02100091 CITY OF CUPERTINO az get' '
BUILDING DIVISION PERMIT CONTRACTOR INFbRMATION n-
RUu2,I8(0P4L!5EsNORTHWIND SQ JUST WATER HEATERS INC PERMIT N02100091
OWf$PDh,,T E:ROTH 1764 NATIONAL AVE APPLICATTd0YT.1Tg2002
Ahk
ONE' 510 2 9 3-9 9 01 SANITARY NO. CONTROL.NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MIii
0 0 0 0
�00 LICI:NSEDCONIRACOR'SDECL.ARAI'ION
xi F 1 hereby r Rem that lam limned under provisions of Chapter 9(commencing
Glu REPLACE WATER J tion
with Sector isinnJof the Business and Professinrc Cat.and my NALED
a in lull tome and effect.
~gF4 Lifene Class LiaM
C,] Dan-I understand my plans shall he used as p.hire records
^^ ARCHITECTS DECLARATION MAR 1 0 2003
w
3wy Licensed Professional
I"t=0e OWNER-BUILDER DECLARATION BUIL
�1'
u�<4 I hereby affirm that I am exempt from the Contractor's License Law for the V LD Lp 2 0
ti.C C following Taxon.(Section 7031.5.Business and Pntreasons Glide:Any city or county
m�+ which requires a permit b)construct,alter,improve,demolish,or repair any structure
prior to its issuance.also requires the applicant Lor such Permit o Glc a signed statement
that he is licensed pursuant to the provisions of the Conuamor's Licenu Law(Chapter 9 3SIl6l3H0 r6A1@lD Valuation
�$ (tom menti ng with Section 7000)of Division 3 of the Business and Professions Code)nr
y that he is exempt Nemfrom and the basis for the alleged exemption,Any violation of
Section 7071.5 by any applicant for a permit subjects Ne applicant to a civil penally of
not mom than five hundred do[].,,pl!i(B. 506P NGAS TEST ccupancy Type
❑ Las owner of the prnpeny,or my employees with wages a their vile compensation,
will do lee work,and this structure is not intended or offered for We(Sec.7044,Bainess 5827 FfN
and Professions Code:The Conuaclo's License law does not apply to an owner of egmre nspeclions
property who buildsor improves themon,and who doessech work himself or Brough his
own employees,provided that such improvements am not intended or offered for Sale.If,
however,the building or improvement is sold within one year of completion,the u amen
builder will have the burden of proving that he did not Wild or improve for purpose of
aid.)
h as owner of Ne Pnopeny,am exclusively contracting with licensed contractors to
Consumer the pmjem(Sec.704,1.Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds of improves duumn,and
who contracts for such projects with a contracuu(s)licensed pursuant to the Contractor's
License Law.
❑l am eacmpt under Sec. ,B dr P C for this recon
Owner Date
i WORKER'S COMPF;NSA'r10NDKLARATION
1 hereby alTum under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self-imuu for Workers Compen-
Winn,a provided for by Section 7710 of the Laioof Calc,tin the performance of the
W
ork for which Of.permit is issued.
❑1 ban and will maintain Worker's Compensation Insurance,as require]by by Section
7700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance caoicr and Policy number arc:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nut hu completed if IM parmil is lin unc hundred dollars(gl(0)
Or Ica.)
1 certify that in the performance of the work for which this permil is issued,I shall not
employ any person in any manner v)as to become subject o the Workers'Compensation
Laws Of Cali forms.Dam
Applicant
NOTICE TO APPLICANT:If,ofmr making this Cer iliuvm of Escm,pood, no should
herome subject to the Worker's Cum pe nation pmvisions of the Labor Code,you must
OO forthwith comply with such provisions or this permit shall M deemed revoked.
z 7) CONSTRUCTION LANDING AGENCY
[r .N. I hereby affirm that Nem is a Conswnion lending agency for the Performance Of
(Y, ? the wvrk(,it which this permit is issued(See3097.CO,C.)
to Q Isnder's Name
tY fender's Address
IL Q 1 ccnee that 1 have real thisapplication
and county
and sora that 00cesand shrive ws nelatinn is
0U correct.Iagrec 10 Comply hireall yatityani countyordinaottsanJ slide lawsr upon to
the
QU abovenmentiomed ion,anJ hembyeuthon prposeumativcs of JtisCity mcnmrupon the
W
above mentioned prolene for inspection keep hs.
t1 (We)agree s,Cove,indemnify ad keep hay in a the City of Cupertino against
fn liabilities,judgments,granting
.,may which may in any way accrue againstacid City
V z A consequence UNDERSTANDS
n(this permit.
t--' APPLICANT UNDCRSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date �
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaHAZARDO Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Tec Capt score or handle IfeaNuus mammal
as defined by the Cupertino Municipal Gxle,Chapter 9.11,and the IIcaIN and Safety
code,Seeann 25532(a)l All roofs shall be inspected prior to an roofing material being installed.
❑vex ❑N.. P P � Y g g � .
Will the applicant Or future budding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil h r,a dous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes C]No
I have mad the hemNous materials mquiremcnts under Chapter 6.95 of the Califor-
niaHealWA Safety Cat,Sections 255(15,21413 and 25574,I undcrsmnd tool if the huilding
Jens not currently have a tenant.food it is my mspomiMlity to nod ly be twmupaul of the
requlomema which must be mel Prior to Issuance of a Cemficam of Ucaponcy. Signature of Applicant Date
Owncrvn aollimimd agent Dam All roof coverings to be Class nBn or better