01050183 CITY OF CUP.RTINO
nun.DINO DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRIH So PERMI'I'NO.
10455 N EY AV JUST WATER HERTERS INC 01050183
OWNHICS NAMP_' APPLICATION SUI{DATE
S 1764 NATIONAL AVE 05/25/2001
HONE: SANITARY NO. CONTROL NO.
01
❑aZ AltClll'1'IiC'I'/I{NC1Ni:lilt BUILDING PERMIT INTO
V,O O IILfIO IiLECIPLUMB MUCH
F� LICENSED CONTRACTOR'S IITCLARATION
zz�'� 1heron af�l mttlI ..n licensedemdet rcl,n 9lmmmer i" Job Description
ya -Prndion.,o per, g
F° wilt Sidon.9rEID)of Dlvieion 3 mane limina..and 1'mfessicam Col,and Inv Iknase
6 n in fell furca and cooed.
ill ueansecDs REPLACE 50 GALLON GAS WATER HEATER
°sl :d o Dam Conitocror
m 3 u.vG ARCHI"fEC'J S DECLARATION
I understand my pinna shall he..sae os public rccnd,
z S
OO I'mcnsnl Pool u4nnd
n a OWNER)excooDER DECLARATION
I hetahy alien that I ton eBasur sfirrad
the Cs,ions of I A nye Law for the
F.-/,�- ¢ mllow i.. n a.(SoHo..7011 5, t,aft nta ProOntario,
d s li Cndc:Any do st tory
$ASO wl q 1 u n 1 pp 1 1 el ani aV al m
F+� p 1 I ear II hr n,Il fl signori arboreal
��—
11.,'her, : 1 ll n I' n Contractors Law Chapter ol S FL Floor Arca Valuation
or y d tie vola{ ne, t n a pit Ir 1 _gym...alien q'
or trial IlyI and lo11 f '0 Illthe 1 A1vbhfn,
ofS f , Ira 51l y III , ...65 hj a;the III rI bol lw all)
nr n n ,are Iran me hllnwal dnaars rs5no{. APN Number Occupancy'Type
o fa,I........I R1,Ir1on Y Y croployces cithwages as[licit sellpons fro. 31633110 00
sell It ffic work I 11h,. n-faclarc s let in, l d I re 1 ho lill(So, 9044.
B II selectors Cod,'I Ile Cos 1.1cclore Law doespyt an Required Inspections
'
I Pray WI 1 Id- 'npmae. lhccl, ll wh A u h
Bach work 'nsdf�I 61 1 1' y ..L '`" ' pm;Or
iiooAee a 502 — FINAL PLUMBING ENERGY
n11 II sal 11 I n 1 ,fly p cit sold dr ,neywrnf
,..plena,the,w,,.hl lderVIM have he hander of ptnvmg that he did not i of 506 — GAS TEST
mprnvc r......pose el,alo.l.
F3 1.asawnern the prapetly,an,..silo.ivelycnflictingwith heeuaedcoolntnarsm 507 — FINAL PLUMBING
coreanict p'ci,r(SO,.]ILW B I Pri:'' Code I I[I.C Ir tot,rn
Li ['low "Ply III coo owoci of[acicity { hiolds Or-on,owesInca..
t 1 still 'IfOrt, 1, erlorl 11th it inter,ion,) 1111.11col po neat In the
Coner,elce,I' I
El Ian exc,pl order Set. ,I3&P C file this t e.nt
O,al Dale
WORKER'S COM PENSA'DON DECLARATION
hereby
I ullrm Mcr Pncnalry of per one ill'the following duluratlnns:
❑ I hone and will ni,iinair a Cerlilemo of C,msenl to self-metol.for Worker's
Cnug)—arlan, ;is pmvlded for by Section 3700 of the L,hor Code, far Ow
pmmnllnee of the work for which This per nil Is mfeed.
❑1 brae wW will notation Worker's Compencalion Instmnec...s.matted by Section
3700 of Inn Labor Cnde,Ino the PcrRsocau,of fl,work for which Nis pennll is
ssunl.My Workers Cnmpcnsatl ce Insurance currier line Policy number are:
Car wr: Policy No:
CFRT FICA'L'ION Oil EXLMP'IION l7bo b WORKERS'
COMPENSATION INSURANCE
(Toth sectioll need not he cnnaplded if the her nn to for one horn l dnllhm
ON 100)orIess.)
I Nndy Ihm in the performance of the wn.R for which This prnnit is issued,1
shall nor....piny!Lily persau to uuy n,wlner so is In become subject to the Wnrkery
(sanlwnsroon 12111 ill'C:ddomia.Dam
Applicant
NOT'ICRol0 A to'he
Worker
If,or,making Nis.or, cele of Exemption,you ti no-1
oold
cohlit.sn hjcal unhc WnhcM1CQsmporvmfon pnrvtst%ha o he(I Laical O,ok you nwsl
Q � I'canhwith c ..,ply win,such prc,tuum or This Pel tel shell he Aecrnul avnked.
Z
FNCY
CONS...,,. ONLctkao eOfi n,a
pp ,olk In,which ohm lhrra,I, nod(So,
lend,Col.C.cy for performance
W Fy of Inn work Tor nolle,This pcmeit is issuul(Sm.0099,Col.C.)
(� Lenders Nnmr,
Z Lender's Address
W1 molly 111,11 hoe recd this appnc,nin,and stole Inco the above Infonn:ninn is
cGy antrum.12Um et men,ply wilt all ciey and en,lmy ntliernces and stole hewn o laling
Q V mbuildmg maslmadnn,rill hetehy;nuhcarize rcpresoval'mes or this o lly I,orru POI
�„ ry
the nbnvecmemiciod pmpc.ty for inspection pttTuses.
y (We)rise. ocse,Indemnify omd keep harmless tire City of Cuppntno:egaiml
V] liahihoics,'InPor nl,S amts nod expenses which rely ill any any iconic agoor,said
SOURCEREGULEItOTANDSANDWILLCOMPLYWI'tHALLNONPOINT Issued
SWRCE RLOULATIONS, y: Date
sigrelnrenrAppliennticonleanr Dale Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
will the nry Ii, nrl..nnebeddingnmapamsone I,noodle harnmenl tnmvdal Type ofRoof
as def and by the Cnpenina Municipm Cede,Chapter 9.12,and the Icahn and Safety
Cud,S-orni 25532u19
0Y, 0N All roofs shall be inspected prior to any roofing material being installed.
wP roe aphheant or Ionic bnndiag Dec..pair(rise imipenem nr duvlea'w1110h If if roof is installed without first obtaining an inspection, I agree to remove
elan hazarolous auas dem,ed by the lay Arc,Atr QuaLy Manrgemem
District p all new materials for inspection. Applicant understands and will comply with
I Yes ❑"° all non-point source regulations.
I havo mad the hnmrdous ntoleriols rcgnlreamnts eeMer 4,I Anr h.95 of Ih,
if lie IN I ninth,IS r coy Cody Secs brain,2550.5,25533 and 25931 andot rob) that
ifthebnl lin fiecn Dololrs elbanaolerIct it toyrcy,ol ni i,ymnobly I Lc
eenpanl of the mquirnncnls,ahieh oma he mel poor to Iwu:mm cat u Ccnihww of
Om..pemey.
Signature of Applicant Date
Owner aran@ndxell agnnt Dale All roof coverings to be Class "B"or better
OFFICE
CITY OF CUP.RTINO
nun.DINO DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRIH So PERMI'I'NO.
10455 N EY AV JUST WATER HERTERS INC 01050183
OWNHICS NAMP_' APPLICATION SUI{DATE
S 1764 NATIONAL AVE 05/25/2001
HONE: SANITARY NO. CONTROL NO.
01
❑aZ AltClll'1'IiC'I'/I{NC1Ni:lilt BUILDING PERMIT INTO
V,O O IILfIO IiLECIPLUMB MUCH
F� LICENSED CONTRACTOR'S IITCLARATION
zz�'� 1heron af�l mttlI ..n licensedemdet rcl,n 9lmmmer i" Job Description
ya -Prndion.,o per, g
F° wilt Sidon.9rEID)of Dlvieion 3 mane limina..and 1'mfessicam Col,and Inv Iknase
6 n in fell furca and cooed.
ill ueansecDs REPLACE 50 GALLON GAS WATER HEATER
°sl :d o Dam Conitocror
m 3 u.vG ARCHI"fEC'J S DECLARATION
I understand my pinna shall he..sae os public rccnd,
z S
OO I'mcnsnl Pool u4nnd
n a OWNER)excooDER DECLARATION
I hetahy alien that I ton eBasur sfirrad
the Cs,ions of I A nye Law for the
F.-/,�- ¢ mllow i.. n a.(SoHo..7011 5, t,aft nta ProOntario,
d s li Cndc:Any do st tory
$ASO wl q 1 u n 1 pp 1 1 el ani aV al m
F+� p 1 I ear II hr n,Il fl signori arboreal
��—
11.,'her, : 1 ll n I' n Contractors Law Chapter ol S FL Floor Arca Valuation
or y d tie vola{ ne, t n a pit Ir 1 _gym...alien q'
or trial IlyI and lo11 f '0 Illthe 1 A1vbhfn,
ofS f , Ira 51l y III , ...65 hj a;the III rI bol lw all)
nr n n ,are Iran me hllnwal dnaars rs5no{. APN Number Occupancy'Type
o fa,I........I R1,Ir1on Y Y croployces cithwages as[licit sellpons fro. 31633110 00
sell It ffic work I 11h,. n-faclarc s let in, l d I re 1 ho lill(So, 9044.
B II selectors Cod,'I Ile Cos 1.1cclore Law doespyt an Required Inspections
'
I Pray WI 1 Id- 'npmae. lhccl, ll wh A u h
Bach work 'nsdf�I 61 1 1' y ..L '`" ' pm;Or
iiooAee a 502 — FINAL PLUMBING ENERGY
n11 II sal 11 I n 1 ,fly p cit sold dr ,neywrnf
,..plena,the,w,,.hl lderVIM have he hander of ptnvmg that he did not i of 506 — GAS TEST
mprnvc r......pose el,alo.l.
F3 1.asawnern the prapetly,an,..silo.ivelycnflictingwith heeuaedcoolntnarsm 507 — FINAL PLUMBING
coreanict p'ci,r(SO,.]ILW B I Pri:'' Code I I[I.C Ir tot,rn
Li ['low "Ply III coo owoci of[acicity { hiolds Or-on,owesInca..
t 1 still 'IfOrt, 1, erlorl 11th it inter,ion,) 1111.11col po neat In the
Coner,elce,I' I
El Ian exc,pl order Set. ,I3&P C file this t e.nt
O,al Dale
WORKER'S COM PENSA'DON DECLARATION
hereby
I ullrm Mcr Pncnalry of per one ill'the following duluratlnns:
❑ I hone and will ni,iinair a Cerlilemo of C,msenl to self-metol.for Worker's
Cnug)—arlan, ;is pmvlded for by Section 3700 of the L,hor Code, far Ow
pmmnllnee of the work for which This per nil Is mfeed.
❑1 brae wW will notation Worker's Compencalion Instmnec...s.matted by Section
3700 of Inn Labor Cnde,Ino the PcrRsocau,of fl,work for which Nis pennll is
ssunl.My Workers Cnmpcnsatl ce Insurance currier line Policy number are:
Car wr: Policy No:
CFRT FICA'L'ION Oil EXLMP'IION l7bo b WORKERS'
COMPENSATION INSURANCE
(Toth sectioll need not he cnnaplded if the her nn to for one horn l dnllhm
ON 100)orIess.)
I Nndy Ihm in the performance of the wn.R for which This prnnit is issued,1
shall nor....piny!Lily persau to uuy n,wlner so is In become subject to the Wnrkery
(sanlwnsroon 12111 ill'C:ddomia.Dam
Applicant
NOT'ICRol0 A to'he
Worker
If,or,making Nis.or, cele of Exemption,you ti no-1
oold
cohlit.sn hjcal unhc WnhcM1CQsmporvmfon pnrvtst%ha o he(I Laical O,ok you nwsl
Q � I'canhwith c ..,ply win,such prc,tuum or This Pel tel shell he Aecrnul avnked.
Z
FNCY
CONS...,,. ONLctkao eOfi n,a
pp ,olk In,which ohm lhrra,I, nod(So,
lend,Col.C.cy for performance
W Fy of Inn work Tor nolle,This pcmeit is issuul(Sm.0099,Col.C.)
(� Lenders Nnmr,
Z Lender's Address
W1 molly 111,11 hoe recd this appnc,nin,and stole Inco the above Infonn:ninn is
cGy antrum.12Um et men,ply wilt all ciey and en,lmy ntliernces and stole hewn o laling
Q V mbuildmg maslmadnn,rill hetehy;nuhcarize rcpresoval'mes or this o lly I,orru POI
�„ ry
the nbnvecmemiciod pmpc.ty for inspection pttTuses.
y (We)rise. ocse,Indemnify omd keep harmless tire City of Cuppntno:egaiml
V] liahihoics,'InPor nl,S amts nod expenses which rely ill any any iconic agoor,said
APPLICANT Issuedb
SOURCE RLOULATIONS, y: Date
sigrelnrenrAppliennticonleanr Dale Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
will the nry Ii, nrl..nnebeddingnmapamsone I,noodle harnmenl tnmvdal Type ofRoof
as def and by the Cnpenina Municipm Cede,Chapter 9.12,and the Icahn and Safety
Cud,S-orni 25532u19
0Y, 0N All roofs shall be inspected prior to any roofing material being installed.
wP roe aphheant or Ionic bnndiag Dec..pair(rise imipenem nr duvlea'w1110h If if roof is installed without first obtaining an inspection, I agree to remove
elan hazarolous auas dem,ed by the lay Arc,Atr QuaLy Manrgemem
District p all new materials for inspection. Applicant understands and will comply with
I Yes ❑"° all non-point source regulations.
I havo mad the hnmrdous ntoleriols rcgnlreamnts eeMer 4,I Anr h.95 of Ih,
if lie IN I ninth,IS r coy Cody Secs brain,2550.5,25533 and 25931 andot rob) that
ifthebnl lin fiecn Dololrs elbanaolerIct it toyrcy,ol ni i,ymnobly I Lc
eenpanl of the mquirnncnls,ahieh oma he mel poor to Iwu:mm cat u Ccnihww of
Om..pemey.
Signature of Applicant Date
Owner aran@ndxell agnnt Dale All roof coverings to be Class "B"or better
OFFICE