12110058 CITY OF CUPERTINO BUILDING PERMIT
I UILDING ADDRESS: 10598 17LORA VISTA AVE CO\1'RACI'OR:AFFORDABLE WATER PERMIT NO: 12110058
HEATERS R
ON;NER'S NAME: JOSEPH PAUL&HWANG WEI 28372 CONSTELLATION RD DATE ISSUED: 11/09/2012
OWNER'S PHONE: 4089960347 VALENCIA,CA 91355 PHONE NO:(661)259-7131
❑ LICENSED CON'fRACfOR'S DECLARATION BUILDING PERMIT INFO: BLDG I_ ELECT❑ PLUMB G
License Class Lie.q
_ r
hIECII r RESIDENTIAL r COMMERCIAL
Contractor Date
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE WATER HEATER,SAME LOCATION
(commencing with Section 7000)of Division 3 of(he Business&Professions
Code and that my license is in full force and effect.
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.FI Floor Area:0 Valuation:$3264
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:32608036.00 Occupancy T)pe:
APPLICANT CERTI FICAT'ION
1 certify that I have read(his application and stale that the above information is
cored.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 6ty of Cupertino against liabilities,judgments, 1811 DAYS FROM LAST CALLED INSPECTION.
costs,grid 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 regulmiau per the Cupertino Municipal Code,Section Issued bv: Date:
9.18.
Signature Date
RF.-ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a 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(heir sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to AL1.ROOF COVERINGS TO BE CLASS"A"OR BE'1-1'F,R
construct the project(Sec.7044,Business&Professions Code).
hereby affirm under penalty of perjury one of the following three IIA-/,ARDOUS i\IATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure 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 Health&
performance of 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
permit is issued. maintain compliance with the Cupertino Municipal Cade.Chapter 9.12 and the
p Ileadth&Safely Code,Sections 25505.25533,and 25534.
1 certify that in the performance of die 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 laws ofCalifomia. If,after making this certificate of exemption,I (late:
become subject to the Worker's Compensation provisions of(he Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRIICFION LENDING AGENCY
I hereby affimn that there is a construction lending agency for the performance of work's
APPLICANT CERTI FICAT'ION 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
cored.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 harmless the City of Cupertino against liabilities,judgments, ARCIII'1'FCI"S DECLARATIONcosts,and expenses which may accrue against said City in consequence of the
graming of this permitrAdditionally,the applicanl understands and will comply I understood 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