02120100 CI'T'Y OF CUPER'1'INO
BUILDING DIVISION PERMIT "CONTRACTOR=INFORMATIONIt' ''..
BUILDING ADDRESS: JUST WATER HEATERS INC PERMI'TNO.
22823 LONGDOWN RD 02120100
OWNER'S NAME. 1764 NATIONAL AVE APPLICATION SUB DATE
TOM MARTIN 12/30/2002
ZONE: SIO 2 93-9 9 01 SANITARY NO. CONTROL NO,
ARClUTECTIENGINEF.R: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
0 0 0 0
elip 0 j LICENSED CONTRACTOR'S DECLARATION
U
F I herebde
y alit.that I am licensed unr provisions of Chapter 9(commencing Job Description
�zuwith Seninn]IXXn of Division 3 of Ne Business and Professindartde.and my license is
fnmOhimeandeffeti. REPLACE WATER HEATER
001X License class Lic. pp�
yDat 1l
—p Conaaclor (40 GALLON GAS) ®
S: I understand my pl m i end he..it as famlim mends
LLo LieensedProfessi„nal JAN, 0 2003
OWNER-BUILDER DECLARATION
WY I hereby affirm that 1 am exempt from the Contractor's License Law for the
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w p O following mason.(Section]031.5.Businermss and Professions Gide:Any city or cuunry BUILDING
a K which requires a Permit tri criminal,alma
improve,demolish,or¢pair any structure
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prior o its issuance,also rcyuims the applicant for such permit o file a signed statement
IS that he islicenedpursuant mthe provisinns(If the ComnmunSLicenseLaw(Chapter 9 Sq. Ft. Floor Area Valuation
�$ (commencing with Section 701X1)of Division 3 of the B usiness and Proms ions Call $775
y that he it exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fora permit subjects the applicant M a civil penalty of APN Number Occupancy Type
Out mom than rice hundred delta.45M). 34233052 . 00
p y YP
I,as owner of the property,or my employees with wages as their sole compensation,
will do the.,it,and Neswcture is not intended or offered for sale(Sec.7W,Business g�,� NL.$�q�y
and Professions Code:The Contractor's License Law does not apply to an owner of 502 - FINAL Y'Le RGY
properly who builds or improves thereon,and who does such work himsel for through his
own employees,provided that such improvements am not intended or nRemd for sale.If. 506 — GAS TEST
however,the building or improvement is sold within ooe year of completion,the owner-
builderwillhavethebuNenofprovingthatimdidnotWildorimprove for purpose of 507 - FINAL PLUMBING
sale.).
❑1,as owner of the property,am exclusively contracting with licensed conditions m
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Lb .
cense Law dues not apply to an owner of progeny who builds or improves themon,and
who contracts for such projects with a conuacmr(s)licensed pursuant to the Contractors
License Law.
❑ 1 am exempt under Sec. ,B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby ali m under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Cousenun self-inmre for Worker'sCompen-
grinn,as provided for by Section 3700 of the Lskr Code,for the performance of the
work for which This parnit is immod.
❑1 have and will maintain Worker's Compensation Insurance,m required by Section
3]00 of the Labor Code,for the performance of Ne work for which this permit is iswed.
My Worker's Compemenima Insurance turner and Policy amok,am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tris union need not k completed if the permit is foron,hu Wreddollars($100)
or less.)
I unify that in the performance of Ne work for which this permit is issued,l sball not
employ any fiction in any manner so as M become subject to the Workers'Compensation
Laws of California.Dade
Applteam
NOTICE TO APPLICANT:If, it,,making Ibis CenifiwM of Exemption,you should
become subjat to the Worker's Compensation provisions of the Labor Code,you most
OO forthwith comply with such prnvisinns o,'this permit shall be deemed revoked.
z CONSTRUCTION LENDING AG ENCY
I hereby affirm Nat there is a construction tenth ng agency liv the performance of
Ci > the work far which this permit is imued(Sec.3097,Co.C.)
011 Q Lender's Name ti
z Lender's Address
U 0 1 unify Oil 1 have mad this application and arRt bar In..hove imagination n is
D. h consul.I.,mem.imply with all city and county ordinanes and s4¢laws rclming I.
O U building construction,and hereby authaire ropseserinwhes of this city to enter upon the
l[1 wood mentioned properly,for inspection purposes.
(We)agree Io save,indemnify and keep harmless the City of Cupenimo against
Fw y
liabilities.judgments,custs and eapenes which may in any way accrue against mid City
U z APPL CANci
TUNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signawrc of ApplicoR [).toHAZADO
HAZARDOUS MATERIALS DISCLO Type of Roof
Will the applicant(it future building occupant state nr haddl hanJlc hurallo v..triol
a,lelineJ by the Cupcninn Municipal Cndc.Chapter 9.12,and the Ilcalth and Safety
cede.Semon zss3z(ay'
❑Yes Na
All roofs shall be inspected prior to any roofing material being installed.
❑
Will the gdfl cim or for..hmdding occupant ae equpmcal or device,which If a roof is installed without first obtaining an inspection, I agree to remove
mit hasaNnm air contaminant.as defined by the Bay Area Air Quality Management all new materials for inspection.
7�ia
istrict/
0Yes 0N
I have read the hmallom nourish nummmen¢under Chapter 695 or Califor-
nealth&&Safety Gale,Sccdss 25m .515,25533 and 25534.I understand Nat if die building
oes not currently haw a tenant,Nat it is my respammitity to nmdly the Omapmt of the
quirment,which mug hemet poor to issuance ofaCenlBn4ofDuapmey Signature of Applicant Date
Owner or authorized agent Dao All roof coverings to be Class "B” or better