12110055 CITY OF CUPERTINO BUILDING PERMIT
BUI LDING ADDRESS: 10360STOKESAVE CONTRACI'OR:AFFORDABLE WATER PERMIT'NO: 12110055
BEATERS&
OWNFR'S NAME: JOHN VALLIS&FANG GANG 28372 CONSTELLATION RD DA'Z'E ISSUED; 11109/2012
OWNFR'S PHONE: 5105412670 VALENCIA.CA 91355 PHONE NO:(661)259.7131
❑ LICENSED CON'TRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT❑ PLUMB
License Class Lic.t!
MEC11 r RESIDENTIAL J COMMERCIAL J
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE WATER Ii EATER,SAME LOCATION
(commencing with Section 7000)of Division 3 of the Business S Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the fallowing 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:$2179
1 have and will,maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of Ute work for which this
permit is issued. APN Number:32647015.00 OccupancyType:
APPLICANT CFRTI FICATION '
I certify that I have read this application and state that the above information is '
correct.l 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 ofCupertino 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 mid will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date:
9.18.
Signature Date
RF:ROOFS:
❑ OWNER-BUILDER DECLARATION All roots shall be inspected prior to any roofing material beiig installed Ira roof is
installed without first obtaining mm inspection,I agree to remove all new materials for
hereby affirm that I am exempt from the Contractor's License Lav for one of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(See.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS I'D BE CLASS"A"OR BE I"1'ER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HA'LARDOUS\IATF.RIA S DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.9.5 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Ilea It It S Safety Code.Sections 25505,25533,and 25534. I 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 Health&
performance of the work for which this permit is issued Safety Code.Section 25532(x)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 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.I_and the
p Ilealth S Safetv Code.Sections 25505,25533,and 25534.
1 certify that in the performance of the work for which this permit is issued,I shall "
not employ any person in any manner so as to become subject to the Worker's Owner or authorized agent:
Compensation Imus of Califomia. If,after making this certificate of exemption,I Date:
become subject to the Worker's Compensation provisions of the Labor Code,1 must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
I hereby affum that there is a construction lending agency for the performance of work's
APPLICA\1'CF.RT'IFIGVI'IO ' for which this pernit is issued(Sec.3097,Civ C.)
I certify that l have read this application and state that the above infommtion 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 for inspection purposes.(We)agree to save
indemnify and keep harnless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCII ITEC`I"S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply I 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