12090235 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10390 MORETTI DR CONTRACTOR:PAST WATER HEATER PERMIT NO: 12090235
OWNER'S NAME: SANG KIM&JOYCE CHEN 12601 132,U'E NE DATE ISSUED:09272012
OWNER'S PI IONS: 4084800818 KIRKLAND.NS\ 98034 PHONE NO:(800)454-8955
❑ LICENSED CON'TRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT ri PLUMB r
License Class Lie.q
blECll r RESIDENTIAL r COMMERCIAL r
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9 3OB DESCRIPTION:REMOVE AND REPLACE GAS WATER HEATER IN
(commencing with Section 7000)of Division 3 of the Business&Professions EXISTING
Code and that my license is in full force and effect. LOCATION
1 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.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the perfommnce of the work for which this Sq.FI Floor Area:0 Valuation:$1136
permit is issued.
,U'PLIC,\N'I'CERq'I FICVI'ION APN'Number:37515002.00 occupancy Type.
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 Imes relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments, -
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: Date:
Signature Date
❑ OWNER-BIIILDF.R DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Lav for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the properly,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BE9-I'ER
hereby affirm wader penally of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Workers IIA%ARDOUS MATERIA S DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of(lie work for which this permit is issued California Ilcalth&Safely Code.Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ileallh&
Section 3700 of the Labor Code,for the performance of the work for which(his Safety Code,Section 25532(n)should I store of handle hazardous material.
Additionall),should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air QualityManagement District I will
I certify that in the performance of One work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Ilcalth&Safety Code.Sections 25505,25533,and 25534.
Compensation laws of Califomia. If.after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
CONS'TRUC1-ION LENDING AGENCI'
A PPLI C\NI'CERTI FICTION
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
comcct.I agree to comply with all city and county ordinances mrd state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned propcny for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accme against said City in consequence of
granting of this pemtit Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulatirns per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records:
Signature Date Licensed Professional