021200941
CITY OF CUPERTINO--
BUILDING DIVISION PERMIT
'CONTRACTORINFORMATION:,,.
4
eUILDINGADDRESS:
JUST WATER HEATERS INC
PERM] rNO.
21125 FREEDOM DR
02120094
OWNER'S NAME:
1764 NATIONAL AVE
APPLICATION SUB DATE
\CHIN HSU
12/26/2002
HONE:
(510)293-9901
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
o
1 hereby affirm Nat 1 am licensed under provisions of Chapter 9 (commencing
p
win Sectinn 7000) of Division 3 of the Business and Professions Code and my license is
in mu force and effect.
REPLACE WATER HEATER
License Clnss Lit. a
Das Cataract., /
(4 0 GALLON GAS)
ARCHITECTS DECLARATION
1 undmeund my plana shall be mad iw public ealmd,
Licensed Profevsinwl
OWNER -BUILDER DECLARATION
1 hereby affirm nal I am exempt from the Cemralum s License law for the
following reason, (Section 703 1.5, Business and Professions Code: Any city or county
.
which inquires a permit to construct, alcor, improve, demolish, or mpair any suucmm
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractors License law Charter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Cole) or
$500
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
32653032.00
❑ I, as owner ofne praperty. or my employees, with wages as their sold compensation,
will do the work, and the structure is nal intended nrnrfered for sale (Sec. 7044, Business
and Professoriat Code: The Contmcmri License taw does nal apply m an at, of
502 — FINAL ]If�iI1Q�e�RGY
pmperty who builds or improves thereon. and who doessuch work himself or through his
own employees. provided that such improvements are not intended oroffcred foriese.If.
506 - GAS TEST -
however, the building or improvement is sold within one you ofcrmpletion,due rwner-
507 — FINAL PLUMBING
builder will hats the burden of proving that he did not build or imports, for purpose of
ecdc.).
❑ I, as owner of the property, am exclusively contracting with 1leernsed contractors to
construct the project (Sec.7 W4, Business and Professions Code:) The Contractors Li-
_
came, law does not apply to an owner of property who builds or improves thereon. and
who contracts for such projects win a comracmrts) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. B & P C for this ..of
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby action under penalty of perjury one of the following declarations:
1 have and will maintain a Cordovan, of Consent) self insure for Worker'sCamped-
sation, as provided for by section 3700 of the Labor Cade, for the performance of the
work far which Bis perms is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, is required by Section
37110 of the tabor Code, for the radiator. of the work fur which this permit is Issued.
My Worker's Compensation Insurance carder and Policy number art:
Carrier: Polity No.:-
CERTIFICATE OFEXEMPTION FROM W KERS'
—
h
COMPENSATION INSURANC •
Miseccoon need not Mcomplewd ifthe permit is for WB „tldnllars IBB)nr
IcssJ1
Dill
certify that in the performance of the work for which this mit is issue ; aPat
employ any person in my manner so as 4l become subject to r pen l In
Laws of Califomia. Date
Applicant
NOTICE TO APPLICANT: If, army making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Lahnr Cade, you must
forthwith comply with such provisions or this permit shall be deemed invoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm thm there is a construction lending agency ter the perit rromm, of
the work for which this permit is issued (Sec. 3097, Co, C.)
Under', Name
,v
Lender's Address
1 certify nm I have this application end sure that the ahnvc information
to
/{//
cording 1 agree ct comply with all city and county ordinances and state laws relating to
with ng
building construction,coneand hereby authon rcpresenutivcs of His tiny to coot upon nc
above for inspection p
keepha.
(We)agreeto save, indemnify and ardidessithe City
(We)a agree
y
hicp may meagainst said doo
Iiubilitics,juJgments,costs and expenses which may in anyway accmc against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINT
Issued by:60 Date
SOURCE REGULATIONS.
Re -roofs
Signature OfApplicarittCruntorder DDataHA7AR
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future store Or handle ha tfduus maurial
Co
as defined by the Cupertino Municipal Code, Chapur 9.12, and the Health and Safety
opal e, Chapter
care. Section 235320)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑Na
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment Or devices which
•unit hazardous air contaminants as defined by be Bay Area Air Quality Management
all new materials for inspection.
D'suict7
I-] yea 0 N
1 have mad the lelmo ms maunals tequirememu underChapmr6.95afdmCalifnr-
25534.1 unraund Bthe at if building
are Health & Safety Cole, Scott. 25505,25533 and dc
does not currently have a of ani. nm it is my responsibility to nosily tlx: Occupant of the
requircmcnta which must be met primo issuance of a Cmdreau of Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or aulhonsed agent Dane