02110086 CI'PY OF CUPER'PINO PERMIT CONTRiC�`TOR INFORMATION,
BUILDING DIVISION
Bul17,5SSDR3LDERWOOD CT JUST WATER HEATERS INC PERMITNO2110086
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A'BR,RLEE CHRISTOPHER Y AND A1764 NATIONAL AVE APPLICATITI1S�talDgTy2002
(510) 293-9901 SANITARY NO.! T CONTROL NO.
ARCHITEC UENGINEER: BUILDING PERMIT INFO
BLDG EhECf PLUMB MECH
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000 affirm
iNSEDCONnsedunOR'SDECLARATION
z w t- 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing p t10B
�L, with Section701XpofDivision3ofmeBusinessandPfnfecionsCode.andmylicenseis REPLACE WATER � A
mete erase rex and effect. t�I_ YALE®
in Toil I Class Llf.a �a 1�
OZ— Datc Contractor
F.L'w ARCHITEC"S DECLARATION
Hdoad l understand my plans shall he used as public records NOV 2 1
Nq 1 gLOOq
au 1\ V L
�LLQan Licensed Pmfcssimetl
I OWNER-BUILDER DECLARATION e
.<S 1 hereby affirm that 1 am exempt from the Cnmmanr's License Law for the ���D� 2 9
r
w as
C O following reason.(Section 7031.5.Business and Professions Cole:Any city or county Q
which requires a Lenoir m construct,alter improve,demolish.or repair any structure
ce prior in its issuance,also"Itims,the applicant for such permiun rile a signed statement
yso lhalheiaLice mind pursuant mthe provisions,ofthe Contractor aLicense Law(Chapter 9 3ggMM&BA@9 - Valuation
sr (commencing with Section 70fro of Division 3 of the B usiness and Prafeseinns Code)nr
of
3$ Nal he is exempt therefrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant far a permit subjects the applicant ro a civil penult of
nos mom Be.five hundred dollars(S5oB). y PN N Occupancy Type
I,as owner of 506 — GAS TEST
❑ pmpeny, remyemntended with r their isle compensation,
will dodmwork,andmeswcmmisnors intended or offered for sale(Sec.)040,Business
and Pmfessinns Code:The Conuannrs License Law does not apply to an owner of equire nspeetions
prepeny who builds or improves thereon,and who does such work himse for through his
awn employees,provided that such improvements are not intended or offered for sale,If.
however.Ne building or improvement is sold within one year of completion,the owner-
Wilder will have the burden of proving that W did not build or improve for pur nose of
sale.).
❑ I,as owner of Ne property,am exclusively contracting wit licensed contractees to
consumer to project(Sec.7140,Business and Professions Code:)The Contracter's Li-
rs.law does of apply to an owner of property who Wilds or impravas thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License law.
❑ 1 am exempt under See. 8&P C for this reason
wrcr Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following declarations:
I have and will maintain a Certificate of Consent O self-insum for Worker's Compete
sarien,as provided for by Section 3700 of the labor Code.For the performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
371X1 of the labor Cole,for the performance of the work for which his permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Caller: Policy No.: _
CERTIFICATE OF EXEMPf10N FROM WORKERS'
COMPENSATION INSURANCE
(This.see need Out he completed if tbe rcrmit is foronc hundred dollars($19))
or teat)
1 certify that in the performance of the work for which this permit is asued,l shall not
employ any grown In any manner,to ai In become suh)ect to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Cenificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Ewe,you must
0 z forthwith comply with such provisions or this permit shall be deemed mvnked.
2 O CONSTRUCTION LENDING AGENCY
PIhereby affirm that there isa construction lending agency liuthe performance of
ai the wok for which this permit is issued(Sec.30,17.Civ.C.)
4 0 Lender's Name
.7 z Lender's Address
V 0 1 certify that 1 have read this application and s4m that the aWve information is
D, F correct.1 agree to Comply with all city and county ordinances and score laws relating to //LG VVV
0 building construction,and hereby authorize rc prevenmows or this city to carer upon the
N ashove-meminned property for inspection purposes.
(We)agree m save,indemnify and keep harmless the City of Cupertino against
I,, liahilisies.judgmlithe'turn
and expenses which may in anyway accrue against said City
V z in nrnuyucncc of the granting of rM1ix permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL,NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signmurc of ApLlicunUCammctor Date o
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle haiudous material
Ar defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
'doLGale.Section 2553200?
❑res 0N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding Occupant If a roof is installed without first obtaining an inspection, I agree to remove
pP 6 pant use a Air Quality
or devices which g p
:milia? sairttrmuminantsudclincJbytheBayAreaAirOualiryManagcmcnt all new materials for inspection.
District/
Dye's El No
1 have read tc hamrdnus materials mquimmentc under Chapter fi 95 of the Cahf(r-
niallcalt&Safcry CId,ScNmts25A)5,25533and2553.lundcrst d tifds Wilding
Jrcs not currently have a mnam,tm it is my respumihility In notify the Occupant of are i
requirements which mus be met Primus issuance of s Certificate of Occupancy.
Signature of Applicant' Date
Owncrminahon,adagent Date All roof coverings to be Class "B" or better