02100088 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BuILp1@cT?1BI5ESMARTINWOOD WY JUST WATER HEATERS INC PERMITNT21000HS
41110 AFH CH 1764 NATIONAL AVE APPLICXFIINyf� ITY2002
apZONE: 510 293-9901 SANITARY NO. CONTROL NO.
ARCIII'FECF/ENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECII
0 0 0 0
�00 LICENSED CONTRACFOR'S DECLARATION p
..P I herchr alirm that l am licensed under provisions of Chapter 9 Commencing REPLACE WATER �ri l;H tion
Gaywish Sec11no 71X118 nI Uivision3nl the nosiness and Profcssinna cage.and mYlimnsc is
in full lace and effect.
T'y? Liccnsc Class bias
oZ— Date Contractor
ARCIITTECTS DECLARATION
K y< 1 understand my plan,shut]be used as public records
apdG
tSLLON Licensed Pmfessiomil
OWNER-BUILDIiR DECLARATION
to <S I hereby al@m that 1 um exempt Iron the Contractors Licence Law I'nr tM1c $500
w_p O following mason.(,Section 71131.5.Business and Professions Code:Any oily or county
n%m which aqui.a permit m construct,alter,improve.demolish,or repair any structure
m
prior o its issuance.also requires the applicant for such permiuo file asigned statement
t�< that heiahamaedparsraFittumepnwiamnaarinccantra<,nr:.uecnsclaw(Chaptcry 35FjSB.ffQ)b2CAI0k Valuation
(commencing with Section 70)x)of Division 3 of Che Business and Professions code)it
y 3 that he is cacmp therefrom and Ne basis for the alleged exemption.Any violation rl
Section 7031.5 by any applicant for a permit subject the applicant Co acivil penalty of 11-N ccupancy Type
not more than fin hundred dollars(s5m). 506 — GAS TEST
❑1.az owner of the property,or my employees with wages as their aide compensation,
will do the work.and the mmmum is not intended or offered for safe(Sec.]Ban,Business
and Professions Code:The Common,',License,law does not apply an an owner of equve nspections
property who builds or improves thereon,and who does such work himadf or through his
own cmplryees,provided that such Fit is sadd wait arc not intended completion,
ol@reJ for role.r.
builder .,the building or den of improvement is sold within one yea of Improv for Ne owner
builder will hove the burden of proving that he did not build or improve for purprm of /
sale.].
❑ 1,as owner of the property,.B exclusively contracting with licensed contractors i.
oast La the project rice. r a4,Business and property
who
CodcJ Theves the hon, Fid
come law d......pply je is with
property who builds or improves Norton,and
whocontractsL cm foramen projects with a cnnvaaor(s)licensed purxuam m the Contractor
License Law.
1 am exempt under Sec. .B&P C for this reason
acs Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following dcdaratirns:
I have and will maintain a CeniEnm rf Conscm la sdbinsum for Worker a Compete
7371)'�N' )of
on,as provided for by Section 370)1 of Ne Labor Cute,for Ne pemormanee of the
k for which this form it is issued.
1 have and will maintain Workers Compensation Insurance.az sequined by Section
Ne loner Core,for Ne pemnrmance of Ne work for which Chis permit is issued.
Workers Compcnsalinn f romance carrier and Policy number am:
mcr: Policy No.:
CERTITICATE OP EXEMPTION FROM WORK ERS'
COMPENSA'T'ION INSURANCE
(This section need not he Completed tribe Permit is for one hundred dollars(91118)
less)
I candy Nat in the performance of the work for which this permit is isamd.I shall not
employ any porsf n in any manner so as m become subjecun the WorkersCompensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:11,after making this Cenifcam of Exemption,you should
heconae subject to the Worker'I Com earominn provision.,of the LaMar Code,you must
OZ forthwith comply with such provisions or this permit shall he deemed revoked '
zO CONSTRUCFION LEN DING AGE NCY
04 k for
rwhich ran Cher thereissued( ec.30 .Cingugcncy By the performance of
ai the work for which this permit is issued(Sec.31197.Civ.C.)
f11 Lender's Nanta
1Add..dcr's AJdm
Z Z //IVl�7�il/
V 0 1 cannily that 1 have read this application and some that the be,information is I
F-' Comet.l agree to comply with all city and county ordinances and some laws riming to
U building construction.and hereby authorize representatives of this city to enter upon the
above mentioned property for inspection purposes.
s� S (We)ague In save,indemnify and keep harmless the City it Cupertino agai nu
liabilities.judgments,Casts and expentts which may in any way accrue against said City
U Z in consequence of the granting of this permil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApNicuwcamractm Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building xueral stem or handle hvandous matenal
M,defined by the Cupertino Municipal Code,Chapter 9.12,and the Ileallh and Safety
-Miiiafc11132001 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
emFWill the applicant orfnamebuilding necurnat use equipment or device.,which If a roof is installed without first obtaining an inspection, I agree to remove
it haamaus air contaminants as dcfnc l by the Bay Area Air Quality Management all new materials for inspection.
Dialon,I'
E3 Ye., 0 N
1 have read the haxamuas mamri ils requirements fancier Chapter 5.95 of the Culifnr-
tie f Iculth&Safety Code.SttGons25A15,25533 and 25514,1 undershot that if to building
does not currently have a¢nam,that it is my respmsibilily to Firmly the ax cuPam rl the
regrimmeas which must be mel pear to issuance of a ccmrcate of Occupancy Signature of Applicant Date
owaerarmthao-cdagenl Dale All roof coverings to be Class "B" or better