12100081 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10607 GLENVIEW AVE CONTRACTOR:AFFORDABLE WATER PERMITNO: 12100081
HEATERS&
OWNER'S NAME: TANG KEVIN FISIAO-CIIANG AND HUANG IIU 28372 CONS`fELLATION RD DATE ISSUED: 10/1012012
OWNER'S PIiONIE: 4083102662 VALENCIA,CA 91355 PHONE NO:(661)259-7131
❑ LICENSED CO\FRACfOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUNIB I✓
License Class. Lia b
MEC11 [ RESIDENTIAL(_I COMMERCIAL IJ
Contractor Date
-
I hereby affirm that I um licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE WATER HEATER,SAME LOCATION
(commencing w'ilh Section 7000)of Division 3 of the Business&Professions
Cade and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
1 have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of(he Labor Code,for the
performance of the work for which this permit is issued. Sq.FI Floor Arca:0 Valuation:$2662
1 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.36926024.00 Occupancy Type:
APPLICANT CERTIFICATION
1 certify that 1 have read this application and state that the above information is
correct.l agree to comply with all city and county ordinances and state law's relating PERMIT EXPIRES IF WORK IS NOT STARTED
m 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(he City ol'Cupertinoagains[liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of this pernit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Issuer] bv: Date:
9.18.
Signature Date
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.Ira roof is
instilled without first obtaining an inspection,I agree to remove all new materials for
1 hereby affirm that 1 um exempt from the Contractor's License Law formic of inspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Dote:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Busineis&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALI,ROOF COVERINGS-1'O BE CLASS"A"OR BF-ITER
construct the project(Sec.7044,Business&Prolcssions Code).
I hereby affirm under penalty of perjury one of the following three I IAZARDOUS NIATF.RIALS 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 Ilealth&Safely 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 Ileallh&
performance of the work for which this permit is issued Safely Code,Section 25532(a)should I store or handle hnzardous 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 ofthe Labor Code,for the performance of the work for which this contaminants as defined Iw the Ray Area Air Quality Management District I will
permit is issued. maintain compliance with The Cupertino Municipal Code,Chapter 9.12 and the
Health&Safely Code,Sections 25505,25533,and 25534.
1 certify that in the performance of lie work for which(his permit is issued.I shall
not employ any person in any manner so as to beconhe subject to the Worker's Owner or authorized agent:
Compensation Imus of Califomia. If,after making this certificate of exemption,1 Date:
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
I hereby oRmi that there is a construction lending agency for the performance of work's
APPLICAN f CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
1 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 had state laws relating
to building construction,mid 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. A RCA ITECI"S DECLARATION
costs•and expenses which may accrue against said City in consequence of the
griming of this permit.Additionally,the applicant understands and will comply 1 understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Date '