01120006 (2) OF
CITY
I BUILDING DNEISSIIONNOPERMIT CONTRACTOR INFORMATION:
BtµY991DDMADOWHILL LA TONY & HELEN CHUNG PERMIT NO.7 yy�� 01120006
(AfbV I HELEN CHUNG AP12/1035/ 2001
AL
4 LONE: SANITARY NO. CONTROL NO.
n O_O ARCHITECT(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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Ny LICENSED CONTRACTT OR'SDECLARATION Job Description
j z:o It a n thin I am liccn d o Wor provisions of Chapter 9lcommencing REPLACE WATER HEATER.
witM1 Scctian]IMNII a!Division J of the Business and Professions Code,and my liter'.
6 m is in full force and effect,
e m 6 Liam.¢Cma Lic.%
0 a`� Dam Commctor
+�3 0 v ARCHIrECT'S DECLARATION
°—' g I undcmond on,plane shall be used as public aveorde
oec.p Licensad Professional
OWNER-BUILDER DECLARATION
aai=' hereby affirm that 1 i m cvc.pl from the Contractor's License Law far the
F Z< fallowing reason.(Section 7031.5.Braine,and Pmfe.,om,Codc:Any city or county $250
E x❑ whmh requires a e it construct.ah improve.demolish,or repairany structure
u°r6132 poor to its assandacc.also requirestit ..ii,ma to,such permn a)file a signed smaera.m. J�N.�}r�M,.
that he licensed p tram to they of the Contractors License La (Chapter 9 .. 3.9 W 6 9lY YYr�� Valuation
(ammo.[ng with Secd 7M))of Di,idon 3 of the Business dProfession,Cade) p„�!,'+ n Js ,y s, �,,.. f.", q.,(.., 7.i i" r
or that he is exempt thcrcf mnf and the basis for the alleged acmpuon.Any violation
of Section 7031 5 by any applicum for o Permit ubjec.the.,,I icant to a civil penalty
of not moa man five hundred dollars($500). 502NPNhb3PIbAL PLUMBIN 'ENERGDccupancyType
own.,of the pmperi,oram employees with wages as their sole compensation, 506 — GAS TEST
ill'Jn'ihe an
and the structure is not Intended or nlfcred far attic(Sec.]Iw. 507 — FINAL PTR j•&Wmpections'
alines,and Professions Cod,:The contractor's License Law docs nm apply m an
owner of property With mild,or improves mereon.dad who docs such work himself
or throogn his own howeicces.pmvidia that such imp,oveis of are not intender or .. ___
-offered for i9c.If.however,the huildin6 m iniprovcmrnt is old wimin one year of, ”"-'--"--'--"-`-- ""-- '---'-` '_.... ._.__. r
completion,the owtmrbuilds,will have the huttlen of proving that hadid not build or
❑L us owner of the pmpenR am Business
d Professions
with licensedcontractorsC mecors m
enhancer (gee. to a.Bamerof a�Prose„ion,Gore,n,.ves thero;, � 5. -2001
Licence law does not apply m an owner th property who Halide or improve,thio the DEC-
i. O
.. .and who conhdns for_such Raleeu.vim a contnctor(s)licenxd pursuant m me .._ . . ._. __ .._._... _
Contractor's License Law.,
❑I am eaemPt uglier Sec. ,B&P C fonhis mason •1' ^'•
Owns, WORKER'S COMPENSATION DECLARATION U I LDI NG
I hereby affirm under,penalty of perjury one of the following declarations:
\ Cl 1 have and will maintain a Certificate of Consent to self-insure for Worker's
Compcdsation, 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 moinmin Wurkcr'a Comperaromm Insurance,as required by Senior
3710 of the labor Code.for the perfoni me.of me work for which tris permit is
v - issued.My Worker's Compcbsotion Insurance carver and Policy number arc:
Cams t PN'Policy No:.
O•
1 t CERTIFICATION OF EXEMPTION FROM WORKERS'
_ ...i. ' COMPENSATION INSURANCE`.;•u••�; .. ,.._._..__.__ _......_. ...._..._._.._.__._.____ __-_ ._ ____._.____ -_
(Thii'>eciion hoed not be,completed if the permit is for one hundred dollars
(5Had or loss.)
s•' .I'cra"Phan➢Person in .'a work for which this permit is issued.I ”`+ -
uany antnntit ., r i.1 i• .
shall not employ
y men cr sit as m become sobjcn to the Workers
Co-7.'uniodlawsof C"Bromars are
Applicant ___
NOTICFIG.,
TO APPLICANT:IL afros making this CeniOcaa of Exemption.you shoultl
hdmna'iubjcer m the Worker's Compensation pmvisionx of the Labor Code,you must
Oforthwith mmPly with such provisions or is permit shall be deemed revoked. _ _ __,
r.VJ ".. ., t"'CONSTRUCTION LENDING AGENCY t
r yaPerformance
7 sof the nark for which this
th,mti is iswcd(Sec 309],Civ.C.) for rite ,
lending agency
Q a ...a., ... __-_ _.._. .... _... ....
LendUrill Addy ..•.• —._ .. _ _ . .
L e'r's Nati
.� Z �, reds
V 1 certify that 1 have rod Chia application and stag that the above information is
W. F, torted.I agree to.amply with an dry dna.aunty nramaacee dna nate law,among
Q Cm3 wbuilding construction.end herbyeotliorire repasentauves of mil city to rnter upon
�] tit.obovcmrntioncd Propcny for,impcction puipasn.
>; !L (We)egree tdwve.intlemnify and keep harmless ilia City of Cupertino against
W liahilitica,judgments,acts¢and enpensee which may in any way acerve againstsaid
1 r
C.> Z City in conscqurntt of the granting of this permit. I
'APPLICANT UNDERSTANDS ND WILL COMPLY N'ITN ALL NON�POT Date
SOURCE REGULATIONS.�, /' ` 61 Issued by:
riga t e rApp1 �Ucnmmemr pace. . Re roofs
HAZARDOUS MATERIALS DISCLOSURE
- x n m app)cant r t bnaamg Paas stow h Jle M1aurdbus mammal Type of Roof -
os def d
d Sa
iC pen Mumc pal Cod eh Pt 9 12 and to Healm Sal _ ., 1 •„
cod S fonon SSJ21a) I(
❑tis ❑rip' All roofs shall be inspected prior to any roofing material being installed.
winme.Pplleant-orfum.e.buuaingoccupant me equipment or devices which If a roof is insialled without first obtaining an inspection,•I'agree to remove
e it ndwamis au eminu unams n,defined by the Bay Area At,Quality Management
District? 'r all new materials for inspection. Applicant understands and will comply with
❑Yes ❑No. .-
. . all non-point source regulations.
i'i haze reed the ha imkhii materials requirements under Choptef 6q5 of the
Cilifomia Health&Safety God,Sections 8505,8533 and 25534.1 undersand that
if the building does not curtently have a round.that it is my responsibility to nobly'be-
occupant of the requirements which must be that prior to issuance of a Certificate of
° Raney ISignature
Si natu_re of A_ pplicant Date
All roof coverings to be Class"B" or better
nr tram...rad agent', : n 1Due
. OFFICE . ..