07010022 CITE'OF CUPERTINO
BUILDING DIVISION PERMIT e � 2A TO INF.
Z IATIDN•,
PERMIT NO.
BUILDING ADDRESS:
22186 RAE LN PLUMB IIS
PERMIT ISSUE DATE
OWNER'S NAME:
RICHARD LAM 1360 MEMORIAL DR STE 140 DI/04/2007
SANITARY NO. CONTROL NO.
)NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: REPLACE WATER HEATER BLDG ELECT PLUMB MEECH
c a LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z u with Section 700�insiness and Profsssi `Code,and enseis
,a„ in full force and tVZ License _assc.>t O Datentractorr S DEC LA I
m U I understand my plans shall be used as public records
a
LC Licensed Professional
OWNER-BUILDER DECLARATION
`>3 a I hereby affirm that I am exempt from the Contractor's License Law for the
r Q O following reason.(Section 7031.5,Business and Professions Calc:Any city or county
K which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to rile a signed statementr; .Ft.Floor Area Valuation
< that he is licensed pursuant to the provisions of the Contractor's Liccnsc Law(Chapter 9 q
y $ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500).
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered forsale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does out apply to an owner of
property who builds or impmves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,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.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a comractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,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 maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued
My Wo r es Compensation Insuran e arri Poli
Carrie Policy No
C RTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for ane hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date--
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
(.t i— I hereby affirm that there is a construction lending agency for the performance of
py> the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lendces Name
a4Z Lendees Address
U 1 certify that I have read this application and state that the above information is
LL E~ correct 1 agree to comply with all city and county ordinances and state laws relating to
Q U building construction,and hereby authorize representatives or this city to enter upon the
above-mentioned properly for inspection purposes.
4Wi (We)agree to save,indemnify and keep harmless the City of Cupertino against
,4 liabilities,judgments,costs and expenses which may in any way accrue against said City
U in consequence of the granting of this permit
APP ANT UNDERSTAND ID WILL COMPLY W ALL NON DINT Issued by Date
S RE ULATI S. j
/ Re-roofs
Sign of Applicam/Conractor Date
HAZARDOUS MATERIALS DIS OSURE Type of Roof
Will the applicant or future building occupant sto or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future buil 'g occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contami2N.
as incd by the Bay Area Air Quality Management all new IT aterials for inspection.
District?
❑Yes
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
norrently have a tenant. my responsibility to*fy the occupant of the
MN i mnn which must be me rior issuance era r tc of Occupant ignature of Applicant Date
-v
Own r n lharized agem Date All roof coverings to be Class"B"or better
I
CITY ov cupp oq o I o0 2�
X40
WATER
MIS' APFLI AT FORM
i
Date:.address:
i �
1 � vne 's yv' ►n d
� amc: ��bi4
' �`�CMac-� l.cc 3
' rn Phone#:
ai
Gnir4ctor:
kl bg S
s S � '
FC 0-11 r aTt—
— `� License#: '
! Cupertino Business License #:
g Permit Info: �
i
Bld--11-2,
0
i job D. elect ❑ ,�.�/ i
3 escrlption: l`ll�rnb T
Mech Q
l j
J Resididntial
t Commercial Q Ho I
Cost of Project:
i
f i
Strappp�d ❑ �01I 'Platform U
� I
s New kation CI
_ Replacement
Qty.i i f
Appli6ble Fee YD
$FW 4EA.T'ER FeL Descriptiop
2h1ITFEE Water heater/Ment Fee Grout)
BENE P UT?bines $ SING
I�.C�xY F'ertnrt issl�ance
$1USI,1C 1PLUN$LIvG
BUS;- eSS l".,ecense
$� LBIhiCr
_ BUILDING
i
lu.dbE �
6111,1111114
I