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B-2016-2630 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2630 10411 FLORA VISTAAVE CUPERTINO,CA 95014-1605(326 28 073) EFFICIENT WATER HEATERS INC SAN JOSE,CA 95110 OWNER'S NAME: HUNG ANGELA DATE ISSUED:08/31/2016 OWNER'S PHONE:408-667-0119 PHONE NO:(408)393-3187 LICENSED CONTRACIOR'S DECLARATION BUILDING PERMIT INFO: License Class 3-36 Lie.#1008381 Contractor EFFICIENT WATER HEATERS INC Date 10/31/2017 X BLDG —ELECT X PLUMB 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: I hereby affirm under penalty of perjury one of the following two declarations: REPLACE 50 GAL WATER HEATER(SAME LOCATION i. 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 ormance of the work for which this permit is issued. z. 1'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:$1500.00 APPLICANT CERTMCATION 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 APN Number: Occupancy Type: and state laws relating to building construction,and hereby authorize 326 28 073 representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the may accrue against said Ci s,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED City of Cupertino against liabilities,judgments,cost y g City in consequence of the granting all this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR :Additionally,the appl' t understands d will comply with all non-point source regulatio P he Cu unicipal Code,Section 9.18. 180 DAYS FROM LAST C LED INSPECTION. Signature Date 08/31/2016 Date:08/31/2016 Iereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1. 1,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) z. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date:08/31/2016 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1. 1 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 z. 1 have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 3. 1 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 shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous 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 Munic' de,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Cod ec'ons 2 ,255 ,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:08/31/2016 1 certify that I have read this application and state that the above information is -CONS CTION LENDING AGENCY correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that the s a construction lending agency for the performance relating to building construction;and hereby authorize representatives of this city of work's for which th s permit 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 iagainst said City in I Lender's Address consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code,Section 9.18. 1 understand'my plans shall be used as public records. Licensed Signature Date 08/31/2016 Professional GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDINGMEP DIVISION 10300 TORRE�AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO: (408)777-3228•FAX(408)777-3333•building&cupertino orq misc MECHANICAL L �, ¢® EIELEcTRicAL r 2Q 6 MSZC EL�LCAN-EOUUS PROJECT ADDRESS Q APN# 3 O �- .NER NAME A PHONE E-MAIL STREET ADDRESS / // ` IJ , STATE,,ZIP /( (l/ �CL�Y/� �( S�� v�• CITYFAX CONTACT NAME 9 - /� PHONE �t / / -a Z r E C J �f4t..i! y� STREET ADDRESS CITY,STATE,ZIP 4�L FAX El OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT \V CONTRACTOR ❑CONTRACTOR AGENT ❑. ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR ;s ` CPQ v � LICENSE R �� LICENSE TYPE BUS.LIC# COMPANY NAME ��frf'C!-�r MAI STREET ADDRESS CITY,STATE ZIP P ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑ SFD Or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE:: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK f j�X � c 10 �l'•l •�C TOTAL VALUATION: `RECEIVED$ - By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have pro ' G is correct. Ij av Description of Work and verify it is accurate. I agree to compI with all applicable local ordinances and state laws relating to din onstructio I a o representatives of Cupertino to enter the above-ide ed proper or imspec' n purposes. Signature of Applicant/Agent: Date: g /1120 PLEMENTAL INFORMATION REQUIRED " O FIC) USE O]YLY W OVEN-THE COIJNTER �" ❑: EXPRESS � ❑I STANDARD LARGE,.- ❑_ MASOR"'. MEPMiscApp_201Ldoc revised 03/16/11