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B-2016-2759 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-2759 10841 JOHNSON AVE CUPERTINO,CA 95014-3879(375 31 066) FAST WATER HEATER 11715 N CREEK PKWY C106 BOTHELL,WA 98011 OWNER'S NAME: LI YONGNAAND jSONG NINE DATE ISSUED:09/19/2016 OWNER'S PHONE:408 726 1896 PHONE NO:(800)454-8955 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class PLUMBING Lic.#9873!98 Contractor EAST WATER HEATER 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: REMOVE/REPLACE 38 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:$1888.00 APPLICANT CERTIFICATION 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 375 31 066 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:Patricia Garcia Date:09/19/2016 OWNER-BUILDER 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 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(See.7044,Business&Professions Code) 2. I,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 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.theperformance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)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 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 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 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 Code,Section 9.18. I understand my plans shall be used as public records. Licensed Signature Date Professional vsi �;,f Lv�c -W" ... �v =CILiir�i=rPct�iY�lirKri'I�E%rH I IVr4 ��� 1�� Lia COMMUNITY DEVELOPMENT OF •BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 D26C�PEF�`1`Ml0. • (`Io9)777-3228•F.AX(406)777-3333•B ild n e I MI.S C MBING MECHANICAL DELECTRICAL MISCELLANEOUS A l6— q PROJECT ADDRESS APNA OWNERNAMB E-MAtL STREET ADDRESS ' CITh,STATE, lP PAX D 1 CONTACT NAME V 1 PHONE 1 � H-MAIL ST.REETADDRHSS. 111rrr ,.9T E,ZIP - FAX ❑OWNER © OWNER•eUMDBR ❑OWNER AGENT MUCTOR ❑COMMACrOILAUNT ARCWTBCT ❑8NOWAR ❑ D13VELOPBR ❑'fEN0.NT CONTRACTOR NAME n LICENSE R T E TYPE HUS,LIC G COMPANY NAME STREET DRES d `(�b crrY. AT ztP Pxo 16 -,b3L-2v ARCHITECT/ENGINEER NAMP• UC8NSE NUMBER BUS,LIC R COMPANY NAME E-MAIL PAX STREET ADDRBSS c[ry,STATE.ztr PHONE USE OF 13 SPDOrDUPM ❑ MULTr-FAMILY PR01ECTmNWI]DLAND ❑ YES PROJECTIN ❑YES ISTMOLDOAN ❑YES BUILDnNor ❑COMMERCIAL URBAN INTERFACE AREA Q NO VLOOD ZONE Q M0 2I041.E1k HONM? ❑NO DESCRIPTION Of WORK k ,)aj�p TOTAL VALUATION: ,lt 13y my Signature below,I certify to each of the following; I am the property owner or authorized agent to action the property owner's behalf. 1 hove read.this application and the Information 1 have provided Is correct, I have read the Description of Work and verily it is accurate. (agree to comply with all applicable local ordinances and state laws relating to building H115truotion. I authorize representatives of Cupertino to enter the above-ident N property for inspacfion purposes, Signature of Applleant/Agent: Date: (1 JGIIQ SUPPLEMENTAL WFORMATION REQUIRED t ' I 1111EPMfi7c,pp_20Il.doc revised 06121/(1