04030058 CITY OF CUPERTINO ,w7,,7,7777777-77-777,777,77777�
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BUILDING DIVISION PERMIT �,C0NTiU"0,T
BUILDING ADDRESS: WATER HEATERS ONLY PERMIT 11-0 4 030058
- 2n220 PTNNTA('F. PT<WV
OWNER'S NAME: PERMIT ISSUE DATE
Ig 1k AGNEW HUANG 970 F. MAIN ST STTIT� 200-- """ CONTROL NO.
IFNE: SANITARY C
(800) 835-
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDr ELECT PLUMB MECH
Z, LICENSED CONTRACTORS DECLARATION Job Description
;§w I hereby affirm Nat I am licensed under provisions of Chapter 9(commencing
with Section 70hob ofD!vision 3 of ft and d ProlessionsCode.ad my Heard is
fit" cl REPLACE WATER HEATER
a-ci;
gE
ARCHI,It� 1%160'76�1 0
an pu a rma�
fli Itmdorstad my plasma] records
0 U
it Licensed Porfia.si...I MAY 10 2004
OVVNER-BUILOSR DECLARATION
I hereby afflon that I am campt from the Contractod's License Low for the
p 0 following soman.(Sued..7031.5,Bilsbuossand Profession.Code:Any chy.r county
ca which requires a permit to construct,attar,improve,manila,or=par any structure
BUILOW $3200
pd.,to its ismacc,also parishes the applicant forsuch Permit to role a signed stmonew
that he is licensed pursuant to the provisions of the Connector's Learn Law(Chater 9 Sq.Ft.Floor Area Valuation
as (commencing with Section 7000)of Division 3 of Live Business and Professions Code)or
than he is exempt therefound and the basis far the alleged cumpflon.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 @NNT01ftibexo 0 Occupancy `J lye
no,mom risen live hundred dollas($500).
0 1,as owner of the property,or my employees with wage an their sole compensation,
will do Lhenoork.and the mucture isatimmucti.,offented far.&].(Sm.7044,Business
ad Profession,Cod.:Th.Contralema's Lt...Loa,does not apply to an owner of Required Inspections
property who builds or unproven thereon,and who does such work himself or through his
own employee,provided that such improvements an not intended or offered for sale.If,
however,the building or improvement is sold within we year of completion,the owner.
builder will have the burden of proving that he did no,Wild or Improve fur purpose of
sale.).
C]I as owner of the propeny,am exclusively contracting with licensed contractors W
cousidect the project(Sec.7W,Business and Professions Code:)The Cmdrommes Li.
come Law does not apply in in owner of property who Wild,or Improves Neuron,and
who contracts for such projects with A conooketods)licensed pursuant to the Commences
License Law.
0 1 am exempt under Sec. B&P C for this mando
her Dow
-
WORKER'S COMPENSATION DECLARATION
I hereby afford under Penalty of perjury am of the following declaniona,
I have and will maintain a Celpficas of Consent in atflf4osura for Weaker's Compen-
sation,
amper.
_sound,as provided!for by Section 37M of ft Labor Code for the performance of the
'l
work for which this permit is Word.
I have and will maintain Workers Compensation losamunce,as required by Section
71M or due ni,or Code,for the performance of do,work for which thin permit is Issued.
My
My Worker's Comps cation Insurance carrier and Policy number ac:
Car - j L� &, 16
Carrier. 3 Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crds section dead not uncompleted if the perrall Is farom,hundred dollars($10()
or In..)
I certify that in the performance of the work for which this permit is Wood,I shall not
employ any person in any mmncrm a in become subject to the Workers Compensation
La.of California:Dam
Applicant
NOTICE TO APPLICANT-.If,after making this Cenificam of Exemption,you should
become subject an the Worker's CoraNdandion previsions of de,Labor Coda you must
Z fordthevidi comply with such provisions or this Permit shall be named revoked.
z CONSTRUCTION LENDING AGENCY
El 1 hereby affirm that them is a construction lending agency for the Perform...v.f
> the wore fur which ffis permit Is Wood(Sm.307,Ch,C.)
Qz Ladces Nome
cl., Lenders Address
1 certify ffiai I have mad this application and slow that the above information is
correct.I gone to comply with all city and county ordinances and slow laws relating to
0 U building construction.ad hereby authorim ommism"tocs of ons city to order open the
;o. Uj Mv.-mentioned property for inspection purposes.
Ow (We)agree to save,indemnify and keep homeless the City of Cupertino against
rF.t P7 liabilities,judgments.costs ad expenses which mayjn any way see=against said City
In conampaurm "'a gaming of P Issued by:
A"LIC,
ICA"NDOEIl D"ZL OMPEV WITH ALL NON-POINT Date
BO RCL S 67
�a� 51T_f" Re-roofs
Sigmemon of ApplicmenZ..1ract. Dow
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will she applicator future building occupants me orluoelle hauledous material
[!tBrad by"a C3uperdim Municipal Code,Chapter 9.12,and the Health ad Safety
&d.Seeded 2552(a)?
I-I Yes All roofs shall he inspected prior to any roofing material being installed.
Will the applicant or future building omupanL am equipment Or devices Which If a roof is installed without first obtaining an inspection,I agree to remove
7mDistrict?
di haaddouN air contaminants as defined by the Day Area Air Quality Management all new materials for inspection.
mit 1_�
E]Yen El No
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11
In mWLhcha7Ardaus=Wrials�uimmenMunderChapWr6.95oftheCalifor.
aH�aiLhaSdeiyCok.&cMm�50.25533a�25534.lun&mmd�ifNc building
wnOLcurronflyhowatenem, at 3 yromensi ilftywradlythcoccupamofthe
quidmnrdta why uslMm d crofiesta.fac. ey. Signature of Applicant Date
ole D
6.n;r
i;. ag n, I All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
ate Telephone(408)777-3228
CITY OF Fax.(408)777-3333
&UPEkTINO
Building Deartment
JOB ADDRESS: PERMIT# 0 4 0 3 O O S
1_0 2 ro car v
OWNER'S NAME: PHONE # a Z —2-09
X GENERAL CONTRACTOR FAX #
;t I am not using any subcontractors: L i��=-� 0� �� 0 0
Signature Date
Please check applicable subcontractors and complete the followinginformation:
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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Ow er/Contractor Signa re Date
10/28/03
CITY OF CUPERTINO
WATER HEATER
aY-0
• CUPERTINO PERMIT APPLICATION FORM
APN# 1 �1 Date:
0 0 c
Building Address: D
Owner's Name: arZAAJt �, Phone#:
Contractor License#: 3 -7e
Contact: Phone#:
Applicant/CoRtMetor:
1J 4S*-k� �5/o> /23 z
Building Permit Info:
Bid& Elect lamb Mech
Job Descri tion:
esidential Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation: "i
Type of Construction: Occupancy Group:
Qty. if
A licable Fee ID Fee Description Fee Group
/ BENERGY Ener BUILDING
BPWHEATER Water Heater/Vent BUILDING
/ PPERMrrFEE Plumbing Permit Issuance PLUMBING
BPERMFEE Bldg Permit Fees BUILIDNG
BMITIGAT Housing Mitigation Fee BUILIDNG
PEE E BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG