12060045 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7591 KIRWIN LN CONTRACTOR:DING WU AND11N 111' PERMIT NO: 12060045
OWNER'S NAME: DING WU AND JIN 11E 7591 KIRWIN LN DATE. ISSUED:06/07/2012
OWNER'S PHONE: 6509968325 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT F- PLUMB r
License Class Lic.q
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter JOB DESCRIPTION: REPLACE 40 GALLON WATER HEATER
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penally 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 Valualion:5300
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. APN Number:35921008.00 Occupancy'fype:
APPLICANT CF.RTI FICATION
I certify that I have read this application and state that the above information is
correct, I 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
indemnify and keep harmless the 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 Cade,Section Issued by: Date:
9.18,
Signature Dale
RE-ROOFS:
❑ O\VNF.R-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.Ira roof is
installed without first obtaining an inspection,I agree to remove all new materials for
hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the struciurc is nor 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 COV ERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three IL\%ARDOUS MATERIALS DISCLOSURE:
declarations: 1 have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insurc for Worker's California Health&Safety Code.Sections 25505,25533,and 25534. 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 Ilealth&
performance of the work for which this permit is issued. Safely Code,Section 25532(a)should I 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 which emit hazardous air
Section 3700 of the labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
pcmhil 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 Ilealth&Safety Code,Sections 25505.25533.and 25534.
not employ any person in any manner so as to become subject to the Worker's Owner or authorized agent:
Cumpensal ion laws of California. If,after making this certificate of exemption.I Dale:
become subject to the Worker's Compensation 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 conslfaclion lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec 3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
coffee]I agree to comply with all city and county ordinances and stale laws 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. ARCHITECT'S DECLARATIONcosts,and expenses which may accrue against said City in consequence of the
granting of This permit Addilionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulatims per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date