03010027 CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRACKTOR INFORMATION
BUILDING ADORISS: JUST WATER HEATERS INC PERMIT NO.
928 MILLER AVE 03010027
OWNER'S NAME: 1764 NATIONAL AVE APPLICATION SUB DATE.
LANGLOIS RONALD L AND GLADYS M 01/07/2003
IF'ONE: (510) 293-9901 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
0W0 LICENSED CONTRACTOR'S DECLARATION Job Description
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing p
'Dwith Section 71XXB of Division 3 of Ne Business and Professions Cade,and my license is
in in 1.11 to.and Chest. REPLACE WATER HEATER.
gZ License Class Lie.# PIIl,4ALED
O Zz :o Dam Cmuranor (4 0 GALLON GAS)F='-'J` ARCHITECTS DECLARATION
•� I understand my plans shall be used as Public records
FEB i 3 rs 003
x�s0 L
adlio Licensed Prnl uxsional
OWNER-BUILDER DECLARATION
Y 1 hereby ufrirm that 1 am exempt from the Cumnctnr's License Law bit the BUILDING
w—o O following extend,(Section 71171.5,Business and Professions Code:Any city or county
�$f which requires a permit sea cmismad.tler,improve,demolish,fir repair any structure
prior to its issuance,also mquircs the applicant for such Permian Tile a signed statement
qs'i< that he is Ifinnixed pursuant to the provisions of the Contractor's License Law(Chipmr 9 Sq. Ft. Floor Area Valuation
aFS Commercingwith Section 7000).1 Division 3of the Business aadPomessionsCode)is, $660
that he is exempt therefrom sandNe basis for one alleged exemption.Any violation o!
Sudan 703 15 by any applicant for a permit subjects the applicant o a civil penalty,of APN Number Occupancy Type
not more than five hundred dollars What). 37541009 . 00
p y YP
❑1,u owner of rhe property,or my employees with wages as their sole compnerstinn,
will do the work.and he sbecome is not amended or offered for sale(Sm.7W.Businea C�{�(y�.yas���$I� 0jj(�p�
and Professions Cede:The Conoazmri License Law dors not apply to an owner or 502 — FINAL YL C11v1D 1 V e M L`R.GY
propenywho builds or improves thereon,and who dors such work himseStmhrough his
own employees,provided that such improvements are not Intended moRercd forale.If. 506 — GAS TEST
however,the building or improvement is sold within one year of completion,the owner.
builder will bass the burden of rmving that be did not Wild m improve far purpose of 507 — FINAL PLUMBING
ale.).
❑I,as owner M the property,am exclusively contracting with licensed conmerors to
construct the project(Sec.70abi Business and Professions Code)The Contractor's Li. .
rens,law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a emulations)licensed pursuant to the Contractors
License Law.
❑ 1 sin exempt under See. .B @ P C fortis noon
Owner Data
70370WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of Perjury one of the following declarations:
1 have and will maintain a Certifcam of Canunt ro self-iman,far Worker's Compmr
0
non,as provided for by Section 3700 of the labor Code,for the pmformance of the
rk for which this Permit is issued.
1 ham and will maintain Worker's Compensation Insurance,u required by Second
of the labor Code,for t e performance of the work for which this permit is issued.
y Workers Compensation Insurance carrier and Policy nmber arertier. Policy Na: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
IThissection need nal he completed if dm permit is fnroac humlred dollars 4HXt)
less.)
I certify that in the Pe,fmmancc of the work for which this Permit is issued,I And net
employ any perum in any manner ser as to become subject to the Workers'Compcnsution
Laws.(California,Dae
Applicant
NOTICE TO APPLICANT:H.after making this Cenificam of Exemption,you should
beeome,subject to the Worker's Compenation provisions of the Lahr Code,you must
OZ forthwith comply with such provisions orchis Permit shall he deemed revoked.
z O CONSTRUCTION LENDING AG ENCY
[r 4 I hereby anirnt that there is a construction lendi ng agency l or the performance of
pi > the work for which this pcomit is issued(Sce.3097,Civ.C.)
QLindcr's No
5 Lender's Address
V 1 certify that 1 have cad thistyapplicationncoand sue that the above information is I
0 U bonding l agree m comply with all city and unary natives 01 and Cute laws relining e
V .1hownmentiorudiroend far
ar by inspection
prposescmatiws nl'JtisCity wcnmr upon Tac
D.l show mentioned 1.saw formnify keep In.
(We)g me ru ave,indemnify end keep harmless the City or Capactins ageiw
y inconwBeudgmenm,costsanof the d expenses which may in any way accrue against said City
V Z APPL CANTeUN ERSTANDSthis
AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
SignaturedAde,linurad7marrierm Use
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum building occupant tore or handleN
aounmaerial
az dennetl by the CuPbnino Municipal GMDe
Code Chapter 4,13,end the Health and Safety
cold.
F1 Yes
zssxa)? All roofs shall be inspected prior to an roofing material beim
❑Tea E]No p p ' y g g installed.
Will the applicant or future building occupant use equipment dr devices which If a roof is installed without first obtaining an inspection, I agree to remove
it havardnus air contaminants m derided by the Bay Arcali
Area Air Quty Management all new materials for inspection.
1d10caner
isuin?
❑Yes 0 N
1 have read the h i,mmous materials requirtmcnu umbr Carrier fi 95 df the Cali for.
rca Health A Saticoy Code,Sectinmc 25N15,35573 and 355W.1 understand deaddeadthe huilding
s nor currently haw a tenant,that it is my respmsihility In noddy the occupant of the
omimmenks which must lc met prior to issuance or a Certificate of Occupancy. Signature of Applicant Date
mataumariadagein Dae All roof coverings to be Class "B"or better