B-2016-2770 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2016-2770
10383 HENEY CREEK PL CUPERTINO,CA 95014-0829(342 48 025) ALL VALLEY
PLUMBING INC
FREMONT,CA 94539
OWNER'S NAME; CHIANG STEPHEN SHENG AND CONNIE KONI TRUSTE DATE ISSUED:09/21/2016
OWNER'S PHONE:650-964-7139 PHONE NO:(510)661-9095
LICENSED CONTRACTOR'S DECLARATION BUILDINGPERMIT INFO:
License Class C=36 Lic.#794890
Contractor ALL VALLEY PLUMBING INC Date 02/28/2017 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 affirmunder 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
erformance of the work for which this permit is issued.
/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:$750.00
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 34249025
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 all
this permit. WITHIN 180 DAYS OF PERMIT'ISSUANCE OR
Additionally,the app ant understands and will comply with all non-point
source regul s the Cupertino Municipal Code,Section 9.18. 180 DAYS FROMTCA T CALILFJIDLgPFCTI1 N
Signat Date 09/2172016 Issued by:MELLSSA
Date:09/21/281.6
OWNER-BUri DER DECLARATION
I hereby 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
r. 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. 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:09/21/2016
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
2. I 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. 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
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 Ar a Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cope i o Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sect" s 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent: - f
APPLICANT CERTMCATION Date:09/21/2016
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this 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 against said City in Lenders 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 09/21/2016
Professional.
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION MEP
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228-FAX(408)777-3333•building(Qcupertino.org misc
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❑OWNER ❑ OWNER-BUILDER Il OWNER AGENT IR CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER TENANT
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USE OF ❑SFD or DUPLEX ❑. MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLERHOME? ❑NO
DESCRIPTION OF WORK L�
TOTAL VALUATION: �f C jj CEIVED B .
By my signature below,LI certify to each of the following: I am the property owner or authorized agent to'act t rty owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building c u I autbon resentatives of Cupertino to enter the above-identified�property for inspection purposes.
Signature of Applicant/Agent: Date: ° +t V�
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE US&:ONLY
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MEPMiscApp_201 Ldoc revised 06/21/11