09080091 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10424 VISTA DR UNIT 13 CONTRACTOR:SOUTH BAY PLUMBING PERMIT NO:09080091
OWNER'S NAME: WILLIAM LIU 441 N CENTRAL AVE STE 3A DATE ISSUED:08/10/2009
ER'S PHONE: 4085060880 CAMPBELL,CA 95008 PHONE NO:(408)370-3535
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG� ELECT I— PLUMB
License Class Lic.#
MECH r- RESIDENTIAL� COMMERCIAL
Contractor Date
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE WATER HEATER
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty 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 Sq.Ft Floor Area: Valuation:$900
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 performance of the work for which this APN Number:31633130.13 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DA S FROM T CALLED INSPECTION.
indemnity and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18
Signature Date_
RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
✓ OWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons: Signature of Applicant: Date:
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE
I hereby affirm under penalty of perjury one of the following three 1 have read the hazardous materials requirements under Chapter 6.95 of the
declarations: California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain a Certificate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should I store or handle hazardous material.
performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I have and will maintain Worker's Compensation Insurance,as provided for by contaminants as defined by the Bay Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Section 3700 of the Labor Code,for the performance of the work for which this Health&Safety Code,Sections 25505,25533,and 25534.
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall Own thorized agent:
not employ any person in any manner so as to become subject to the Worker's _ Date e—Ar
Compensation laws of California. If,after making this certificate of exemption,1 16/
become subject to the Worker's Compensation provisions of the Labor Code,I must CONSTRUCTION LENDING AGENCY
forthwith comply with such provisions or this permit shall be deemed revoked. I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued(Sec.3097,Civ C.)
APPLICANT CERTIFICATION Lender's Name
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 Lender's Address
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
it lify and keep harmless the City of Cupertino against liabilities,judgments,
e. and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point sourc regulation r the Cupertino Municipal Code,Section Licensed Professional
9.18,
Signature Date���"
G
CITY OF CUPERTINO 01USOO
if
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
All 1�3 1 2 ` Date:
Building Address: :l
Or
Owner's Name: Phone #:
Contractor: Phone #: 3av -2�r
go,71- j�al ���'�,' l '"`9 Fax #:
Cupertino Business License #: Contractor State License #:
22 60 5 -( 2 � - 7
Contact: Phone #:
A I-ex Fax #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb K Mech ❑
Residential 14 Commercial ❑
Job Description: �
�� G
Strapped E0 On Platform 0 Bond& ❑ New Location ❑ Replacement
Valuation (cost of project): h4<
Project Size: Express ® Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to
the application or if applicable, include in plan set & the sheet index.
Green Building Points achieved:
Revised 01/07/09
CITY OF CUPERTINO
WATER HEATER
CUPS Of
PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCWHEATR Commercial Water B PCWHEATR
HeaterNent
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission FE;e .
1BSEISMICOM Seismic Commercial B
f 1PRWHEATR Residential WzLter B PRWHEATR
HeaterNent
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
1BSEISMICRE Seismic Residential B
` 1PPERMITFEE Plumbing Permit P
1 TRAVDOC Travel & B
Documentatio n
1BUSLIC Business Lice:.ise B