02110039 CITY OF CUPERTINO :�a;�
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
Bt-HIP9941DETRENDA CT JUST WATER HEATERS INC PERMITNO2110039
Ow[RUTtM NAOMI 1764 NATIONAL AVE APPLICATTr1SyU)6ry2002
IIN 1ONL: (510) 293-9901 SANITARY NO./ CONTROL NO.
ARCHI'ITCDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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On,I CONTRACTORunder p DECLARATION p
<� 1 LercM1y affirm that I am licensed under previsions of Chapter Y(commencing REPLACE WATER
�Zly wiffiSc,hm7fXXL,fDivision3 of the Buvinc.mrd Prommions Codc,wid my licence ix
inmufnmeand effect. � (50 GALLON GAS)
ZO�Z Dole Class Conor
OZ� Dale Lic.0 r IIL+v I�
O
FL~� ARCHITECTS DECLARATION
my plans shallbeuseJaspublicrecords EC 1 1
aoie °G •2002
F'. .caned rrnmsalonal
g OWNER-BUILDER DECLARATION
ffi
<OP I hereby arm that 1 am exempt from The ContractorsContractorsLiccnLicenseLformunTh �'�®'
to C.F O following reason.(Section 7131.5,Business and Professions Code Any mtyaw or i NG
3 which ac,m es a Nmor or am food.alma improve,demolish,or rcpal,any structure gtl�7t $690
I—Zapoor,,its issuance,aim requires the applicant far such Kraft file a signet stammer
that islicened pursuant to the Pravisionsof the Contowsms License law(Chapmr9 Sq. Ft. Floor Area Valuation
y�0 (commencing with Section 7l(1()of Division 3 of the Business and Professions Code)or
i $ that he is exempt merriment and the basis for the alleged exemption.Any violation of 36943007 . 00
Section 7131.5 by any applicant for a Permit subjects the applicant to a civil penalty of APN Number Occupancy e
not more than live hundred dollars($5A0L 502 - FINAL PLUMBI G ENERGY p yTyp
❑I.as owner of she properly,a my employe.with wages as mei,sale compensation.
will do the words,and the structures,is not intended or offered for sale(ice.7099,Business
and Professions Code:The Comrxnors License law does nor apply to an owner of 507 - FINAL IftWections
property who builds or improves thereon,and whodoes such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however.me building or LargumsMeem is sold within one year of completion.fee Owner,
Wilder will have the burden of proving that he did not Wild or improve for purpose of
sale).
❑ I,asr of The propm
property,am exclusively contracting with licensed contractors
construct The pmjen(Sec.709,1,Business and Professions Code:)The Contractor's Li-
cense law docs not apply To an owner of property who Wilds or improves thereon,and,
who contrai for such projects wire a contranor(s)licensed pursuant o the Contractor s
License La W.
0 1 am exempt under Sec. .B&P C for this reamn
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby afford under penalty of Perjury one of me following declarations:
❑ I have and will maintain a Certifcale of Consent lo.off insum for Worker's ComPem
sation,as provided for by Section Told,of The Labor Code,for the performance of The
work for which this permit is issued.
❑ I have and will mainmin Worker's Compensation Insurance,as requi,cd by Section
3700 of she labor Code,for the performance of me work for which This Permit is issued.
My Worker's Compensation Insurance carrier and Pul icy number am:
carrier: Policy Na: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TTis.secdnn need not N compleled if the Permit is fo,one hundred dollars(S 10(h
or less)
1 certify that in the performance of the work for which this permit is issued.1 shall nm
employ any Person in any manner so sun become subject o the Workert Compensation
Laws of California.Date
Applicam
NOTICE TO APPLICANT:If,after Making this Cc moreem of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Cole.you must
O O forthwith comply with such provisions or this permit shall W deemed revoked.
Z N CONSTRUCTION LENDING AG F.N'CY
gI hercM1y affirm that marc is a commalium lending agency to,the lodurrancenf
a M the work for which this Pcmil is issued(Sec.3097.Civ.C.)
W� 0 Lender's Name
Lender's Address --
V Q 1 certify that 1 have read this application and sum that the above information is
44 (: correct.1 agree m comply with all city and county ordinances and state laws relating or
C) U building contraction,and hereby authoriec rcpresc ustives of this oily menmr upon the
} (v above-mentioned property for epcnies purpowhich ms.
Far (We)agree I....indemnify and keep harmless the City of Cupertino against
y in
equnce of ts,the costs granting of thissesmit, may in anyway attra against said City
U Z A consequence NDER granting of thisPermit,WILL
Issued by. Date
'^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
SOURCE REGULATIONS.
Signature of APplicaDale
Re-roofs
HAZARDOUS
US MATERIALS DISCLOSURE Type of Roof
Will the applicant of future building reeupam.anre nr handle hazardous material
as defined by The Cupertino Municipal Cale.Chapter 9.12,and the Health and Safely
code,Sc Yea
❑Ye2ss3z(a)'!s ONO All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
mil ha'rardom air commitments as defined by the Bay Area Air Quality Management all new materials for inspection.
_ District!
❑Yes CjNo
1 have rtad the hoomdous materials mquircmcan under Chapter 695ofthe Cali for-
aid Ilexlth&Safety Cole,Sections 25515.25533 and 25539.1 understand mat if me building
es
donot curfeady have a Tenant,mat a is to,resP r ihility to m dry The raeuPanT of me
requirement,which must be MCI poor toissuance ofaccrlircateofacaprm, Signature of Applicant Date
Owncror authorised.,Mu Da,e All roof coverings to be Class "B" or better