10060170 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 809 ROSE BLOSSOM DR CO;JTRACTOR:FAST WATER HEATER PERMIT NO: 10060170
OWNER'S NAME: JEAN SUN 126,11 132 AVE NE DATE ISSUED:06/28/2010
gER'S PHONE: 4088136633 KIFKLAND,WA 98034 PHONE NO:(800)454-8955
❑ LICENSED CONTRACTOR'S DECLARATION rF
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH F RESIDENTIAL r COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JO 3 DESCRIPTION: REMOVEIREPLACE GAS WATER HEATER
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I 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
performance of the work for which this permit is issued. Sq.Ft Floor Area:0 Valuation:$1055
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:35903005.00 Occupancy Type:
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 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 of Cupertino 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 and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date:
9.18.
Signature Date _
RE-ROOFS:
L-1 OWNER-BUILDER DECLARATION 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
I hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Sig iature 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I L ive 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. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the cor ipliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Sat ety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Ad Iitionally,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 coy taminants as defined by the Bay Area Air Quality Management District I will
permit is issued. ma ntain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
He dth&Safety Code,Sections 25505,25533,and 25534.
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 Om ner or authorized agent:
Compensation laws of California. If,after making this certificate of exemption,I _ Date:
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. CONSTRUCTION LENDING AGENCY
I hi reby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Le)ider'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 Lei ider's Address
upon the above mentioned property for inspection purposes.(We)agree to save
tmify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I ui Lderstand 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