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CITY OF CUPERTINO
Q ",
CONTRACTOR INFORMATION
BUILDING DIVISION PERMIT
pulLPIM2A7&isE3AHL ST
JUST WATER HEATERS INC
PERMITNO2110041
OWIIr DN@AVALLINI
1764 NATIONAL AVE
APPLICATT11YUl61)T 2002
ONE:(510)293-9901
SANITARY NO. CONTROL NO.
ARCIRTECTIENGINEF,R:
BUILDING PERMIT INIU
BLDG ELECT PLUMB MECII
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licenced under provisions of Chapter 9 (commencing
0100
REPLACE WATER
with Seener71k0) of Division 3 of the Business and Professions Codc. and my liecnmis
in full function! effect.
( 5 O GALLON GAS )
License Class Lic.N
°ate TfiC on DECLARATION GtSDECL
ARCHIARATION
DEC 1 3 2002
1 understand my plans shall he used as Public Trends
BUILDING
Lieresed Proctsim ul
U DECLARATION
Oat
1 hereby rept fir
I am exempt
that 11. cxcmpl foam me Comms Law far tW
Any
reason. (Ser Co :
iooli Code: Any city no aunty
"ores (Section ]03L5, Business and c
whfolch requires a Permit m ss. de
alley, impress. demolish. or repair any tremor
$829
,mm, t mrsuun,
f far suchpermit nfile ssigned snnmem
priorms its issuance,also myI) the the provisions y
mincingwidwrction7thepravi,ision3(necemmemsandPhaeLaw
Sq. Ft. Floor Area Valuation
(comthat
(commencing Section ]Ia of 'sC(al(Chapter
Gdc) of
Busaged exempt
(cat
32613102.00
he is basis for theif
d al on. Any si
Nal he is exempt the¢frnm and the basis for the allege) exemption. Any violadnn of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more thanfive hundred dollar, (E500).
APN Number
Occupancy Type
502 - FINAL PLUMBI
G ENERGY
[:]I. as owner of use, property, or my employees with wages az their sole eompewdcar,
will do the work, and the mare ere is not intended or offered for sale (See 70411, Business
5e6 GAS T -F
and Pmfessinav Code: The Conuacmrs License Law does not apply to an owner of
507 - F I NALjgc i1jq _pections
property who builds or improves demon, and whodoes such work himself or borough his
own employees. pmvded that such improvements arc not intended oroRceml for sale, If,
however, the building or improvement is wild within one seat of completion, the owner -
builder will have the burden of proving that W did not build or improve for purpose of
sale.).
❑ I, as owner of the progeny, am exclusively compacting with licensed contractors n
mswa the project (Sec. 7044. Business and I'Mmsomeas Code:) The Conteanmi Li-
cense Li w does not apply to an owner of property who builds or improves thereon, and
who cnnuacts for such peri with a contriteness) licensed pursuant o the Contractor's
License Law,
I am exempt under Sec. ,B& P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby a?an under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self insure for WorkersCompcn-
motion, as provided for by Section 3700 of the labor Calc, for Use performance of the
work for which this p .,I is issued.
❑ 1 have and will maintain Worker's Compensatinn Insurance, as required by Student
3710 of one "Nor Code, for the performance of the work for which this permit is issued.
My Warker i Compensation Iran.. courier amt Policy number art:
Cance. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This asedon recd not Wcompleted iftM pemiil is foronc hunmeddollars (ERAq
les"')
1 certify Nat in the performance of the work for which Nis Permit is issued, [shall nal
employ any person in any manner IT, as n become subject o the Worker' Compeandon
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Cenificam of Exemption, you should
become subject to the Worker's Compensation provisions of the "NIT Code, you must
forthwith comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hcrchy affirm that there is a cormfunion lending agency for the performance of
the or, for which his permit is issued (Sec. 3097, Civ. C)
Lender's Name
lF tle AJdtess
I certify Out 1 have read thisapplication
and coup and dna Nm the about information
rcn, I agree n complyand with all city and county ordinances ng is
and wart laws relating
{�
building construction. and hereby authomc representatives of his city to corer upon me
of e
/
aWvc-ms.judg d progeny for penes pearprowhich
(We) agree to save, indemnify and keep harmless the City of Cupertino against
a
ms.
cows and expenses which may in any way attrvc against said City
hies taus
in ou of the
anhcRantingaSA pe
of this
nLICA
T WILL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by. Date
SOURCE REGULATIONS.
Re -roofs
Solution of ApplicanOCunoamor Dan
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant o1 future building ..part more o, handle ha,adous matnial
as defined by the Cupertino Municipal Gine, Chapter 9, 12. and the Health and Safety
Roam 25532(a)'!
O Yes 0 N
All roofs shall be inspected prior to any roofing material being installed.
�Cok,
Win mea applicant or Iunm building Occupant use e
pp b p or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
g p
mit ha,adous air contaminants as defined by the Bay Arca Air Quality Management
a Air Qu
all new materials for inspection.
DistriclP
❑Yes 0 N
I have head Be hamdous materials equimmmnrs under Chapter 6.95 of be Califer-
malhath & Sultry Code. Sccuonv 25515.25533 and 2551%. l understand Nat if me Wilding
does not currently have a tenant, BUT it is my responsibility of nouly the (occupant of die
requirements which mum M mel Friono issuance of a Cmifcm, of Occupancy.
SIgOffiUTC Of Applicant Date
All roof coverings to be Class "B" or better
Ownerm aathmied agent Date