10070120CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19840 BAYWOOD DR I COP TRACTOR: DEMPSTER PLUMBING PERMIT NO: 10070120
OWNER'S NAME: FULTON & KELCY CHEN I 1635 POMONA AVE I DATE ISSUED: 07/16/2010 I
1 --PER'S PHONE: 4085975877
G LICENSED CONTRACTOR'S DECLARATION
License Class 4L_-3 Lie.# D 8 _b
Contractor Date 7
I hereby affirm that I am licensed under the provisions of Chapter 9
(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:
t. 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.
2. 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 yv(ii9h/tfijs
permit is issued. (L�
APPLICANT CERTIFICATION
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
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify 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 with
all ur
non -point source
reg ions p r the Cupertino Municipal Code, Section 9.18.
Signatur/A Date 7 1/f /Zd
OWNER -BUILDER DECLARATION
t —reby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons:
t. I, 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, Business & Professions Code)
2. 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
t. 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.
2. 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.
3. I 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
Compensation laws of California. If, after making this certificate of exemption, I
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.
APPLICANT CERTIFICATION
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
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ts, and expenses which may accrue against said City in consequence of the
ing of this permit. Additionally, the applicant understands and will comply with
# ....ion -point source regulations per the Cupertino Municipal Code, Section 9.18.
Signature Date
SAN JOSE, CA 95110
PHONE NO: (408) 295-3911
JOB DESCRIPTION: RESIDENTIAL [:1 COMMERCIAL ❑
REP] PE IN L COPPER FROM METER TO ALL FIXTURES.
Sq. lit Floor Area: 0 I Valuation: $6500
APP Number: 31631016.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by �-� �— "ate: -�—�
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
instilled without first obtaining an inspection, I agree to remove all new materials for
insp.ction.
Sigr ature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
Cal fornia Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
coir pliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
He, Ith & Safety Code, Sections 25505, 25533, and 25534.
Owner
Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for vhich this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lei der's
ARCHITECT'S DECLARATION
I ur derstand my plans shall be used as public records.
Licensed Professional