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00110004 CITY.OF CUPERTINO 11L?J G otvlsloN ' , PERMIT CONTRACTOR INFORMATION: BUILDING ADDRESS: PERMIT NO. OWNER'S N ,. BE BI_VB ` A LICATI A {ONfs: +• t784 NATIONAL AVE - SANITARY D. O%Z ARCHITIiCHENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH. ay nLI CONTRACTOR'S ONTRs anDd IPiCr.fexsions OCN zS , Inm;hm I am licensed under arovisonsr ofClnapwmre,9 e(ncdom-mymIelcnceninug ]. ob Description = with Swims itDisio fall terminal etem. n LicenseCws , Lic.# Date Contractor ' ARCHI'1'F.CT'SDECLARATION ' 1understand myplem,lmhre, set a,public retools REPLACE 100 GALLON GAS WATER HEATER }0 ' OO Licensed Professional e ff Oat Ia. UILDGRno the immerN _ I hereby uE imm that 1 1. exempt fn nn the Cmion,Coe License Law forme folfav�3 O which ng dcmoo.(Section]onstr t.ific,s and improve. it Profession,CMe:Any cit,or country , Y x 0 which qu - ps n construct. he p Je I sh Or re,ourtm, waurc mesad`t Fari s provisions t f h p t t 1 't, J t temcnt s— man r :it p . t t m p . ,. rm cam et e I e La ren orle) Sq. FL Floor Area Valuation or that a is awith Section]a10nd thDivision is3 of the Business and Professions n.Aryvi Cwe)or that he is 31.5 hi..,Ilam and the aper it rtheo alleged exemption.Any violation of Sectione than v any hundred drat fur a permit suhjccta.e applicant m u civil p.nnhy nrnmmnre.anR.emmnd,aamlat.a5on1. APN Number Occupan�r(yyT pe 01,mownedit me ,,inn Inecs with wages their cora oration. $3B5t propery, yeas ) ges offered pe will ne ,rte work,and the sticture is nam hnewed ae,Law for sale(Sec. to an -Business and eromsio ewe;The Gm,,he,ci License Law dies nm apply m an Required Inspections' or fourth Whaltloybuild,tor osidedethat rich and tuna Joos such t mmimself 3�F,0 ](dy., LSO or thrugh has own emse,er,t provided that suer imprwcmemt are not intended oc ,mares far sale.If,howevm,the building or ins eti ni u,n is that within one Year of _ _ - cnmpletion,the owner-builder,will have the burden eelFarnving that be did.,it mildo, ' impose for Fauq,a.e"'ofe.). - 502, — FINAL PLUMPING ENERGY' - ol,aaawnedannepraprty.mmseaem,i lrmm,r,fnswimfieenueeanu coram 505 — GAS TEST construct the project(sec.90FL Business and profa..tons Cade)The Commcoti s License Law does not apply m an owner of property who builds or improves thereon, 507 — FINAL PLUMBING and who contracts for such pareds with a contractor(,)licensed Fairmont to the ' Commoner Lord.Law. . ❑I ran uni under Sec. ,B&PCror this reasmn• Owner Dare WORKER'S COMPENSATION DEFLARAVION I h...thy affirm under penalty of perjury one of the following declarations: i I have and will maintain u Cenllicme of Consent to self-insure for Worker', 'erpemation, m pmvlded far by Section 37011 of the Ichor Cwe, far the ' performance of the weak fnr phich this permit is issued.. ❑1 time and well rearrnin Worker',Gm.pensmibmi Insurance,-camand by Section m J]BB of the Labor Gale,lith the penbnnance of Newark for which this p.emit is sued.My Worker's Compensation Insurance carrier and Policy number are: Gdrri,: Policy No.: 1 CERTT IFICA]ION OF:EXEMPTION FROM WORKERS' r COMPENSATION INSURANCE (This section need not be cemplmcd if the permit is for one hundred dollars (S 1011)or less.) „ I certify that in the performance of the work for which this permit is issued, shall it.,employ any pttwn in any manner w as em become subject to the Weaken' Compensation Laws of California.Date Applicant NOTICE TO APPLICANT,If.after makiril Ccnificam of Exemption,you should became subject to the Worker's Compensation provisions of the labor Code,you must z 0 fonhwi,h wm comply ith such provisions or this permit slmll he deemed revoknL . rte^ IA CONSTRUCTION LENDING AGENCY , Kt > 1 hereby aBirm that mere i,a comme'ron lending agency for the perinmarwe W of the work for which this permit is issued(Set.3097.Civ.C.) 0 Lender's Noma � z LcnJcr'eAwmss I certify that 1 have read thi,application and state mat he above information is t W F, coram.1 agree to eornply with all city and county ordinances and state laws relming O U m building construction,and hereby author.representatives of this city to enter upon W the above-men,itued Pmprny for inspection porpn.us. [r Ilk (We)agree it,save,indemnify and keep limbless the City of Cupertino against (4 liabilities,judgments,cost and expenses which may in any way accrue against said V ZL City immaisegmmceol,he grantingofthis permit. , APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. y Signature of Applamu/Contmewr Dane Re-roofs HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future Wilding omupaut stare or handle aired am rtmtedel ` Type of Roof , as defined by the Cupertino Municipal Cone,Chapter 9.12,and the Heal.and Safety Cat,,Section 25532(x)] O Yes 0 N All roofs shall be inspected prior to any roofing material being installed. Will the appheamnrfuture building occupant use afnipbmatordevices which If a roof is installed without first obtaining an inspection, I agree.to remove emit hamNous air conmminants as defined by the flay Area Air Quality Management 11 mtHeR all new materials for inspection. Applicant understands and will comply with ❑Yes - 'o No all non-point source regulations. .I hive rend the hazardous mammals requiremenri under Chapter 6.95 of the California Health&Safety Cwe,Sections 25505;25533 and 25534.1 understand that if,he mildingdoe.s not currently have acont,that it is my resprmsibilitym notify In, _ occupant of the requirenmme which must he amt prior to issuance of a Certificate of 0,vi paray' Signature of Applicant Date Owner or authorized agent Date All roof coverings to be Class "B'•or,better OFFICE City of Cupertino Building Permit Application E-Mail d© 1I �Oo�(- jobsite Address: 10690 N. de Anza Blvd. Owner's Name:---Pepperm ill Restaurant Phone No.(408)988-3282 APN#: 316-02-104-------------- Project Valuation: $3850.00------- Building Permit Info: Bldg----- Elect___— Plumb—_X__ Mech_ Job Description Replace 100 gallon gas water heater. Contractor Information Company: just Water Heaters Inc. Phone: (510)293-2012 .• Contact Name: Fax: (510)293-2022 Address: 1764 National Ave. E-mail: permits@justwaterheaters.net City, State and Zip: Hayward,CA. 94545 State Contractor's License# 591 329 Exp. Date: 3/31/02 Worker's Comp#: 03KR0001018 Carrier: Clarendon Exp. Date: 4/1/01 Credit Card Information Credit Card #: 5474-6331 -7168-6326 Name on Card: just Water Heaters Inc. Expiration Date: 9/02 Visa MasterCard Comments .z:�i y/zeee 14•SG ,,,S3G:49fl':51 �i a- .• .cm oE�cuesarrw � ,.. .. ' 9w.uwo w9nmi PF.Rhf[T' �•I...v� �- RndlP.ogNf rs:xn r P Lw.1i RJ.K .I '.• _.,.—.. .• LmrfLTl;f.O iVt -�� . .I.ql:! x•P:tMrnL. (OwIttYD J �S aMuiltl.T�tHiMJ:1• .•••• ••,_�•M i R•1-'V:•0!.IMn:W y 1zE{,`[ WIPO \#1 Y.'4G NY]f hC Lm:im6Am:.-�na'f JLw:nl,v, Ipe JJ9p� lOn •L1Z'.\3 t'_�' •r0 r:., µ..v;rn MMx(rvn:w.[a Iw:t lmr la l.n vi[V I•«;«n.•nr:Yuillx l:N rt:,•n win nxl.ey..i.f Pnn;n "V, W, w•e Fr. :.:�i.Iw.J...r.G.�n:••«r....-'u+.. 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