03020025 CITY OF CUPERTINO
BUILDING DIVISION PERMIT a CONTRACTOR INFORMATION'
BUILDING ADDRESS: JUST WATER HEATERS INC PERMITNO.
21602 COLUMBUS AV nin2nO2F�
ItOWNER'S NAME: 1764 NATIONAL AVE APPLICATION SUB DATE
NANKIN GARY C AND SUSAN M 02 O7 2003
ONE (510) 293-9901 SANITARY NO. CONTROL NO.
ARCHITEC`UENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
O
LICENSEDCONTRACTORSDECLARATION Job Descr1 1���
❑hiss 1 hereby affirm Nal 1 am Incensed under provisions of chapter 9(commencing ti_�-��1
in with Sermon 7(N10)of Division]bf the Business and Professions Code.and my license is
&34 Nmnm l awerfeoL REPLACE WATER HEATER
=m" License Cl ass Link
t-� Dare Contractor (50 GALLON GAS) FEB 2 7 2003
ARCHITECT'S DECLARATION
I understand my plans shall W used as public records
�LLOk' Licensed Professional
BUILDING
OWNER-BUILDER amunninfir DECLARATION
a f I hereby.Sectord on 1 1. exempt from the Cortins Co License Law for the .,
,E:00 following reason.(Section 7031.5,Business and Professions Code:Any city or runty
which requires instance,pomit o amstrthe alter,improve,de Permit
t ore a sir any structure
prionoirsensepurmarequiree provisions of for such the Contractors
Liccasignedstasemem
C
that hcrnvin with
hSsction7 00)of Division3oftheBuance,an Pose Law nnorC apter 9Code)
Sq.FL Floor Area Valuation
$ (cat he is xempt therefrom
71and of basis
r the
the alleged
exempt Professions Cnde)or
.. Net io u exempt therefrom and or basis far the alleged exemption.Any violation of 1317
Section7031.5Been five
any applicant meapetmiuubjects the applicant acivil penalty of APN Number Occupancy Type
not more Nan five hundred dollars($300). P Y YP
❑1,es owner of the property,or my employees with wages as their able compensation, 35618053 . 00
will do tW work,and the structure is not hounded or offered for safe(Sao 7044.Business
and Professions Code:The CDa=IDl a License Law does not apply to on owner of 502 - FINAL YL�QIVIS i N Ci CL'N L'.RGY
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sals.If, 506 — GAS TEST
however.the building or improvement is sold within one year of completion,the owner,
builder will have the burden of proving that he did not build or improve for purpose of 507 - FINAL PLUMBING
sole.).
❑I.as owner of the property,am exclusively contracting with licensed convectors to
construct the project(Sec.7044.Business and Professions Code:)no Canvaetor's Li-
comae Law does not apply m an owner of property who Wilds or improves thereon,and
who contracts for such projects with a conbaclor(s)licensed pursuant to Ne Contractor's
License Lew.
❑I am exempt under Sec. B&P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations;
is 1 have and will maintain a Certificate bfebnsenuo aelf-insure for WorkersCompen-
aramn,as provided for by SCNon 37W of the Labor Code,for the performance of the
work for which Nis permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,es required by Section
3700 of the Labor Code,for the perfonmence of the work for which this permit is issued.
My Workers Compensation Insurance currier and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
o bissectitm need not W completed if the permit is for one hundred dollars($[BE)
or less.)
1 certify that in the performance of the work for which this Kn til is issued,1 shall not
employ any person in any manner so as m Wm
coe subjectm the Workers Compensation
Laws of Coliform..Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject in the Workers Compensation provisions of the Labor Code,you must
OO forthwith comply with such provisions or this permit shall W deemed revoked.
z fn CONSTRUCTION LENDING AGENCY
El hereby affirm Nat there is a construction lending agency for the performance of
7 The work for which this print,is issued(Sec 3097,Civ.C.)
4 0 Lender's Name
z Lender's Address —
V Q 1 certify Out 1 have reed this application and state that the above information is
I24 H cored.I agree to comply with all city and county ordinances and state laws relating to 111
U building construction,and hereby guthodm representatives of thio city to enter upon the
W shove-mentioned pmperty,for inspection purposes.
FYs (We)agree to save,indcmni fy and keep harmless the City of Cupertino against
t,s fn liabilities,judgments,comes and expenses which may in any way aceme against said City
V zconsequencein of the granting of
APPLICANT UNDERSTANDS tAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signature of APPlicaDau
HAZARDOO US MATERIALS DISCLOSURE Type Of ROOF
Will the applicam or future building e,Chapter
store or handle Heallous material
as
define)by the cupertinn Municipal Code,Chepmr 9.12,and the Health and Safety
code,section xsssz(an All roofs shall be inspected prior to an roofing material being Installed.
❑res ON. P P Y b' 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 hamfdoes air contaminants m defined by the Bay Area Air Quality Management all new materials for inspection.
imricty
Oyes ❑No
I have mad she hamrdous meurialsrequircments under Chapkrfi.95 of Ne Califor-
m.Hemth&Safety Code,Sectio.255)5,25533 and 25534.1 understand Ne building
does not currently haste a unapt.that it is my responsibility in notify the reception of he
requirements which must W met prior us issuance of a Cerificakof Occupancy. Signature of Applicant Date
Owner or aulhoricd agent Date All roof coverings to be Class "B" or better