10010101CITY OF CUPERTINO BUILDING PERMIT
CONTRACTOR: FAST WATER HEATER
BUILDING ADDRESS: 883 SEPTEMBER DR
OWNER'S NAME: YEN SHOUCHERN &HWANG TSUEYUAN
4ER'S PHONE: 4085171121
LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor
Date
I hereby affirm that I am licensed under the provisions of Chapter 9
3 of the Business &Professions
(commencing with Section 7000) of Dives
Code and that my license is in full force and effect.
12601 132 AVE NE
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. provided for by
I have and will maintain Workers Compensation Insurance, as p
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that
te es and staove te ation laws relating
is
correct. I agree to comply with all city and county
to building construction, and hereby authorize representatives of this city to enter
inspection purposes. (We) agree to save
for ins
upon the above mentioned property P
indemnify and keep harmless the City of Cupertino d Cgainstity in cliabequence othe judgments,
costs, and expenses which may accrue against
understands and will comply
granting of this permit. Additionally, the app
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signa
I hereby affirm that I am exempt from e
the following two reasons:
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)
I, 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:
I have and will maintain a Certificate of Consent to self-insure
for on the Worker's
Compensation, as provided for by Section 3700 of the
Labor performance of the work for which this permit is issued. provided for by
I have and will maintain Workers Compensation Insurance, as p
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
I certify that in the performance of the work for which this permit is issued,
not employ any person in any manner so as to become subject t
Compensation laws of California. If, after making this certificate Labor Codeof ol must
become subject to the Worker's Compensation provisions of t
he forthwith comply with such provisions or this permit shall be deemed revoked.
Date
KIRKLAND, WA 98034
BUILDING
PERMIT INFO: BLDG
PERMIT NO: 10010101
DATE ISSUED: 01/21/2010
PHONE NO: (800) 454-8955
ELECT PLUMB
MECH RESIDENTIAL
f— COMMERCIAL
JOB DESCRIPTION: REMOVEIREPLACE GAS WATER HEATER**SEE NOTES**
I Valuation: $850
Sq. Ft Floor Area: 0
I Occupancy Type:
APN Number: 36212021.00
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
DAYS FROM LAST CALLED INSPECTION.
180
Date:
Issued by: --------------
ture
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
O
WNER-BUILDER DECLARATION installed without first obtaining an inspection, I agree to remove all new materials for
th Contractor's License Law for one of inspection.
Signature of Applicant:
APPLICANT CERTIFICATION
I certify that I have read this application and state thatordinances and stave te laws relating
ation is
correct. I agree to comply with all city and county
to building construction, and hereby authorize representatives of this city to enter
for inspection purposes. (We) agree to save
upon the above mentioned property P
nify and keep harmless the City of Cupertino against liabilities, judgments,
and expenses which may accrue against said u is in ands and will comply
nsequence of the
granting of this permit. Additionally, the applicant
with all non -point source regulations per the Cupertino Municipal Code, Section
19.18.
Date
Signature
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements undo and hapten 6.9I of the
maintain
California Health & Safety Code, Sections 2550 5,25533,
Chapter 9.12 and the Health &
compliance with the Cupertino Municipal Code,
Safety Code, Section 25532(a) should I store orhandle hazardous which emit hazardous air
l.
Additionally, should I use equipment or device
contaminants as defined by the Bay Area Air Quality Mancha ter ment Dist and the P
maintain compliance with 25505, 25533e Cupertino , and 25534.
Health & Safety Code, Sections
Owner or authorized agent: Date:
CONSTRUCTION LENDING AGENCY
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.)
Lender's Name
Lender's Address.
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional