •f� �.(
Dyes . 0Noi All roofs shall be inspected prior.to,any.roofing.material being installed. ..
Will the applicant or ramre building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit harardous vv comaminant as defined by the Bay Also Art Quality Management
Dhuief! all new materials for inspection., Applicant understands and,will comply with
oyea( -- -- :,GKd - all non-point source regulations.
I'have read the liaurdoux'materiels requirements'under Chapter 6.95 of the
Celifomia Health&Safety Code Sectiom 25505.25533 and 25534.1 andevmnd that
if rho W ildinB does Clot armntlY hove a tenant,that it is mY rtaponsibility to nbtifY the
dccupmn of the raltmeradnv which most be mer prior m issuance of a Geri of
v ° "p'"ry' Signature of Applicant Date
owns.pr isuthodeed agent - Data All roof coverings to be Class"B"or better
s
.. .. _. .. - - OFFICE