03030115 CITY OF CUPERTINO
BUILDING DIVISION PERMIT p F z�.C,u261NFURMATIQN•
`5 yua ++I ' .< u+t ryyr:i
BUILDINO ADDRESS: JUST WATER HEATERS INC PERMIT NO,
:7F44:7 DR LA FARGE DR
OWNER'SNAMB: 1764 NATIONAL AVE PERMIT L� A
g;
(510) 293-9901 SANITARY N OL NO.
ARCHITECTYENGINEER: BUILDING PERMIT INFO
BO eO PLUMB 0
am Z' LICENSED CONTRACTOR'S DECLARATION JobDescri tion
1 hereby effl m But I am licensed lamdalom of Chapter 9(commencing Dip
tion
Secaop7ml�of Dlvim..3of: Bus' de end Profusium Co e..dnglicensels
In full!am�ggefrt , 3(P 9137 WATER SERVICE LINE
w( RCHITECPSDI RATION (FROM THEaT HE HOUSE)
I underwnd my Plain shall beuad UTnhlie«cords
Licensed Professional I I7)
OWNER-BUILDER DECLARATION
---�
1 hereby Maso Offira on I am exempt from the COntns Co License law for the
pO followinguire,a.(Salton nDIS,Bumoe. and Rafeemoli Code:Any city or county
$ which mqusca n pernite,also a enc,the alar,Improve,demolish,,m repair anY srrm'ure I
b prier In ha Issuance,elan requires the applicant for permit se Ne aligned sutemenl
sF<
dust heIsllmnsedpuuumttothe Provisions nfthe Contnctor'sLicense Law(Ch
Floor Area
?� (commencing,with Section 7000)or Diddon 3 of the Bu0nam and Profession Code)or :.
3 that MIs exempt thcrtfrom endNe bug,for the ellejed eeempdM My vlobUoo of
Section 9031.5 by em Rpplicanr for a permit subjects the Applicant m a civil penalty of APN Number Occupancy Type
act Rome than raw hundred dollars($500).
❑1,As owns ofux pmpmry.m my employme with wages As their Role cmnanuuon, 35926027 . 00 .
will do the wok and theatmcmn m notinrented mortared forum(Sec.7014,Buuneea Required Inspections
and Pmfesdoru Cod.The Canlnctm's Liana Law does not apply u e an Owner of q P
property who buildsorlmprowa Nerecn.endwho doeuuchwmk himselforthrough his 106 - SEWER & WATER
ownemployees.provided that such lmprovemenu are nothdoam«offend fm We.a, 2OZ — UNDERFLOOR PLUMBING
however,the building m improvement is sold within on year of eampletion.the owner-
buima will hoe the burden or proving that he did not bund or impmve for purpose of 3 01 — ROUGH PLUMBING
ram.).
01,As owner of de propene am exclusively contracting with licensed conuactmsm 302 - TUB & OR SHOWER
contract the project(Sec.70".Business end Profeamon Code:)71.comrawes U- 502 — FINAL PLUMBING ENERGY
come law does not apply to an ower of property who builds or Improves thereon,and,
who contracts for such pmjects with a contractor(s)licensed pursuant to the Contremoes 506 - GAS TEST
License Law. 507 - FINAL PLUMBING
❑Ilse exempt under Ste. ,B&P C for this noon
t031000.1
Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty,of perjury one of the following deelarWOn:
he and will«alai.aCenifteate ofComentu self-inum for WOrkeYlComPen-
as provided for by Section 3700 of the lahor Code,for the performance of the
r which this permit Is leaned.
w and will meinWn Worker's Compensation InturRoa,vee required by ScNan
the Labor Code,forda,yqrformanef the work for which this permit is luued.
rkefs Cnm ensu Ion 1 [arenanrtia and Policy au Mrare. liry No.. Z a��
CERTIFlCA OF EXEMPTION her
COMPENSATION INSURANCE
CTbLL rection need not he completed Etie permlt It fm On hundred dollan($10111)
Ar ICU)
I certify that In the perfmmence of the work for which this permit is Issued,I shall not
employ anypersen In my manner an As In hecomcwbjmi to the Workeri Compensation
Laws of Glifonla.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccnincam of Exemption,you should
become subject m AM Worker's Compensation provision,of the labor Code,you must
O O forthwith comply with such ProWsinns or this permit still be deemed tracked,
CONSTRUCTION LENDING AGENCY
H www l hereby affirm that dwre Is a construction lending agency for the performance of
ai the week for which this permit B Issued(Sec.3099.Civ.Q
Ik3 Q Lender's Namc
az Lender's Address
U O I certify that 1 haw reed this application and Rote that the show uromatlon e,
Iy!'y correct.I aPa to comply with all city and county on inamxs and Rude,laws misting to
C rV^ building construction.Rod hereby euthodn mpresenuddves of this city m enter upon We
W ,how-men coned polpeny fm InpeNon l urpous
LL
(Wo)agree m ata.Indemnify and keep humorless the City of Cupertino against
rest y nabllltles,judgmcnu.cO,u ander nes which may In"Way agsinn said City
V'l In eonsegtrntt We granting thts permit.
APPLICA
DE'
S AND W Y WITH ALL NON-POINT Issued by: Dale
SOURCE TIONS,
2 Re-roofs
u Appltwn n nom Due
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
ill the applicant m future building Occupant atom m handle hevndous materiel
sa ned by the Cupertino Municipal Code,Chapter 9.12.and We Health and Safety
Code.s:1 .a 25532(1)9 �N All roofs shall be inspected prior to any roofing material being installed.
❑Yes W
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 'CA
sir contaminants As dented by the Bay Ana Air Quality Management all new materials for inspection.
Brice
❑Yea Bhlu
I have read We hom ons motor lala requirements under Chapter 6.95ofthe,Califor-
aMHcalth&Safmy Code, 1=25305 3Jptt 125534.1undenmMdwlfhe building
doe nru �rt tiY haw A riant th I s co pomimliry u Rod fY Occupant of the
mqul en which easmell oncAof,Ccnincemofocc en Signature of Applicant Date
�2
mannan. ascot Date All roof coverings to be Class"B"or better