03020012 CITY OF CUPERTINO1 11 1 1 -
Ex
BUILDING DIVISION PERMIT `'CONTRACTOR INFORMATION ,',:
BUILDING ADDRESS: 'JUST WATER HEATERS INC PERMITNO.
6566 CLIFFORD DR
OWNER'S NAME. 1764 NATIONAL AVE APPLICATION SUB DATE
CHEN WEI-LIN D ET AL 02/06/2003
ONE: (510) 293-9901 SANITARY NO. CONTROL NO,
ARCHnECGENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�BOZO LICENSED CONTRACTOR'S DECLARATION
U F I herchy affirm that I am licensed under provisions of Chapwr 9(commencing Job Description
with Section 7001)of Divisinn Sof the Business and Professions Code,and my license is
t „ mmBand REPLACE WATER HEATER
iyyaZ License Class Lic.g
Date Contractor (40 GALLON GAS)
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
SO1U
Iso Licensed Professinnal
s—„
OWNER-BUILDER DECLARATION
d <Y I hereby affirm that I am exempt from the Cimur is Licemn Law for the
s..00 following reason.(Section 7101.5,Business and Professions Code:Any city or county
- $ which requires a Permit to construct.alter,improve,demolish,or repair any structure
prior m its issuance,also requires the applicant for such Permit to file a signed statement
�< that he is licensed pursuant o the prnvisionenf the Cmumem,s Lice..Law(Chafer 9 Sq. Fl. Floor Area Valuation
�$ (commenci ng with Section 7yX)of Division 3 of the Business and Professions Code)of $1374
Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500). 36924035 . 00
❑ I,as owner ofthe pmpeny,or my employees with wages as their auto comMosauon,
will do the work,and the structure is not intended or offered for sale(Sec.7000,Business SS�y
and ProRsshms Code:The Contractors License Taw dors not apply ro an owner of 502 - FINAL �i 1V Uo c RGY
property who(wilds or improves theme ,and who does such work himself or through his
own employees.provided thud each improvements are not intended or offered for sale.If, 506 — GAS TEST
however,the building or improvement is said within one year of completion,the owncr-
Wacker will lave the burden of proving Nat he did not build or improve for purpose of 507 - FINAL PLUMBING
sok.).
❑1,as owner of die proper,am exclusively contracting with licensed contractors to
construct the project(Sec.70ad.Business and Professions Code:)The Contractors Li
cense law does not apply to an owner of proper who Wilds or improves thereon,and
who contracts for such projects with a comriefor(s)licensed pursuant an the Contractors
Lk—Lina. --�
❑I am exempt under Sec. .B&P C far this reason
Owner DateAm
WORKER'S COMPENSATION DECLARATION w
1 hereby eTo-under penalty of perjury one of the following declarations:
I have enJ will maintain a Cenlficate of Consent m If insure for Wurkeri COmpen- _
Milan,as provided for by Section 3700 of the labor Code,for the performance of the
work far which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37(X)of the Labor Code,for the performance of the work for which this permit is issuenl.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EX EM PITON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed itthe(omit is(crone hundred dollars(5100)
or less.)
1 cenify that in the Performance of the work for which this Permit is issued.l shall not
employ any person in any manner na as to become subject no the Warken'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Compensation previsions of the Labor Code,you most
OO forthwith comply with such provisions or this permit shall the deemed revoked.
Z CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the Performance of ` )
a the work fur which this permit is issued(Sec.3097.Civ.C.) /IAA w I l
aQ Lendcr's Namc r�/IkAll/',v
.7 z Lender's Address
(� 1 cenify that I have read this application end state Nat the above information is
FcOnfect.1 agree to comply with all city and county ordinances and state laws relating to
U building construction.and hereby authorise representatives Of this city to enter upon the
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmleas the City of Cupertino against
na sn liabilities,judgments,costs and expenses which may in any way accrue against said City
U 4 in consequence of the gnantingnf this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of APPlicaDam
HAZARDOUS
MATERIALS DISCLOSURE Type of Roof
Will the applicant orfuturebuilding tee Capt sore or handle hazardous material
as defined by the CuPeninn Municipal Ctdc,Chapter 9.11.and the Health and Safety
,gliCode.SCMmn 1553xa)? All roofs shall be inspected prior to an roofing material beim Installed.
❑Yea [:1 No
P P Y g g
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
it hvandous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yea 0N
I have mad the haaaNtws materials tournaments under Chapter 6.95 of the Califon.
ria Health&Safety Code,Socdore 155115.15533 and 2553x.I understand Boaz ifth Wilding
fres nm currently hale a tenant,that it is my Maponsibiti y m notify me occupant of the
requirements which must be,the
print it)issuance OfaCenificataofOccupancy. Signature of Applicant Dale
owner on embodvcd a gear Date All roof coverings to be Class"B" or better