04110091 CITY OF CUPERTINO ',,,'CONTRA
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-BUILDING DIVISION PERMIT. CO ",TRACT
BUILDING ADDRESS: HOT WATER INC PERMITNfb4110091
- 11867 WOODHII.T. CT
OWNER'S NAME: ,. PERMIT ISSUE DATE
KEVIN WANG 2531
ONE: - SANITARY NO. CONTROL NO.
(650) 298-8494
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
ELECT_ PLUMB_MECH
+�OZp LICENSED CONTRACTOR'S DECLARATION
- Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing • -
^� bh Section 701o)of Division 3ofthe Budnnsautd Profmium Code.andmylicenwis -
iorwlmaandeIT .REPLACE WATER HEATER -
�, License Clan _ L&.r7 -
Dam Cont=mor -
ARCHTTECTSDECLA64
IN _
? Ian erstanJ my plans¢hell be used as public=cards l
io Licensed Porfessiomd
OWNER-BUILDER DECLARATION
M O 1 he=hy affirm that 1.I. exempt from the Connectors e:Any c Law for the
i❑O following=moa Permit
t 71ommu Business and improve.
de nm Code:Any city or county Q
a�$ which requires a pctmil re commuter.aline impmsu,h Permit
t fir=pair ed atrnnum
r=< prior o its issuance.purse =quirts dovisiappon ofnt(or such rector's m se Law(Chaps e 9 .-_. -
(comand mencing
relicgwithuntion7the)ofDiviomafNcConuinessU�nmlsiw(Coda)9 _ Sq.F[. Floor Area ...__.. _Valua_tion_
K $ thamaI,exempt
Section and or Divisidn3 oath-eged emand ption.Any vicade)m -' -- - ----
Natio M eacmpt Lha=from and oe burs for be alleged w=ant to Any violation of
Section7031.5thrut by any red dans fora permit subjects Nc applicant to a civil penally of @IQ Q (]CCU anC e '
no[more Ilan Box hundred dollars(f3t10). I3 y it p '
C],1.as owner of the property,army employees with wages u their ole compensation, -
C. will do the wad:,and the wctu=is not intended or offered for sale(Sec.7W,Business
sad'Pmrrssimu Code:Th.Conlncmra Liwme Law does net appy In an owner of ... — Required Inspections
property who bui Ida or i m proves Merton.end who does such work himul f ea omugh his
own employwa.provided that such impmsemenu are not intanded oraRered forsale,If, -
- however,the Wilding or improvement is old within one year of completion,the owner.
builder will have the Wrden of proving that he did not Wild or improve for purpose of '---
sale.).
❑1,as owner of she property,am exclusively contracting with licensed contractors in
construct the project(See.7044.Business and Pmfeasiuns Cede)The Commons U.
cense taw does hot pply in an owner or property who Wilda or impmws thereon,and.
who contracts for such projects with a contractor(a)licensed pursuant in Use Cortuacto's -. -. ---- - - -
License Law.
Ismaemptunder Sec. ,B&PCforthbrtuon
17�0(1
er De=
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following decluallons: _
I ham and will maintain a Certiftsmm of Consent to self-imam for Wodrls ComNn.
won,u provided for by Section 3700 of the Loo Code,for Um Performance of are _
k for which this Permit is issued.
I have and will maintain Worker's Compensation Insurance,m required by Section
or the labor Code,for are parforoaace or the work for which this Permit is issued
Worker mpensaGOln�Inasra nrim and Polity nu�b�ar�art6rier. 1rZCa0 Polity He.:
/�'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TTissection need not W completed if Ne permit is two=hundrtAdellars(SIM)
or Mas.)
1 aniry the,in the Performance at the work for which this pamit is issued,I shall not
employ any person in say mannergo u to become subject to the Workers'Compenwlan -
LawsofCeliromis.Date
Applicant - - -
NOITCE TO APPLICANT:IL after making Nis Cenincam of Exemption,you should
Werme.object in On Workers Campcmauon pmvMions of the Leber Cook,you usual -
.J O forthwith comply with such provisions or this Permit shell he deemed revoked.
z 2 CONSTRUCTION LENDING AGENCY
�.n ► 1 hereby affirm that Vert is a construction lending agency for are pedormatace of
Ci
to work for which this permit is issued(Sa.7(197,Clv.C.)
�W 0 Lender's Name
D Z Lenders Address
tJ Q I certify dull have read this applieuion and sum oar thea Wee information u
U.f" corms.1 gree he comply with all city and county ordinances and sum laws relating to
O V building construction,and hereby aulhodm mpresentadhos of Nis city to enter upon Bin
W aMvcmt,judged Pm.c costs
for inspection purposes.
D. (We)agree o saw,indemnify and kap harmless dm City of Cupertino against
h incraggluengm of the
s tsand expensesmit. may in any way acemc against Said City
U z A APPLICANT
NDER TAN or this permit. Issued by: Date
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SO�'Rf E�RE�GU�LA71�r+s. �/
vvt'w�r 3C�1��r l(11h10Y Re-roofs
Signora of AppliantaConoroam, I Ban
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant or fuwrt '(ding acupam 4mrc orWMlc hvaNaus mamriei
C"
"caned by Na Cupertino Muni o el Code.Chapter 9.12,sed sec Health and Safety
cod,Sa y.2ss32(a)? All roofs shall be inspected prior to any roofing material being installed.
Will the applicant m"sure il"i"occupant oo cyuipmenl or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil ha Maas oit em.munbtra "-Bond by the Bay Area Air Quell,,Management all new materials for inspection.Damao?
❑yes Nu
Ihnwrez"the Wrgrdoosm 5505, 5533requamc5534,1under Chapodthatr 6,95 if the
Wildingr. /l / �� �K4/''WC!/W�"'� l(!�/b7"
nix HcelN&SafctyCodc,Sations5505,255330"23534.1 undersand Nuri the Wil"ing l/ tel/��W 1
does not currently haw a knot,that it u my responsibility o notify the oaupent or the
tri menu which must be me,pdorto issuance ofs C 'imam Occupancy. Signature of Applicant Date
Owner ar,athadvee as-fit Data • ' - All roof coverings to be Class"B" or better
Community Development
10300 Torre Avenue
s' Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: PERMTr#
11 9V7 WODdktl( 0 Y �lcx�R /
OWNER'S NAME: «U I K PHONE # 747671,A-5 2
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
hd 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 710 C r
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
a
WATER HEATER
• CUPER INO PERMIT APPLICATION FORM
APN # Date:
Building Address: V I_\ l I C±f n �-
Owner's NamePhone#:
UI V\ uj yob �Z67 _ .z7S5-
Contractor: one: License#:
46f W a-+e yr 1 AC- • -7(o (� �-
Contact: Phone: Cupertino Business License#:
ri , L/ V ,7:5-7 X21 X11
Building Permit Info:
Bldg ' ❑ Elect ❑ Plumb LZY Mech ❑
Job Description: J /&-<i1L W a4-e- ' / /0
Residential Commercial ❑
Cost of Project:
Strapped ❑ On Platform Bopded El
New Location ❑ Replacement L—dam/
Qty. if-
A Ka le 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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