05020079 (2) CITY OF CUPERTINO ' a + ?:•'
BUILDING DIVISION PERMIT A CONTRACTOR INFORMATION "':
BUILDING ADDRESS: PERMIT NQ 5020079
OWNER'S NAME: PERMLT ISSUE DATE
KENT SOO HO
JNE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMITINFO
Bre E�,� PWMB O
u00 LICENSED CONTRACTOR'S DECLARATION JobDescri tion
C 1 Imrcby affirm that 1 am licensed under provisions or Chapter 9(commencing p
b with Section 7M))of Division 3 fthe Businee and Professions Cook,al my license is
^oma mon roma a^°c t. gZg�� REPLACE WATER HEATER.
7vz License Clss Lic.N
Dam z canmemr 'CONTRACTOR: BETER WATER HEATERS
ARCHITECTS DECLARATION
�i e a I ondcryandwiy plans3hall M ucyapu publiv icomd, .
o Lkcnsed Pmfcssmnal
S OWNER-BUILDER DECLARATION
1 hereby affirm Out 1 am exempt room One Contractor's License Law far the
c2 following reason.(Section 7031.5,Business and Professions Code:Any city or county
ym which mquirra a permit m construct,alter,improve,demolish,or repair any swentic
prior to its issuance,also requires the applicant for such permit to file a signed statement
_X that he is licensedpursCoruscate, Sq. Ft. Floor Area Valuati("00
�h$ (commencing with Section 7")of Division Sof the Business and Professions Cade)or
y _ that he is exempt themRrm and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more Nan five hundred dollars($51)07.
0I,ss ownerof the property,mmyemployees with wages az their sol.compensation, 32647006 . 00
will do the work,and the awcmm is not intended or offered for sale(See 104,1.Emotions ma
and Professor Code:The Contractor's Lt..taw does not apply C an owner of � k CgOiredl,IApecIioona
progenywho builtls orimpraves thereon,and whodassmh work himadthrough his SFY1 y/.'' ( " yqy(-,�,,hH
own employees.provided tat such improvements are not intended or offered for We.If, ver(E,Y,exy
howeveq the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively convecting with licensed convectors to
convect the project(Sec 9064,Business and Professions Code:)The Contractor's Li- BUIL
Nf ggg pB pp�aatttttt,,,'''
cense law docs not apply b ot owner of property who Wilde or improves Centra,and t)��
who contacts for such projects with a contractor(s)licensed pursuant m Ce Convenors okRls
Lie taw.
l�am�e'x�amp�t�qBdpcScc B&PCfor Cis mazon
kzi
Owner Dam
WORKER'S COMPENSATION DECLARATION -
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Cenificam of Consent to self-insure for Workers Compcm
cation,ss provided for by Section 37M of the labor Code,for the Performance of the
work for which Cisµnoir is issued.
❑1 have and will maintain Worker's Compensation ¢
Compensation Insurance, quired by Section
3100 of the Labor Cade,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section sea mono completed done poria is forms.hundred dollars(ilm
or leas.)
1 cenify that in Cc pe,f...ncc of Cc work for which Out permit is issued,l shall nut
employ any person in any manner m az to Woome subject to thc Workers''Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Coni fate of Exemption,you should
became subject to the Worker's Compensation provisions of the Labor Code,you mus
.,O foMwidt comply with such provisions or this Permit shall W deemed revoked.
Z` CONSTRUCTION LENDING AGENCY
[r I hereby affirm Oat there is a convection leading agency for On Nrfurmance of
C(i the work for which this permit is issued(Sec.3097.Civ.CJ
W Lender's Name
z Lender's Address
U 0 1 certify that 1 have read Cis application and We Out he above information is
W E" correct.I agree to comply with all city and county ordinances and sum laws relating to
building convection,and hereby aulhorim representatives m(this city to enter upon be
Y' above-mentioned property for inspection purposes.
(We)agree a.save,moronity and keep harmless the City of Cupertino against �� s
tFr req liabilities,judgments,costs and expenses which may in any way acetue against said City
V Z in consequence of On graining of this permit.
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date o
LATIONS. �I
�� Re-roofs
Signature of Applicant/Conuactar Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will to applicant or future building Occupant store or handle hmardous material
az defined by the Cupeninm Municipal Codc,Chapter 9.12,and the Health and Safety
ode,Section 25532(,1)? All roofs shall be inspected prior to any roofing material being installed.
0Y.e
Will the applicant or future building occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
mit havardous air emntaminanu az clined by the Bay Arca Air Quality Management all new materials for inspection.
Diaries?
❑Yes
I have mad Ce haaardrus materials mquimments under Chapter6.95 of the Califor-
milHealth&Sam,,Ccde,Secume255)5,25533 md25534.I bosom and thmif Ne building
Jas not currently ham a tenant.that it is my miNmiolily In real,the a:cupnt lure
:IxmetpDrrRrtz,tan.e aCegeeateortxa�y. � Signature of Applicant Date
Owner or aathori..d agent I!— /Dar. All roof coverings to be Class"B"or better .
Torre Avenue
F Community Development
It es C10pOrtinoCA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
�UPEkTINO
Building Department
JOB ADDRESS- � - PERMIT
OWNER'S NAME: e.tT °0 PHONE # Z 'S L13
GENERAL CONTRACTOR: s g FAX #
I am not using any subcontractors: ° -zA 'Z/O �
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
AAh Tile
2-
Owner/Contractor Signature Date
Community Development
1 - 10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408) 777-3333
SUPEkTINO
Building De P artmen
JOB ADDR -216/o Ess. +Z eA 1 U PERMIT #�`� 2 D DC"Q 1
OWNER'S N v / 'PRONE # •577-.3� t-/ .3
GENERAL QONTRACTO S g' FAX # '
7S 5
I am not usin`g-any subcon ac \ _
1 � S v Signa • e Date
Please check applicable subcontractors and complete the followinginformation:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electricoe"
Exca on
Fencing
Flooring;;; peting
Linol�lim/ Wood
Glass / Glazing '
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing '
Roofing
SepticTank
SheetJMetal
Sheet Rock "
Tile
,o Owner/Contractor Signature Date
•a
CITY OF CUPERTINO b
WATER NEATER
OF
CUPEkTINO PERMIT APPLICATION FORM
APN# 326 147 c� o � Da2
Building Addre$s
2-
Owner's
Owner's N e: Phone #:
- e.�`� Soo �o0 25-7 31y3
Contracto �V`IPhone�SO -6672 Licve� 8RI L(
Contact: T 1 A _ r� .0 J r / e p Phone: Cupertino Business License#:
Building Permit Info: ('1 ��/ �/ /l /$
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description: W/ 1
Residential Commercial ❑
Cost of Project- „I)
Strapped V On Platform LLr B9rtded
New Location ElReplacement C9'/
Qty. if
Applicable Fee ED Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING