01010092 CITY OF CUPERTINO
aDII.MING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: - PERMIT NO.
19161 MURIEL LANE JUST WATER HEATERS INC 010100922
OWNER'S NAME: APPLICATION SUIT DATE
REYERS CARE HOME 1764 NATIONAL AVE ' 01/222/2001
•.
PHONE: SANITARY NO. CONTROL NO.
(510) 293-9901
0 ex p ARCIIII'ECI'A?NGINUEll IIUILDING PFRMIT INFO
HLDG FIXCIPLUMB MECH
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zv=Ni= LICENSED GONTRACnUR'S DECLARATION Job Description
O a_0 1 hereby surd that 1 ad p licensed1 ,ir under provisions of Chapter 9 and
(commencing
m 1–ca wish Stt'tinn711(Illlof Divisionlal the llusincxs and Profcs,ians Cale.soil my linn.w
ay E� i,in full force and effect. REPLACE 40 GALLON GAS WATER HEATER
x exd u la w ClassLie.a
Date n Cowmmor
w 3 w H ARCHI I'I!C.T'S IIECLARAI'[ON
I nndersland hay plans.bell be used as food,record.a. ,
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OWNER-BUILDER DECLARATION
w:m i hcrcby all thin 1 am exer,In I the Contractor's License Law lin the
F Y'Q billowing waam.(section 7031.5.limincs,and Pmfes,ions Cute:Any city or county
E s O which require,a Imrmit m con.suun,Cher.ihnprow.demolish,fir repair any etructnre
ce
an 3 p o,its issuance,also requires(be applicant for such foam to file a signed satehnehn
Mahe isfnenaJp uannotheprnvisionsnnhe Cnnir toes Licen,eiaw(Cluhper0 Sq. Ft. Floor Area Valuation
(cancrarde ng with Section 7(X)1 of Division 1 of the Business and Professions Code)
or that be,is exempt therefrom and the basis for rhe alleged exemption.Any violation $647
of Section 7011.5 by any applicant for a fermis.objects be applicant d a civil Penalty
of not inure than five hundred dollars I15001. APN Number Occupancy Type
Cl i,a.....urof the ac,r y.ar n,y employees with wage,a,Ihelr sum en f,s n.,:uloo. :-,79086410. 00
will pill the work,and the.anemic is mil Intended or onehcd for sale lsec.7014.
Hhh, nt1 rrrc, ,Coda:'nha Cnhhohh,mh',L'h¢we law due.,fid v,ply to air
Required Inspections
h�0 prnpany who build,fit I rpnrvcx hheeou,and who dx,mcb work.Ihlmm
nn
o,�hrooglh hi,own virme ce,.prn,;ded non,a,h im,nowanew,me inn iweudc l d 502 — FINAL PLUMBING ENERGY
oHced]in>ale.If,however,the milding of improvement is sold within one year o1'
mhpletion,tlhenxnu-huimer will have the humeri of proving that he did not build fir 506 — GAS TEST
improve f'..pa'fo"`nf`"I", 507 — FINAL PLUMBING
01,as uputroll the property,inn a eti,iwl,anmmeing with licensed contmel—to
nnswetwthe project(Sec.7tRl Iiu,inos and Professions Ca]e:)The Cold mer,r's
License Law Jon nut all to an owner of Property who builds or improve,Iherehm,
and who contract,for such project,with a contmmons)licensed pursuant to the
Cammebre,Liceree law.
0 I am exempt under Sec. .H&P C for this rearm
(lwn,r Ilene
-WORKI!IPS COMPENSATION DECLARATION
1 herehy upturn under penalty o1'fc,jmry nn,of Inc following declarations:
�. 0 1 here and will nhaintnin a Ccrtiti.c of Consent ah self-inwrt lin Wader', /
'Compemntinn, a, provided for by Section 3700 of the Iabm Cod, lin the !/
perhrtn eme of the work for which this unit is issued.
01 haw and will maintain Worker's Cod wifalion Insurance,a%required by Section 0/
171)of the Lb,r Code,for the performnux of the work for which this crout i,
wed My Worker,Compenvdion Insurance carrier and Policy number are:
Curler. Policy No.:
CERTIIICATION OF EXEMPTION FROM WORKERS' _
CGMPI. A'1'ION INSURANCE
I'I'u%section nen]not he mnhplcmd if the pern,it is for one hdldreA Jnllum
SIgf fir luvrod
I carl that in the pvrfomurice of the work for which this permit i,issued,1
shall not employ any Kron in any manner It,as ho became'object u,the Workers.'
Compensation Lax,of California.Date
Applicant
NUI ICE APPLICANT.If.vilermaking this Certificate of E¢mptiun,you should
become wbjea m the Worker',Compensation provisions of the Lahr Code,you must
Q O forthwith comply with such pnwixons or this permit shall be decided invoked.
z
F r_ CONSTRUCTION LENDING AGENCY
Ix 7 hereby album that i,,caie i.r,cnnnlmnlon097,C agency lin the fetimnuncc
ill the wad lotme which Oi,peh'hnit i,ksncJ(Sec. lending11102 Civ.C.1 ,
hY ❑ Lender',Nunho
7 z LcnJcr',Address
U O 1 ccirl y that 1 have read this al,plicatinn and state Oat the above ialonnotion is
4>: correct.I span ,,comply with u11 city anti cotim,on icurce,and,late laws rculing -
O [) mbuildin,ermwaion.and hercbyaut...riA,p tro,uatives offlik city to emer ufsm
the aMne.mentoned property for inspection purpows.
L Olip agree to save.indemnify and keep hamdess the City of Cupertino casino
rp liabilities,judgment,,amts and expense which troy in any ray name against said
U "L. City in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLYWITII ALL NON-POIN'T Issued by: Date
SOURCE REGULATIONS. Y•
slgnawre ofnpphcanucr,n,weror Date Re-roofs
HAZARDOUS MA'I HItIAI S DISCLOSURE
Will the hhppuc,d or nhahhe buBdhhg uccnpad Bare mhadBc harrndnu,tna Gal Type of Roof
"definnl by the Cr,ninu Monidpul C'sa,cle cr9.12,and the Ilndth and Safety
CoJc,smnun 35532Iu11'
O Yes 0 N All roofs shall be inspected prior to any roofing material being installed.
Will heappli,an,wfuture lmlldingraeo,ordantegaipmcdmdeviccswhich If a roof is installed without first obtaining an inspection, I agree to remove
emit hazardous air O maminant,us defined by the Itay Area Air Quality Management
Di,lHcrr all new materials for inspection. Applicant understands and will comply with
0 Yet, °No all non-point source regulations.
I have read the hazardous materials requirements under Chapter fi 45 pull the
California Health&Safety Code,Sections 25505,25531 and 25534.1 understand that
If the boildi ng docs not currently haw a it that it is my mslnmsihi lily to noti ly the
Oecupant of the requirements which nd,t be met prior to issuance of a Cenllicam of
,cupanay.
Signature of Applicant Dale
Owncrapatch di,magenl Dat, All roof coverings to be Class `B" or better
OFFICE