07010059BUILDING DIVISION PERMIT
BUILDING ADDRESS:
101-V
OWNER'S NAME:
,CHEN FRANK T AND ANNE S
ONE:
ARCHITECTIENGINEER:
O p LICENSED CONTRACTOR'S DECLARATION
e u P I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
= Z vVi with Section 7000) of Division 3 of the Business and Professions Code, and my license is
I'- in full force and effect,
Z License Class Lic, #
3 F, z Date Contractor
ARCHITECTS DECLARATION
C4 U I understand my plans shall be used as public records
0
iC y Licensed Professional
n.'l OWNER -BUILDER DECLARATION
`> <x I hereby affirm that 1 am exempt from the Contractor's License Law for the
r Q O following reason. (Section 7031.5, Business and Professions Code: Any city or county
t $ which requires a permit to convect, alter, improve, demolish, or repair any structure
u Z y prior to its issuance, also requires the applicant for such permit to file a signed statement
< that he is licensed pursuant to the provisions of the Contractor's license Law (Chapter 9
YF (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
❑ 1, 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
and Professions Code The Contractor's License Law does not apply to an owner of
property who builds or imprnves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, due owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
ccnse Law does not apply to an owner of property who builds or improves thereon, and,
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exerypt under Seo. B & P C ar this reason
Owner Date 0
WORKER'S COMPENSATIONDECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
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] I have and will maintain a Certificate of Consent to self -insure for Workers Compen-
uttion, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
A & A
924 E FREMONT AVE
REPLACE WATER HEATER
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any mannersp a9 to becothe �hhiacd to the Workers' Compensation
Laws of Cali(o - ate SL
Applicant 0�,
NOTICE TO APPLICANT: If. a cr ma�ng tR, C rtatc of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Scc. 3097, Civ. C.)
Lender's Name
Lenders Address
I certify that 1 have read this application and state that the above information is
Correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon Lhc
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCF REGULATIONS /I(?/
(?/ () �
Signature of Applieant/Contraaar / !Signature of Deter
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes
Will the applicant or future boding occupant use equipment or devices which
emit hazardous air contaminants as cfincd by the Bay Area Air Quality Management
District?
[-]Yes u
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
reuuiremvpts which must be me -I prior to issuance of a Certificate oLOccuoancv.
Owner or authorized
Date
�q. Ft. Floor Area
3264705E.AVRVN
Issued by
Re -roofs
PERMIT NO.
PERMIT L95UE DATE
01/09/2007
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
$1250 Valuation
Required Inspections
Type of Roof
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
All roof coverings to be Class "B" or better
Date
%!
CITY OF
CUPEf�TINO
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
100 ao58
APN #
. -- Y_..___ _____
Water Heater / Vent
Plumbing Permit Issuance
Energy
Business License
Date: r /(� Z U 7
Building d r s:
2�� t (' A
Owner's N e:
- � N
rel
Phone #:
G --01 o-7
Contractor: Phone:
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5 ,- J b
License #:d�
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Contact: Phone:
Cupertino Business License #:
Building Permit Info:
BI d ❑ Elect ❑ Plumb lJ
Mech ❑
Job Description:
C,j ��. Gl i_'�it n,
S � t,�, a OJ
Residential Er Commercial ❑
Cost of Project: , oZ S C)
Strapped On Platform LcY Bonded [
❑
New Location Replacement
Qty. if
T _ TT
FPP llPcrrintinn
Fee Group
Applicame. Fee 1„
BPWHEATER
PPE FEE
BENERGY
BUSLIC
. -- Y_..___ _____
Water Heater / Vent
Plumbing Permit Issuance
Energy
Business License
BUILDING
PLUMBING
BUILDING
BUILDING