02120006 CI'T'Y OF CUPERTINO �?, -
BUILDING DIVISION PERMIT C0NT%ACTi3O*INF RMATION:
u
Bul Es? JUST WATER HEATERS INC PERMIT N02120006
oaY@.EG&W: DOZIER 1764 NATIONAL AVE APPLICATT`2` lU-3TY2002
sh
ZONE: (510) 293-9901 SANITARY N0. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
�0, LICENSED CONTRACTOR'S DECLARATION �tp6 a �(j�p�
oar F I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing WA {;eH AT jt$j A'ffL[ta'j[SkT
with Section VOlgp of Division 3 of Om Business and Poirreuons Cndc,and my license is bA•
in fen mrceand effect (4 GALT)
,204 License Class Lica
SO Z H O Date Contract.,
50 6
ARCHITECTS
I understand my plans shall he edas as ecoids
3 a Licensed Professional
F Legg OWNER-BUILDER DECLARATION
1 hereby.(firm Not 11. cxcmne from the a mons Cis License Law for the —
1s 00
Which
or tcasun.Permit
t 703L5.Business end Professions CMe:Any city ser county
$ which recrosses n permit m atm.the atm,,impmssu demolish.Or roam,any structure .,
ZaPdnnn its issuance.also reyvires the applicant for such Permit u tilt ax Law lUptorm
that he is licensed pursuantintheprovisionsoftheContractor'sLicenseWwlChapmr9 Sq. FL Floor Area Valuation
a $ (commencingwith Section 700dofDivision 3ofthe Busoessand ProfessionsCodo'n 37505033 . 00
Nat he is exempt therefrom and dm hssis for the alleged exemption,Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than fisc hundred dollars($50% 502 - FINAL PLUMBI G ENERGY
❑1,Us owner of the property,or my employees with wages as their sure compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7DM,Buaincss
and Professions Code:The Conametor's License Law does not apply m an owner of 507 - F I NAL g08jQ&actions
property who builds or improves thereon,and who docs such work himself or through his
own employees,provided that such improvements arc not intended oroRered for sale.If,
however,she building or improvement is sold within one year of completion,the owner-
builder will have the Widen of pmving that he did not build or improve for purpose of
sale.).
❑ 1,as owner of the proper,am exclusively contracting with licensed contractors to
construct the project(Sec.7W,Business and Professions Code:)The Contractor's Li-
cense Ijw does not apply to an owner of property who Wilds or improves Ihem9n.and,
who contracts for such projects with a contractors)licensed pursuant o the ContmemYs
License Law.
❑1 am exempt under Sec. B&P C for this mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penally of perjury one of the following declarations:
1 have and will maintain a Certificate of Catsenno self-imum for Worker'sCompcm
seism,as provided for by Section 37M of the Labor Cade,for the a fm dut.of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as recruited by Section
37M of the Later Code.for the performance of the work for which this permit is issued.
My Workers Compensation Insurantt carrier and Polity number are:
Carrier: Policy No, _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if be remit is forum hundred dollars($I W)
or less.)
I certify that in the performance of the work for which this Permit is issued,l shall not
employ any penin in any mannerso as N tecome subject to the Worker's Contradiction
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,arm,making this CCAdwam of Escmpsion,you should
Waome Subject to IM Workers Compensation provisions of the Labor GMC,you must
O O foMwlN comply with such provisions or this permiuhall W deemed revoked.
0 CONSTRUCTION LENDING AGENCY
[-+ I hereby affirm Nal there is a construction lending agency for the Performance of
ai i Be work for which this permit is issued(Sec.31197,Civ.C.)
aQ Lender's Name
U. P I certify Out 1 have read Nisty ad.. and atom that the ahovc sus rating is
U. U mrtL.ding conreestruction.
to comply hereby uth and coup sentatnanres and sure latus rupong to
(] V u1nowngcotionedonantl hemhyamhonrercpresematives of this city to toter upon she
ahovc-(We)agree
propertysaw,for inspection purposes.
G (We)agree to cave,indemnify and kith harmless the City of Cupertino against
fly in
fOuS costs and expenses which may inany way.acme egemn said City
U ,Z A consequence of UNDERSTANDS
of this D WIL
F-t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signalurcof ApplicaDatc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant nor ine
bunting k,Chapter
store Oran handle h eaNuus mammal
as dchneJ by the Cupertino Municipal Cork,CMpmr 9.12,end IM Health and Safely
Gsdc.Sccdon 25533(.)? All roofs shall he inspected prior to an roofing material beim Installed.
❑Yea ON.
P P Y g g
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit h u ikes air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yrs 0N
1 have mail the hamrdous materials requirements under Chapter 6.95 of Be Califor.
.is Health&SafetyCak.Sections 25505,25533 and 25534.1..&. it then if the Wilding
docs not currently have a tenant,Nat ii is my msrysmibility m nod fy the Occupant of the
requirements which mustW mel pnonn issuance Of a Certificate of Occupancy. Signature of Applicant Date
owner or amWrixMagcal Date All roof coverings to be Class "13" or better