02120015 CITY OF CUPERTINO - "-
BUILDING DIVISION PERMIT CONTRACT,OR'INFORMATION:
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Bul11*90&EsFARALLONE DR JUST WATER HEATERS INC PEIRMITNO2120015
GwWA,1uKER JAMES P AND MARGARET V 1764 NATIONAL AVE APPLICATIp2S�104112002
orONE: (510) 293-9901 SANITARY NO. CONTROL NO.
ARCIUTECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MPRH
Poo LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing REPLACE WATER -WUlSgLlDI100
with Section 700(0 of Division 3 of Ne Busineo end Professions CaIC,and my license is L1 1 L'.fC
in fallrowcMdeneet, (50 GALLON GAS)
fig: License Class Lie.
F<w t- Dale Codtracor _
CRATION
ARCHITECTS
I understand my pland
s shall he unit public records
ON
tai Be Licensed Professional
i 0 OWNER-BUILDER DECLARATION / h 1'
r�i m 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
W.Z:a O following moon.(Section 703 L5.Business add Professions Code:Any city or county
$E which requires a Permit it)construct,alcor.improve,demolish,or repair any structure F7n x -
Fiy prior to its issuance,also requires the applicant for such permit to file a signed statement
Fqqxx<
that he is licensed pursuant to the positions of the Contractor's License Law(Chapter 9 Sy. Ft. FI Valuation
DyF$ (commencing with Section 7000)of Division (it the Business and ProfessionsCode)or 36929015 . 00
Nat he u exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil Penalty of APN Number Occupancy Type
not mom than five hundred dollars($500). 502 - FINAL PLUMBING ENERGY
❑1,as owner of the property,or my employees with wages as their sole comptroller,
will do the work,and the structure is not intended or offered for sale(Sec.7w,Business
and Profeulons Code:The Contractors License Law docs not apply In an Owner of 507 - FINAL (I bj �tj�ections
propony who builds or improm thereon,and who doessuch work himselfor through his
Own employm,provided that such improvements are not intended oroRered for We.If.
however,the building or improvement is wild within one you of completion,to ewder-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of Ne propeny,am exclusively Contracting with licensed conuacmre to
construct the perjecf(Sec.7044.Business and Professions Cede)The Contractors Li-
cerise Law does not apply to an owner of propeny who builds cur improm diamond,and
who contracts for such prMccts with a contractors)licensed pursuant to the Contractors
License Law.
❑1 am exempt under Sec. .B&P C for this reason
Owner Dar
WORKER'S COMPENSATION DECLARATION
I hereby eRrm under Penalty of Perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Camped-
cation,as provided for by Section 3700 of the Lat or Code,for the performance of the
work for which Nis perroit is issued.
❑1 hale and will maintain Workers Compensation Insurance,as required by Section
37M of the Labor Cak,for the performance of the work for which this permit is issued,
My Worker's Compensation Insurance carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the Permit is for one hundred dollars(511X))
M less.)
1 certify Nat in the perfamtance of the work for which this Permit is issued,l shall net
employ any person in any manner so az to become subject n the Wsakert Cempenotion
Laws of Califemia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenilicare of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Calc,you must
OO forthwith comply with such provisions or Permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
[-.. nNi I hereby affirm that there is a consuuctlon lending agency for the performance of
(Y. > the work for which this permit is issued(Sec.3(192 Civ.C.)
Q Lender's N.
z Lcialk, Address
U 0 1 certify that I have read On application said Some that the above information is III/ /I llllll
{k. F correct.1 agree to comply with all city and county ordinances and state laws relating to
DU building ctostoetion,and hereby mahcheempresemativesof this city to corer upon the
W abovomeefoded property for inspection purposes.
(We)agree to save,indemnify and keep hartalem the City of Cupertino against
V) Iiabilities.judgmem,contained tapenses which may in any way ac I.agaiot mid City
U 7 in coacquence of the granting of this permit.
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WI7'11 ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
Re-roofs
Signature ofApPlicaHAZA rDOr Date
HAZARDOUS MATERIALSeupana mom
Type of Roof
Will the applicant or future building oecupam croft ser handle hvardous material
az defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
code. [DYeazs53z(a)7 All roofs shall be inspected prior to an roofing material being Installed.
[D Yea ❑Ne P P Y g g
Will the applicant or future building Occupant use equipment a,devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
Coit haardous air conumidems as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes 0 N
I have read the hvardnus dratinala requirements under Cook,695 of the Califor-
nia Holm&Safety Code.Sections 255115,25533 and 35534.1 undersand dtu ifdtc building
does not currently have a tenant.Out it is my resNmihiliiy to notify IN atupmt rf the
requirements which must be mel Prior lis lamanre Of a Certificate of Occupancy. Signature of Applicant Date
Owner ora ddrindagent Date All roof coverings to be Class"B" or better