030100091
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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTORINFORMATION: ,
BUILDING ADDRESS:
JUST WATER HEATERS INC
PERMITNO.
10046 CRESCENT RD.
03010009
OWNER'S NAME:
1764 NATIONAL AVE
APPLICATION SUB DATE
JAY ASHJAEE
01/03/2003
ONE:
(510)293-9901
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I herby affirm Thal I am licensed under provisions Of Chapter 9 (commencing
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with Section 700) of Division 3 of the Business and Professions Crok. and my license is
in full force and effect.
REPLACE WATER HEATER.
License ClassLie, a
(50 GALLON GAS)
Dam Contractor
ARCHITECTS DECLARATION
I umdersund my plans shall he used as public records
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LiccnscJ Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from she Contractor's License law for the
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following mason. (Section 7031.5. Business and Professions Code: Any city or county
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which requires a permit to construct. alcor, improve, demolish, or .,.it any shucmm
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prior to its issuance, also mquiroe she applicant for such permit to file a signed statement
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that he is licensed pursuant 3o the provisinms of the Contmmor's License Law (chapter 9
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(commencing with Section 7000) of Division S of the Business and Professions Code) or
anM u exempt therefrom and db basis for the alleged esemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit objects the applicant to a civil penalty of
not more Nen five hundred dollars ($5011).
326170839.00
❑ 1, ad, owner of He pmmny, or my employees with wages as their ante compensation,
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will do the work, and the smmcture is not intended or offered for sate (Sec. 700,1. Business
and Professions Code: The Conwaore License law does not apply to an owner of
property whobuilds orimproves Hereon. and whodoessuch work himselforthrough his
502 — FINAL PLIJI"l i T
Own employees. provided that ouch improvements are not intended mattered for sale. If.
506 — GAS TEST
however, the building or improvement is sold within one year ofcmmplefion. He owner-
507 — FINAL PLUMBING
builder will have HWiden iden of proving that he did not Wild or improve for purpose of
sale,).
1, as..a, of He property, am exelukuwly committing with licensed comment, la
comswcl the project (Sec. 700, Business and Professions Code:) The Commactoh Li-
cense law does not apply to an owner of property who Wilds or improves Ihemon. and.
who contracts for such pmfec%with a contr0tbrod licensed Nutation to He Commaclof s
License Law.
❑ 1 an exempt under Soc. . B & P C for this noon
Owner Dat
WORKER'S COMPENSATION DECLARATION
1 bemby affirm under Penalty of perjury ane of the following declarations:
I have and will maintain a Cenificak of Consent to self -insure for Worker's Comfort.
within, u provided for by Section 3700 of He Labor Conde, for dk Performance of the
work for which or, permit is issued.
❑ 1 have and will maintain Worker's Compensation los,ance, as required by Section
3700 of Ne labor Code, for the performance of the work for which this Permit is island.
My Workers Compensation Insvmnce artier and Policy number arc;
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section nerd nal be completed ifthe MMit is for one hundred dollars (51011)
Or less.)
1 certify Hat in the performance of the work for which His permit is Issoed. I shall not
employ any person in any manner m as or hecoma subject to the Workers' Compensation
Laws Of California. Dam
Applicant
NOTICE TO APPLICAT: IL after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the labor Com, you must
forthwith comply with such provisions ser this permit shall W deemed revOkcd.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construr ion lending agency for be performance of
the work for which this permit is issued (See. J(Y9], Civ. C)
Lando', Name
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Lender's Add..
1 certify that I have read this application and sue that He above inbxmatiun is
Corea. I agree to comply with all city and county ordinances and shite laws mining IO
Wilding construction. and hereby authone, mie=dutives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments. costs and expenses which may in any way accme against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:9 Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
Signature of Applicam/Conuactor Date
HAZARDOUS MATERIALS DISCLOSURE
Will He applicant Or future building Occupant store or handle haysNaus material
u defined by she Cupertino Municipal Code. Chapter 9.12, and He Harbor and Safety
Code. Section 25532(x)?
All roofs shall be inspected prior to an roofing material beim Installed.
P P Y g g
El Yea ❑No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment or devices which
nu ax dced by the Bay Arca Air Quality Management
mit herardous air condominiums fin
all new materials for inspection.
District?
❑Yes 0 N
1 have mad the haaaNnus materials requirements under Chapter 6.95 of He Califor.
nix llcaM&Safety Code. Sections 255115, 25533 and 25530.1 understand that if the Wilding
does not currently have a lenam, Nat it is my rcapmsibility to molly the necupanl of the
recomments which must he met prior to issuance of a Cenincau of Occupancy.
Signature Of Applicant Date
All roof coverings to be Class "B" or better
Owner, mHmired agent Date