12050101 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7554 DE FOE UR CONTRACTOR:FAS"I'WA"I Eft I II:.\rER PERMIT NO: 12050101
OWNER'S NAME: NGAI HARRISON AND MARY 12601 132 A\'F:NE DATE ISSUED:05/102012
OWNER'SPHONE: 4082571955 KIRKLAND,%VA 98034 PDONF;NO:(x00)454-x955
❑ 1 ICEN'SFD('OYI'RAC'I'OR'S DF-CI.ARA7'ION r
BUILDING PFRA)IT INFO: BLDG r ELECT r PLUMB
License Class Lic.b r F_ r
tr1ECF1 RESIDENTIAL COMMERCIAL
Contractor Date
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE 50G WA I'ER I16AI ER
(commencing with Section 7000)of Division 3 of the Business&Professions
Codc and that my license is in full force and effect. -
I hereby affirm under penalty of perjury one of the following two declarations:
I 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 permit is issued. Sq.Ft Floor Area:0 Valuation:$1300
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Codc,lir the performance of the work for which this
pcnnit is issued. ACN Number:35924027 00 Oecupaney'fype:
APPI.IC.\N'1'CER'1'IF'ICA'I'ION
I certify that I have read this application and slate that the above information is
correct. I agree to comply with all city and county ordinances and state Imus relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this cityto enter
upon the above mentioned properly for inspection purposes- (We)agreclosave WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and.keep harmless the City of Cuperlino against linbilitics,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: Dale:
9.18.
Signature Date
RE,-ROOFS:
❑ OWNER-BUILDER DECLARATION All rools shall be inspected prior to anyroofing mulerial being installed II'a roul'is
installed without first obtaining an inspection.I agree to remove all new materials for
I hereby affirm that I am exempt from the Contractor's License Law for one or inspection.
the following two reasons:
[,as owner of the properly,or my employees with wages as their sole compensation. Signature of"Applicant Date:
will do the work.and the slmcuuc is not intended or offered for sale(Sce.7044,
Business&Professions Code)
h as owner of the property.ant exclusively contracting with licensed contractors to ALL ROOF COVERINGS I'D BE CLASS"A"OR BEI'I'ER
construct the project(Sec.7044.Business d professions Code).
hereby affirm under pen all)of perjury one of the following three 11:%ZARDOIIS NIAT :RI:% S DISCLOSIIRI•:
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Ilealth&Safety'Code.Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided fix by Section 3700 of the Labor Code-for the compliance with the Cupertino Municipal Code,Chapter 9.12:tad the Ilealth&
performance of the work for which this permit 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 fix by Additionally,should 1 use equipment or devices which emit hazardous air
Section 3700 ofthe Labor Code.for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code.Chapter 9.1'_and the
permit is issued Health&Safety Code,Sections 25505,25533,and 25534.
I certify that in the performance of the work for which this permit is issued,I shall
not employ anv person in any manner so as to become subject to the Worker's Owner or authorized agent:
Compensation laws of Californin. ll',after making this certificate of exemption,I Date:
become subject to the Worker's Compensation provisions of the labor Code,I must
forlhw'ith comply with such provisions or this permit shall be deemed revoked CONSTRUCTION LENDING AGENCY
I hereby allinn ilial there is a construction lending agency for the pertimn:ace of work's
APPLICANT'CERTIFICATION for which this permit is issued(lice.3097.Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property lot inspection purposes.(We)agree to save
indenhnify and keep harmless the City'of Cupertino against liabilitics.judgmenls. ARCIII'rEC 1"S DF-CLAR.\'ZION
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used;is public records.
with all non-point source regulations per the Cupertino Municipal Code.Section
9.18, Licensed Professional
Signature Date