01040007 CITY BUILDING DIVISION o PERMIT CONTRACTOR INFORMATION:
I
BUILDING A DDR HSS: PERMIT NO.
10423 HENEY CREEK PL JUST WATER HEATER INC01040007
OWNBR'S NAME: - APPLICATION SUB DATE -
RINERSON DARRELL 1764 NATIONAL AV04/03'/2001 .
PRONE: SANITARY NO. CONTROL NO.
(510)293-9901
O O ARCHITECI'IENGINHER. ' - _ - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH ,
LICIiNSiiDCONTRACTOR'SDECLARATION
Job Description
Z4 - Ihercby:dlintthinlandliecmcdmdc,uwof
isionsChapter9lcnmmen<'ing , ' .y.
Dy�W wih5 h 71XffE I)i,, 3dlhe Bi: to:aJP fsxions Cale mW ny license '• '�',. .• - I
o ul�fic a: «Contractor REPLACE 50 GALLON GAS ,WATER .HEATER.
w'3Ov, _ ARCHI I IGTS DICTARAI ION - 1 •t -
C 1 1: dcmumd nay plam.h:h bv,w.d os mbl c records , • t ,
yC O Licensed prohassionul .. - .. ,' •P
OWNIiR-BIIILDER DECLARATION -
1tit� hereby anirm Ihal I nm exempt from the Contrucmr's License Low for.the
following prison.(Suction 70315.Business and Pndes,ono C dent Any city or century -
Y s 0 which reyuires it pamul ro cnmdmet,alter,improve,demolish,cr repair any smicwrc
'
a3�
prior it)in issuance,also It the applicant tori permit file a signed statement t
that heoliect.<.lInitiation lemepmvoBronsoftheComtacmlSLcanml,aw(Chapter9 Sq. Ft..Floor Area Valuation
(commencing with Section 71X0)of Division 3 of the Business and Professions Coca)
or that he is exempt therefrom and the basis for do,alleged exemption.Any violation - $1069
of S<etwo 7031.5 by any applicant for a Permit suhjeas the applicant)a civil pamdry Occupancy Type
s. efts o n...re than five hmtdted dnuata(3501/. A PN Number
01.a,6wner ofthe moperly.of my employees with wages as meir sour emnpcnwuon, lPLi 13020. 06 .
will do the work,and the slmnurc is not intended or offered for tale(Sec.70-W., -
Hiairess and 1'mfnaios s pole:The Contractor's License Law does not apply to an - - Required Inspections .
oven,od Ion .,Who builds or improves thereon,and who does .Or work hinxell - .
or Parodic his own employees provided III.,Such improvements are nobinmaded nr I 502 — FINAL PLUMBING .ENERGY.
offered for xalc,If,M1nwevcr,the holding or improvement is sold within one year nl
nmnpleium,the owner-bander will base the contained provins lhat he did tan build ser 506 — GAS TEST
uprt)rc fa pappose of saint''" 507 — FI_NAL PLUMBING
0 I t(in,p p sy am ev'Itia,dy combating with F,aawd nowa,bor,III
analimicLo It(S 71oaolt ( tits Code:
) I'hCmrtlr'x FINALE'D w
, Icer 1 : Hoyt fl pet, -b lank np n, o
and who ,nr lux urs,Jl Png<mx w1h a<mita<t oUe)Icenxc,l po rauum to tan .. - .
Q lItran a0 R,a under
See s :'`. , i
❑luta exempt under Su'. ,n&PChn this rcnsrn: JAN, 0 9 2002
'Owner Data
WORKER'S Co MI117NSA'1'ION DECLARATION
I hereby affimo under penalty of perjury one of the mHowing dedamtions: BUILDING
1� 0 1 hove and will maintain a Certificate of Consent to self-insure for Worker's s
Compensation, as prwidul for by Section 37W of the Labor pole, for the
performance of the work lin which this pannit is issued.
01 have and will comment Wbder's Compensation losurram,as required by Section
37101 of me Labor pole.for the performance of the work for which this permit i. '
sued,My Woroo's Continuation Insurance carrier and Policy number am: .. '
Cartier: Policy N., +
CERn19CA13ON OF i;.XrM'TIDN FROM WORKERS'
COMPENSATION INSURANCE t
�(I his sermon Imcd not he completed if fe permit is for one hundral dollars I '-
($100)or lesR.) .
Icattil'ntnt'Inme wrh..'.cancc oflbo work for which Ed, I '. , t
y Permit In i.asned.l
hall not nnploy any lie mnll In nay munutcr so,ax m become suhlect In the Wndurs'
Cnnlpersmirnl haws ul'Culilioufu,,Duro
ApplCmll 1p •.
NO ICI IO APPLICANT II B rknh thsCint ate orL Ii y n hod , 't
Met) bl I I,the Wickets Coun,riu,ion inrivikimm of the[..be,C le,
y us
Q fuIdnIith our,l,with well Emoillon,er tlus pmt r shall he deemed revolted - -
CONSI'RUCERN LENDING AGENCY
7 1 he
aflimn that there is a construction lending agency for the perommunce
of[be work for which thispermit is issued(Sec 3ti Civ.C.)
L Q 'larder's Name -
z LanI Address
U 0 -, I certify that 1 Lars,mad this application and state that the above attenuation is
emmin.I amse u,comply with 011 city and county ordinances and store laws relating
•� f,J Iohuildingcon,madon,cad hereby amhonae repneonaetwi,,of this city u,enn•r urym .
} rW the above-menlinnml propcny,for imsl,edion purposes.
nFL (We)ugrccmRm<,indemnily and keep harmless the 01yof Cupertino again.
t7'-I 4 liabilities,judgment,cogs and..peones which may in any way mane against.said '
d z Cal in con equenae of the Emitting of this permit. .. -
APPLICANTUNDERSTANIISANDWILLCOMPLYWITHALLNON-POINT Issued b
SOURCE'REGULATIONS, y: Date
simvp ma nr Appuallmrenlnraemr hale .Re-roofs , - -
HAZARDOUS MATHRIALS DISCLOSURE "
Will the ap,k,:ul nr I'uave lniiding,Kcumtm sunt,or handle huaadons unmuriW Type of Roof
;is dcftacd by the Cupmioo Munlulpul Code,Chapmf 9.12,and the I Icahn and Sakdy -
Coda,Smlion25532(u)9' 1 .,
°Ys,' FJ No , - All roofs shall be.inspected prior to any roofing material beingInstalled.,
Will the appEclntI n, ons bnHdmg,wa.,ent.,a egaipanam e,devieas which If a roof is installed'without first obtaining an inspection, I a ree oto remove
.vmath Np'ur, ntannm,ase find by theBay ma uA QualityManagementp g
-1
all new materials for inspection. Applicant understands and will comply with
` °Ye °N all non-point source'regulations.
1 have read the hranudkatcs n claims requimmentn unJ r Chapter fi 95 of the
California Health&SAity Cale,Sections 25505,25533 and 25534.l understand that
if the building loco col co mall have a lananL that it is nay msrymeibility to notify the '
occupant of the rcgniremems which must M mel prior to issuance of a Cmificate of -
Signature of Applicant Date .
owneroriamon,edage.( Dene All roof coverings to be Class"B" or better .
OFFICE .