12050130 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20362 VIA PORTOFINO CONTRA0014:FAST WA I'ER I II:A I ER PERMIT NO: 1200130
OWNER'SNANIE: DANIEL WONG 12601132 A\'E NF: DAE ISSUED:05/16/2012
OWNER'S PI ION F.: 4082825879 KIRKLAND,WA 98034 PIIONF.NO:(81)11)454-8955
❑ LICENSED CONTRACTOR'S DF.CLARKrION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.q r r r
MECII RESIDES"EL\L COMMERCIALContractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RENIOVF AND RITI.ACE GAS WA'fCR I IFA I ER IN SAME
LOCATION,GARAGE,
(commencing with Section 7000)of Division 3 of the Business& Professions
Code and Ihnt my license is in full force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a eeniticate 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.
1 have and will maintain Worker's Compensation Insurance.as provided for by Sq.Ft FlowArrc 0 Valuation:S750
Section 3700 of the Labor Code,for She performance of the work for which this
permit is issued
A PS Number:316011 ig.00 Oreupancy'I'rpc:
APPI.IC:\N'I'CER'1'IPICA'I'ION
1 certify that I have read this application and state that the above in Rlrmatiun is
correct I agree to comply with all city and county ordinances and state laws relating
to building construction.and hereby authorize representatives ollhis city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned propcny for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities.judgments. WITHIN Igo DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accmc against said City in consequence of(he 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued b): Date:
Signature Date
❑ OWNER-BIALDER DECLARATION RE-ROOFS:
All tools shall he inspected prior to any rwfmg material being installed. If n roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of Installed without first obtaining an inspection,1 agree to remove all new materials for
the following two reasons: inspection.
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 oDired for sale(Sec.7044, Signature of Applicant: Date:
Business&Professions Code)
1,as owner nllhe property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,lousiness&Professions Code) AL1.ROOF COVERINGS 10 TSF.CLASS OR I3F:illi l(
":\"
1 hereby affirm under penalty of perjury one of the following three
HAZARDOUS NIATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's 1 have read the hazardous malerials requirements under Chapter 6.95 of the
Compensation,ars provided for by Section 3700 of the labor Code,for the California I Iea1Rt&Safety'Code,Sections 25505,25533,and 25534. 1 will maintain
perlbnnance ul the work for which this permit is issued, compliance with the Cupertino Municipal Code.Chapter 7.12 and the Ilealth&
I have and will maintain Worker's Compensation Insurance,as provided for by Safely Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of Ihe.work,for which this Additionally,should I use equipment or devices which emit hazardous air
contaminants as def ned by the Bay Area Air Quality Management District 1 will
permit is issued maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall I Iealth&Safety Code,Sections 25505.25533,and 25534.
not employ any person in any manner so as 10 become subject to the Worker's
Compensation laws of California. If,after making this certificate ofexemption,1 Owner or authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Dale:
-
forthwith comply with such provisions or this permit shall be deemed revoked.
CONS'IRU(:HON LENDING:%GEN(Y
APPLICANT CERTIF1CXr10N I hereby alum dot mere is a amsinletimn lending agency for the performance of wor 's
I certify that I have read this application and stale that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct. I agree to comply with all city and county ordinances and stale laws relating Lender's Nance
to building construction,and hereby authorize representatives of This coq•an enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabi nics,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this perm :it.Additionally.the applicant understands and will comply •\RCIII"fF:C"I'S DE( 1.
with all non-point source regulations per the Cupertino Municipal Code.Section I understand my plans shall be used as public records.
9.18
Licensed Professional
Signature Date