00120081OFFICE
CITY OF CUPERTINO
CONTRACTOR INFORMATION:
'BUILDING DIVISION PERMIT
BUILDING ADDRESS:
21.868 OAKVIEW LA
JUST WATER HEATERS Ili%
'"T"0
001.20081
OWNER'S NAME
CASEY ROBERT M AND ALLENE
H TR 1764 NATIONAL AVE
AI'PLICAI'1p $111 1 Alli '
i�ilo�cD00
PHONE.
SANITARY NO. CUM Rot. NO.
(510)293-9901
Z
ARCHITECT/ENGINEER:
-
BUILDING PERMIT INTO
❑�❑
RLIK ELECT PLUMB MECH
y
I-1 LJ CI Cl
hICENSED C'ONTRACTOR'S DECLARATION
Job Description
I hcmhy nflinn than I ,uu IieatneJ unit,, pnwiniann of Clu porr 9 (innnnnming
at
with Sefton Divish,rn ornt,aa iaeasltml rntlr .Inn. enae.nnJ ler rren+e
GALLON CCAS WATER HEATER
reland ri
is in full fors, unit effect.
REPLACE 40
6
Class Lic.p
U
n
Dane Commcmr
)am
IDN
1 unJcmunJ of plum shall M uxJ as Public rtcnNs
lam be used
,
jL Ieenwil Pom"ional
a
OWNiR-BUILDER DECLARATION
I hereby infirm than 1 ane essron from the Contra ..... '+ License Lvw It,, the
fellow my reason. (Section 703 1.5. Rosins, and Pntfe.+sinnn Cade: Any city or county
7
which ¢quirt u permit to Construed. alar, improve, dentin kh, or repair any snussum
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priorm isissuance. also requires the applicant for such prod to file a signed statement
Sq. Ft. Floor Area
Valuwu8q�7
- that he is licensed pursuant to the provWines ofthe Conductor ,License law(Chapter 9
(....am,nug will, See, 701001ofDivixion 3ofthe Hu+incss a ad Proo,sinm Code)
na
or than he I, eoonpt thradol n Iual Ilm basis for the nncged ,avernnin i. Any violntloa
of Section 7131.5 by any applaanl for a permit vmbjecp the oppiwain o, a nail penalty
live hundred dollars
A PN Number
Occupancy Type
of am mom man ($500.
32619107.00
employees with mages as their sure cmnamation,
owner of prope. or any ema
❑l. as ftrty,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. N/N
lusmess anti Protection+ Cade: The cnntmcmr'x Liven+e Law d«, not apply to an
ox r of property Who bdtids or 'nnpoue_, thereon, and who does rich work hintclf
502 — FINAL PLUMBING ENERGY
or through his own entpinyc.. provided than smh improvements are not intended or
in,n n; nnwes,t, m, budhlhtg i,npmvenant is vola wiroin one of
506 — GAS l_ EST
ouared star. or year
oanpletiarn` the o .cr4Wi'e,r rill have the burden of proving that he did not mild or
improve
507 — FINAL PLUMBING
puma'
❑ 1, as owner of the pmprVy, ant exdmively contracting with licensed contractors ru
n the pmlca (Su:. TOT Novi toss and Profcssians CadvI Cnntr
Llsn+iva, Law dor, not apply to ;in ow ter of propvny who but Ids at inq,rawce thereon.
or he
and who for Loth ryajau with n ennlrnclor(q Iieen+W Pnnuum n, the
frod! II
rs, Licets
Contractors, Liccnsclaw.
❑ I am excmpt under See. . If A P C for anis naw
voi
Owner Dane
WORKERS COMPENSATION DECLARATION
I hcrehy ,JRnn undc,pcmdry of pc jury enc of the f Mowing Jcdnnuiunn:
p I have and will maintain a Ccrti kale of Convent In %ell mum lin Worker's
O /
Compensation, as provided for by Section 3701 of the Labor Cade, for the
performance of the work fist which this pearth is i,sued.
❑ I bave,mJ will maintain W'orker's Compensation Insurums, as required by Section
3700 of the Lahor Coale, I r the perlbrntunce of the work for which this per nit is
issued . My Worker', Cour a sallnn Insurumud Catrie,' and Policy nmoner ane:
,
Camcn ]'.]try No.:
CERTIFICATION OF E%EMPIION FROM WORKERS'
- COMPENSATION INSURANCE
(This section need not be camtpleted if We permit is for one hundred dollars
[$11X1) nr le.)
I ttdily than in the Iredonuffer, of the work ho which this permit is issued. I
.
shall nut ca ploy any Person in any manner ,o as In Mcomc +uhjen to the Waders'
Compensation laws of Calif nnia. Date
Applicant
NOTICETO APPLICANT. lt: after nuking this Cenificam of Exemption, you should
became subject to the Worker's Cannlxmsminn novisiaur, of the Lahor Cada, you must
for nwim comply with sndt fookien, of rots pemnl +h:dl be oriented mvokeJ.
p
CONS rRucl'ION LENI3ING AG12NCY
1 hereby affirm that them is a conslnetion lending agency for the pedonance
of to work for which this permit is issued (Sec'. 3197. Co. C.)
Lrnar's Name
Lendor's Addris+
tiI
eetilq that I have read Ihls appllcntiou aad sun, Ihan Ihaabove Intomturmn is
test. I agree an entad, want ,a city ,and county an11na6Cµ and state laws misting
"
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to building mmlmmon. and hereby authorimmprexnmtives cfthis city na anter upon
the doventa tionci pmpeny for impetllon parpatses.
L.
(We).,me n, save. indemnify and keep harmless the City of CuNdino against
n
liabilities, judgments, costa and expenses which may in any way aa'nm against said
City is doocauvtice of the grinning of this permit.
APPLICANT UNDERSTANDS AND WILL COM PLY WITI I ALL NON-POINT
Issued by: Date
y'
REGULAI SONS,
Signature of ApplivanVCommctor Date
Signature
Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Win the applicant or future Wilding occupant sone or handle Womous material
Type of Roof
"
as defined by the Cupertino Municipal Cade, Chapter 9.12, and the Health and Safety
Code Sited 29532(ayf
❑Yrs 'o No
All roofs shall be inspected prior to any roofing material being installed.
Willtnc opppcuntnr future buildingaccupunt use equipment nr df,i,es which
If a roof is installed without first obtaining an inspection, I agree to remove
,mi, hanrdous air cnnlnmin:mu as Jif sed by the day Arca Air Quality Maagement
Di,mrt?
all new materials for inspection. Applicant understands and will comply with
0YO, 0N
all non-point source regulations.
I have real l the hamnlous m:noials requirwnrnts under Chapter it 95 of the
calidoo ill Ioalth A Safety Codd. Sectio I, 25545, 25533 trod 255)4. I undcruun l that
if the hnllding does tan,rnently hme it mnanl, that it is ,ny mononobilhy to notify the
,option of the requifemenr+wltlrh amt be nmt prior it, issuance of a Ceditirane of
Draapane,
Signature of Applicant Date
II All roof coverings to be Class "B" or better
Owner ar aaf W,iAd agent Date
OFFICE