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B-2016-1960 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1960 20432 SILVERADO AVE STE 5 CUPERTINO,CA 95014-4454(369 52 005) A T C SERVICE INC SUNNYVALE,CA 94085 OWNER'S NAME: FANG FRED AND JOANNA DATE ISSUED:05/17/2016 OWNER'S PHONE:408-309-5995 PHONE NO:(650)968-1100 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class WARM-AIR HEATING VENTILATING AND AIR-CONDITIONING Lic.#524622 X_BLDG _ELECT X PLUMB Contractor AT C SERVICE INC Date 03/31/2018 _MECH X RESIDENTIAL_COMMERCIAL 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 JOB DESCRIPTION: license is in full force and effect. UNIT 5A-REPLACE 3 GAL WATER HEATER BENEATH BATHROOM SINK 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. z. 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 Sq.Ft Floor Area: Valuation:$800.00 permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above 69 Number: Occupancy Type: 3 information is correct.I agree to comply with all city and county ordinances 369 52 005 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 PERMIT EXPIRES IF WORK IS NOT STARTED City of Cupertino against liabilities,judgments,costs,and expenses which WITHIN 180 DAYS OF PERMIT ISSUANCE OR may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point 180 DAYS FROM LAST CALLED INSPECTION. source regulations per the Cupertino Municipal Code,Section 9.18. _ (Y � Issued by:Abby Avende Signature/ 1j ' \ Date 5/17/2016 Date:05/17/2016 au�, G�(AIU 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: installed without first obtaining an inspection,I agree to remove all new materials for 1. I,as owner of the property,or my employees with wages as their sole inspection. compensation,will do the work,and the structure is not intended or offered for sale(Sec.7044,Business&Professions Code) Signature of Applicant: i. I,as owner of the property,am exclusively contracting with licensed Date:5/17/2016 contractors to construct the project(Sec.7044,Business&Professions Code). 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 HAZARDOUS MATERIALS DISCLOSURE performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the z. 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. Health&Safety Code,Section 25532(a)should I store or handle hazardous s. I certify that in the performance of the work for which this permit is issued,I 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 will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and Worker's Compensation laws of California. If,after making this certificate of the Health&Safetyode,Sections 25505,25533,and 25534. 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 Owner or authorized age be deemed revoked. Date:5/17/2016 APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is 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 permit is issued(Sec.3097,Civ C.) relating to building construction,and hereby authorize representatives of this city Lender's Name to enter upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address judgments,costs,and expenses which may accrue against said City in 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 Professional Signature Date 5/17/2016 GENERAL PERMIT APPLICATIONMEP COMMUNITY DEVELOPtdiENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333• building(a cuoertino.org CUPERTINO U I Z & — Q 6� l �e V ®PLUMMING ❑I'ECILANICAL []ELECTRICAL / ❑MISCELLANEOUS PROJECTADDRESSS��VQ � I APN# {B S U11 s— 57F-5 OWNERNAlt / , P ��E 3Og-��9 E-M-AIL STREET ADDRESSM y 1D A JIY(.ST�AT�ZIP y� g A/ - ?(�� CO. Kkla r� $H � -7-1 E-AZAIL CIT�f.ALIT NU v�`� g FAl qZg El OWNER ❑ 01AI r'-F.t-BUILDER ❑ OWNER AGE\T CONTRACTOR ❑CO\"TRACTOR AGE T ❑ ARCHITECT ❑ENGIEER ❑ DEVELOPER ❑ TENAI.'T CONTRA 0 S C C / C� LICE�UD lj Z Z LICE' ZG 3 BUS.LIC O r. COMPANY E-MAIL (' FAY, IT S; gblpRESSn /z CITSTA E, A/RCHJTECTT/ENG NEERNAI,4E LICENSE NUMIDER F�BUS.LIC r COMPANY NAME E-kiA1L FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ NiL-LTI-FAMILY PROJECT IN R'ILDLAN'D ❑ YES PROJECT IN ❑YES IS TAE BLDG AN ❑ YES BUILDIING: ❑CONLKEE tC1AL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO DESCRIPTION OF WORK Lc)�4 /�'� V vl� S c �1 �J a'' I ►^fib TOTAL\CALUATION: �Q RECEIVED Bl ; By my si_*nature below,I certif},to each of the following: I am the property owner or authorized agen act on the 'o N h read this application and the information I have provided is collect. I have read the Description of'Work and verify it is accura e. (agree to comply with all applicable local ordinances and state laws relating to ildingc onstruc'on I z orize representatives of Cupertino to enter the above-identified property for inspection purposes. IS- Signature of AD. tti-- Date: j to SUPPLEMENTAL INFORMATION REQUIRED usmv s ❑ EaPR-ESS� �,�a ,s a� i. ' �. ❑ ST-TA1\T34RD fiz'�F.r e- + �w� RJt �1EPl/isc,4pp_2011.doc remised 06/21/11