01090085 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
7862 ROBINDELL WY CUPERTINO PLUMBING 01090085
OWNER'S NAME: APPLICATION SUB DATE
CHEN CHIH-CHUNG AND LIU BIH-SH 10297 S DE ANZA BLV 09/20/2001
PHONE: SANITARY NO. CONTROL NO.
(408) 253-0618
O O ARCHITEC iENGINEER: BUILDING PERMIT INFO
mC BLDG ELECT PLUMB MECH
5 N= LICENSED CONT'RACTOR'S DECLARATION Job Description
i Z-O I heinby affirm Thar 1 an licensed under provisions of Chapter 9 kommencing
,ntw w+Nseamn]BOO)ofDivision3ofNeBusinessandProfesxionxCuba.andmylicense REPIPE & WATER HEATER.
S m5 ,s in mu force mi f(al.-k o
ce u,u License Class C-—/ Lic.p / 1
Dae Comma m,
3 a LLO ARCHITECT'S DECLARA
m; I undersand my plans shall W used as public records
3.'
Oo O Licensed Professional
OWNER-BUILDERemtfrom
m the Contractor's
uK1 1 hereby affirm that 1 1. uusin stun the Cessions is Licenu Law for the
following season.(Santo t 703 1.5.Business and improve.
de Possessions Cade:Any city st county $5000
Fd D whichrequitenpc.1m,mroresmat Jmvimprove,demolish,arrepair say swetom
i m Pn mcqua PDn,o ssincslsaodse,UO,(Ch Code _�i,�,`.T.',3
nations INY0rMf,alW � SdKa 1 rfafs«h Ila hleaal lCl atalemenl�
that he,ii licensed pursunm to rhe provisans of the CommutoiLicemetaw(CM1apler9
(commencingwith of Division 3ofthe B Valuation
f1• �,.I ._.r.F.� E ti,.
or that be is315exempttmr appli and the basis for the alleged exemption.to Any violation I
of Section]03LS by aOY applicant far a permit zubjau the applicant a civil Pendry
Of Out team than five hundred donan 06500). 106AP-NSTFONIZ & WATER Occupancy Type
❑1,as Owner"(the property,Or my employees with wages no them sale compemadoq
will do the work,and the swcmm is net intended or offered for sale Sec.7614,
Businax ndd Pro1b&,mo,Code:The Cnntmsim's License Law dees not apply to an 301 - ROUGH PII ill0sp'ections
owau of Progeny Wba bull&or irnpmv.thereon,and who does such work himself 302 - TUB & OR SHOWER
qr thmu h his own employ« ma
s.provided that such improvcems arc not intended
..11k for mile.IL however,on building or impressment is sold within one year of 502 - FINAL PLUMBING ENERGY
completion,the gwnenW ilder will have d¢Wdan of proving that he did net build a
mpmv.fm,mposeofmle.), _ _ 506 _- GAS TEST g�J - _
IT`S `
.. O i,os er awmof the propany,amp ci,uIm vat,caoGachng with licensed contractors to 507 - FINAL PLUMBING •�
onswo the does
no(Sec.]OCs.Business and m a who
Code:)The improves
t emor', '
License law d«s nor apply uc man owner of a carry who Wilds or improv«sto the
.. and who ',Lviens for such Pml«u with a comm<mrt,)licensed purswm m the ..
C naazwfs Licenu Law..
❑1 am esempt under Sec. B&PC for this mason 9 O
owner .. .Data
��� l 1
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty,of perjury'one of the following d«lamlions:
❑ 1 have and will maintain d Certificate of Consent to self-insure for Worker's
Compensation, as provided for by Seclino 3700 of the Labor Cde, for the
performance of the work for which this Permit is issued.
❑1 have u d will maintain Worker's Compensation Imurnnce.as required by Seedon
3700 of the Labor Code,fes the performance of the work fse which this permit is
:. :.
issued.M/y�,�Woprkers Compensation Insurance carrier d Policy number am:
Cemn !_`'CJO� % '..n Poley No. "/ l 3 D /v. TO O V f,,,,�• f' "A 1;,.,,,.,1 . ! .y,, .�•ii .,
'Y
CERTIFICATION OF E%EMPTIONP FROM WORKED RS( -mom- 4 I" )•''f Y."\.•LkI1\
COMPENSATION INSURANCE'
' 'ITLis senion need nor be completed if the permit is for ane hundred dollars J,
"'• I\ i
(S100)or less.)
d certify that in nhe,pciforniance of the for which this pemdl is issued,)
hall not employ any person in any manner u as,to become ubjar res the Workemi '
Compensation laws ofcuifomia.Dae -
.Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Eumplum.you should "
become subjem m the Winces Compensation provision..,Of the labor Cade,you must
Q 0
�forthwith comply with such provisions or this Permit shall be deemed invoked.
F L' CONSTRUCTIONLENDING AGENCY
I bercby affirm that rheic is a conswcrion leding•age«y for the perfommance
W of rhe work for which this permit is issued(Sec.309],Civ.C.)
�a_Zlender',Name'
Isndds Addrcssi Q
U Qi certify that I have d this application and slue rhaphe above infomution is '
W [-1 mucmrmm I agree to comply with all city and count,oNinences and sum laws.]ai.g
Q V to Wilding construction.and hereby aurho en representatives of Ms city in enter upon
y (z]
the above mentioned property for inspection[�- e. PlWwes.. „Q. (We) and keep harmless the City of Cupertino against
(iG liabilities,judgments,costs and esl emes which may in any way accrue again.,said
V
City inconsequence f the graming of this permit:AFF UNDESTANDS AND WILLCOMPLY ALL NON-POI Issued by: Date
SOU �T� Zl —0
Signs.. ofAp PC Imam - " .Date Re-roofs
y W, SURE i' .
wtitmca hdanlarronYeWudingoauhaptmmrcofandtheHe;lthandSaf;m Type ofRoof
._ .,.. .. _. -'-- .... .__.
HA ROOUS MATERIALS DISCLO
as dchned b' 25 32 a).vo Munki I Cdc,Chapter 9.13,and dm HdnM1 and Safety l N.-i - P 1 Ye' !'s V s ] '
Cdc.Sarion 25532 a).
.. ., -� .f. \e'it.
❑ram . : '.o Nn',, ,. - ?''. All.roofs.shall be.inspected.prior to any.roofing material being installed. --'-ill
the applicant or fumrc building occupant use equipment or devices which Ifaroof is insfalledwithoutfirs[obtaining an inspeetiori, Iagreetolremove
mil haeardous air conmminams a defined by the Bay Arca Air Quality Management
Di.tsic n all new materials for inspection. Applicant understands and will comply with
ores ON. all non-point source regulations.
nim Health&lSa e,,Codus maim,,2 require505.,2mems under Chapter understand
of ms
California HmhM1 s Safcty Cdc.have
a to ant,tit 35533 and 25534.1 understand that
If of
tl«s not currently have u tenant,that it is my responsibility in notify the _
occupant of rhe quirdmp u wbicM1 mum h act prior m ismmnce OYa Cenifd¢of
C./'_Z i_0_� Signature of Applicant Date
own«n eathona .,gem - L _ Date All roof coverings to be Class "B"or better
._ -I . . OFFICE