B-2016-2984 CITY OF CUPERTINO BUILDING PERMIT
BUILDING 23ATE ORDDADDRESS: CONTRACTOR: PERMIT NO:B-2016-2984
7623 WATERFORD DR CUPERTINQ CA 95014-5243(36617 086) ECONOMY ROOTER
INC
SANTA CLARA,CA
95055
OWNER'S NAME: 2HENG LIANQUN AND LI XIAOWEN DATE ISSUED:10/25/2016
OWNER'S PHONE:408-249-4922 PHONE NO:(408)249-4922
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class_QW Lic.#892045
Contractor ECONOMY ROOTER INCDate 05131/2018 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(1)40 GALLON WATER HEATER-GARAGE
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
performance 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:$900.00
APPLICANT CERTIFICATION
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 36617 086
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 ainst said City in consequence of the granting of this permit.
Additional) h applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source reg r the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature'.% Date 10-25-2016 Issued by:Kim Dunbar
Date: 10/25/2016
OWNER-BUILDER R DEC ARATT(1N
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(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:10-25-2016
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 ofthe 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
s. 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 theBay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with tho Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Co ns 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:10-25-2016
I certify that 1 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
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.
Signature Date 10-25-2016 Licensed
Professional
- I
GENERAL 'PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•GUPERTINO,CA 95014-3255 '1 S C
CUPFFRTINO (408)777-3228•FAX(408)777-3333•building(?i�cupertino.org
Zdl� -egg
PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS , APN#
OWNERNAME
//Y PHONE. EMAIL
STREET ADDRESS 1 'ot CITY,STATE,ZIP FAX
CONTACT NAME
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STREET ADD S /1 .6 CIT STATE,ZIP �
11�d f(LID6V ?57
2/ FAX
❑OwNER ❑ OwNER-BuiLDER . ❑ OWNERAGENT LG CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER. E'TENANT
CONTRAC&A,Tv(� LICENSENUMBER LICENSE TYPE BUS.LIC'' -
COMPA NAME E-MAIL FAX
ST.RE T S `� CIT ,STATE,ZIP PHONE
ARCHITECTIENGINEER NAME LICENSE NUMBER - BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
TJSE OF 'F'D.rDUPLEX F1MULTI-FAMII,Y PROJECT IN WILDLAND ❑ YES PROJECT IN El YES IS THE BLDG AN ❑ YES
BUILDING:
El COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLERHOME? ❑NO
DESCRIPTI F 011
TOTAL VALUATION: ® &-0 RECEIVEI)BYy�,
By my signature below,I certify to each of th allowing: I am the property owner or authorized agent to act on the property owner's behalf. I bave read this
application and the infonnation I have provi d's 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 build' ction. I authorize representatives of Cupertino to enter the above-i entified ro/perty for inspection purposes.
/
Signature of Applicant/Agent: Date: L 0 b
SUPPLEMENTAL INFORMATION REQUIRED
_OfFICE USE ON
fl.h OVER-THE COI U TER
A. �i c
STAND CIiD
❑'':LAROE".
L�;,MAJOR-------------
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MEPMiscApp_2011.doc revised 06/21/11_