B-2016-1634 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1634
20647 GARDENSIDE CIR CUPERTINO,CA 95014-5082(362 32 009) FAST WATER HEATER
11715 N CREEK PKWY
C106 BOTHELL,WA
98011
OWNER'S NAME: CHIU CHENG-I AND YIN HSIN I TRUSTEE DATE ISSUED:03/25/2016
OWNER'S PHONE:510-299-8841 PHONE NO:(800)454-8955
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: l
1
License Class PLUMBING Lic.#98739g X BLDG —ELECT —PLUMB
Contractor FAST WATER HEATER Date 10/31/2017 —
_
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
REPLACE 50 GALLON WATER HEATER
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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. Sq.Ft Floor Area: Valuation:$1530.00
APPLICANT CERTIFICATION
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 62 Number: Occupancy Type:
362
and state laws relating to building construction,and hereby authorize 332 009
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 PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date Issued by:Susan Winslow
Date:
OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the
All roofs shall be inspected prior to any roofing material being installed.If a roof is
following two reasons:
1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(See.7044,Business&Professions Code). Date:
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 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. HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance,as provided for by
California Health&Safety Code,Sections 25505,25533,and 25534. I will
Section 3700 of the Labor Code,for the performance of the work for which this
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued.
3. I certify that in the performance of the work for which this permit is issued„I Health&Safety Code,Section 25532(a)should I store or handle hazardous
material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of Will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
correct.I agree to comply with all city and county ordinances and state laws of work's for which this per
relating to building construction,and hereby authorize representatives of this city mit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records.
Code,Section 9,18.
Licensed
Signature Date Professional
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GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(400)777-3333-buil g0-gupertlno.ornMISC
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USP OF PG®tOUTLEX ❑ MULTI-FAMILY PROJECT IN WILDLANO ❑ YES PROJECT IN ❑YES IS71-MBLDGAN ❑Y13S
BUILDING: COMM13RCTAL URBAN INTBRPACE AREA C ❑ NO PLOpn ZONE ❑No. ) (Bt�CHLERA0ME7 ❑NO
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By my signature below,1 certify to each of the following; I am the property owner or authorized agent to eat on the property owner's behalf. I have read this
application-and the information t have Provided is correct. [have read the Description of work and verify it is accurate, [agree to comply with all applicable locale
ordinances and state laws relating to building construction. 1 authorize representatives of Cupertino to enter the abov0dentified property for inspection purposes.
Signature of ApplicantlAgent Date:
SUPPLEMENTAL INFORMATION REQUIRED
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A/1EPMis&4pp_29114oc revi.S-ed 06/21/11