01030096 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PGRMIT NO.
873 FERNGROVE DR JUST WATER HEATERS INC 0103009E
OWNER'S NAME: APPLICATION SUB HATE
SMITH DAVID G AND BETS R 1.764 NATIONAL AVE 03/19/2001
PHONE: SANITARY NO. COM'ROI.NO.
(510)293-9901
BUILDING PERMIT INFO
O O ARCtIIT1iCDF.NGINEER: BLDG ELECT PLUMB MECli
uG
C,<�
Z 8-,4 LICENSC:D CONTRACTOR'S DECLARATION Job Description
Z_ 1 Irerehy aft inn'hal I Linn Ilacnecd under,pn,viaion.nI CMgnor 9(canntencing
with Section]aaH of Division 3 of the Business unit PrfmsOas Ede,and my license
li ae�6 Liacuseel xa°nitaffect. Lic.Is 't^r REPLACE 40 GALLON GAS WATER HEATER.
ARCHITECT'S DECLARATION I A
t^•a O 1 understood my plans,hull he rad m public records
�}f
.p O Licensed Professional
OWNER- GILDERDECLARATION /
I hereby e1Hnn that 1 am eBu,ir from the Cessions Co License Law'for the
t < which ire remote.(Section]HDL0. t,alter, and Professions Code:Any city or county
D which its e a issuance.cost re construct,applicant
improve,demolish,Lire a sh any strctare
an pnormsxenseparstamm,the he ancone;t forthe Conuch tractors
License Law
w(rl smmmem
thatheiniff, il o Seaamrothepl Division 3 uI the Tho,nrsland se Lawlcn Code) Sq. FL Floor Area Valuation
(aommvmis ewith geelinn]IHIO)ofDivision 3 of the terseness mp ion. ny vi Code)
or that he is 31.5 b Iany aplicant the basis for the alleged exemption.Any violation
$'789
of hoStation (ban os umr applicant fl its a I,ermh aniecax me appucan,,a a ci.0 remtahy
of nm more mate Rose hundred dalmrs(ssoo). APN Number Occupancy Type ,
❑1,as owner of the property.or myctnployecswith wages astheir sole compensation, 37339049. 00
will do be work,and the urnamre is Out intended or efiered for ale(Sea.]OIJ,
Badness dad Prumaiiams Code:The Cnntmcmra License Law does not apply to ad Required Inspections
clot vropedy Who bids or hoproves harcon,ami wen dace such wuahimselr X04 — UNDERFLOOR FRAME
or through his own employees.provided met such improvements art not intended it, t_
offered for ale If,hoxevcr,the building or improvement is hold within one year of
amplelion.rhnawnar-bmmarwill havrthe hmdenofprovingthat hedid not build or 301 — ROUGH PLUMBING
improve lot purowo6nlef. 303 — ROUGH MECHANICAL
OLasowner ofthe propeny.amexclusively contracting with Ecen.sedcontractors m 304 — ROUGH ELECTRTCAL
[Instruct the project(Sec.91114,Husiness and Profeasin w Coda:)'I_he Contractor's
construct I.aw doe.ten apply ,,n own"Of in any who h^dde m ima m
prn.eamon, 505 — FINAL ELECTRICAL
and who contracts for such phi with a contracmrbl licensed persona,to One
Contractors,Liana Law. 507 — FINAL PI_UMBTNG
[I 1 an,axenlpl under Sea ,If&I'C for(hie mason
Owner Data ' 508 FINAL MECHANICAL
•
WORKER'S COMPI;NSA'r10NDECLARATION 514 — FINAL PUBLIC WORKS '
I hereby affl n,under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self-insure for Worker's
Cm„pcnsa ima, is provided for by Section 37110 of ma Labor Cmle. for the
performance of the work ti,r which mix permit is issued. '
[I I have and will maintain Wurkcr'e Compensation Innmmnce,m re9alred by Section '
37110 n1'the Labor Code,lin(he performance of the wink far which Nie prune,is
issued.My Worker's Compensation Insurance carrier and Policy number arc:
Canlcr. Policy No.:
CI'.KI'IFICADON 01'HX EMPTION FROM WORK17RS1
COMPENSATION INSURANCE
(This arch 0 head net the arnmiamd irate promm,is far ene hmmdmd dOunm .
IS lap of less.)
I cannily that in the performanm of the work for which this permit is issued,I
,hull nm Outlay nay portion in any Inaer xo aelu
s nm brce subjce to m^W..kere' -
Compensation Laws of Calili,mia.Dale
Applicant
NOTICH"fO APPLICANT.IL after making this Cenifcam of Exemption,you should -
Frannie mbl�t to he W..kur'n Conr ensal inn unwidi na at the Lubar Code,you mus(
Z O ronhwim comply with such provisions or this period sholl he denied revoked. '
CONSTRUCTION LENDING LENDING AGENCY -
7 1 hmehy xlfirnuhauhere is o construction heading agency for the paroarmince
of nhc work for which this permit is Issued(Sec.3097,Civ.C.)
LLQ Lender's Name -
r7 Z Lender's Acidness
V C 1 orml (hat I have read this application and ase mauhe above information is
Lit E;. eenem.1 agree to comply with all city and county ordinances and state laws slating
CC.� ...building amoso tion,and hereby au(hnrieereprese^ta6ves of this city m entero on
>a r� the above-mentioned properly for inspection parp,ses.
f" 0. (VA)agree to save,indemnify and keep harmless the City of Chronic,against
to liabilities,ji dgmOns,coos and expenses which may in any way acre against said
V Z City i^ unw,rouh,of the gmn(ir,ul this Or it.
APPLICANT UNDERSTANDS AND WILT,COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE..REGULATIONS, y'
SigaatmenfA,ch,awcnmmcom Dal= Re-roofs .
+ HAZARDOUS MATERIALS DISCLOSURE
Will,nrappuaantOrmmmla,ilaimg«.:.pant:tadmha,dlenaard„ax material Type of Roof .
as defined by the Ctmeman Mmlicipil Gale,Chapter 9.12,and the Hardihood Safety
Calc,Savior 2 5 5 3 2110 7
[Ives 0 N All roofs shall be inspected prior to any roofing material being installed. '
Will the upplicam nr liuurr building acctlpanl use u{uipmem ter devise,which If a roof is installed without first obtaining an inspection, I agree to remove
snit hamrdous air conmtninluus as dctined by the Bay Area Air Quality Management
D,ariftYes ❑Nn all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
1 have road(he haaardeax martinis mquiremrma under Chapter 6.95 of the
California Health A Safety Gavle,Sections 15505,25533 and 25534 1 uta
ndennd,hat
if the building docs not currently have a tenant,that it is my responsibility it,notify the ,
capon(of the rnquirehmntx which mra
must he ni m o
prior Isauancit ro Conifla
ce Of
occupancy .
Signature of Applicant Date
0wmerortnmmtaedagem .Due All roof coverings to be Class eB'e or better
OFFICE