12030023 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10435 IMPERIAL AVE CONTRACTOR:CHRIS PLUMBING INC 'PERMIT NO: 12030023
OWNER'S NAME: CHEN JUI-HSIN AND HUOY-JIU.4NY 1935 REPUBLIC AVE DATE ISSUED:031052012
OWNER'S PHONE: 4082533928 SAN LEANDRO.CA 94577 PHONE NO:(510)3464402
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT C PLUMB 1-
License Class Lia k
MECH r RESIDENTIAL r COMMERCIAL r
Contractor Date
1 hereby affirm that I out licensed under the provisions of Chapter 9 JOB DESCRIPTION:WATER HEATER REPLACEMENT
(commencing"hh'Sectiou 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
hereby affirm under penalty of perjury Otte of the following run declarations:
1 have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 Of the Labor Code,for the
performance of the work for which this pemlit is issued. S Ft Fluor Area:0 Valuation:$269
1 have and will maintain Worker's Compensation Insurance.as provided for by 4
Section 3700 of the Labor Code,for the performance of the work for which this
pemtit is issued. APN Number:35719102.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state Unit the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indenmitn•and keep harmless(lie City of Cupertino against liabilities.judgments' 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of this Permit. Additionally,the applicant understands and will comply
with all non-point Source regulations per the Cupertino Municipal Code,Section Issued bv: Date:
9.18.
Signature Date
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without(-am[Obtaining an inspection,1 agree to remove all new turacrials for
I hereby affirm that 1 am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole congnensat.on, Signature of Applicmt: Date:
will do the work.and the structure is not intended or Offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
1 hereby allirm under penalty Of perjury one orthe following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
1 have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25.574. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Henith&
performance of the work for which this pemtit is issued. Safety Code,Section 25532(x)should 1 store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices%'inch emit hazardous air
Section 3700 of the Labor Code,for die performance Of the work for which this contaminant..as defined by the Bay Area Air Quality Management District 1 will
pCnilli IS issued. maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
Health&Safety Code.Sections 25505.25533,and 25534.
P certify that in the performance of the work for which this permit is issued,I shall
rent employ any person in anv mmmer so as m become subject to the Worker's Owner ar authorized agent
Compensation laws mf California. If,after slaking this certificate of exemption,I Date:
beconne subject to the Workers Compensaion provisions Of the Labor Code,I must
forthwith comply with such Provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
1 certifv that L have read this application and state hist the above infortnation is Lender's Name
correct.I agree to comply with all city and county ordinances and state Paws relating
to building construction,and hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this Penni.Additionally,the applicant understands and will comply I understand my plans shall he used as public records.
with all non-point source regulations per the Cupertino.Municipal Code,Section
9.18. Licensed Professional
Signature Date ,
to building construction,and hereby authorize representatives of(lis city to enter Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgnnents,
costs,and expenses which may accrue against said Ciry in consequence of the ARCHITECT'S DECLARATION
granting of this pemlit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records,
with all non-point source regulatiahs per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date