01110131 OF
CI BUILDING DIIVIISSIIONNOPERMIT CONTRACTOR INFORMATION:
ff I,YpgOT NCHO VENTURA ST JUST WATER HEATERS INC PERMIT No. 01110131
`fffgff"!�ONESON AND YUE 1764 "NATIONAL AVE ApPLPGTTtOynsPHT,
/ ' PHONE: (510) 293-9901 SANITARY
3 NO. CONTROL NO.
w 0 0 ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
UW C U1 I—I C7 LJ
DS=eo2 LICENSED CONTRACTOR'S DECLARATION �J��bb pp�� ri
y s tion
Inarny affirm that Iwoheensedander provisions ofChapte,9(commencing REPLACE WATER HEATE�.p
with Section 7")of Division 3 of the Business and Pmm fessioCode.and my lice.-
a is in fall force and effect. (5 0 GALLON GAS)
s z g a License Class Lie.p
O n O Date Contactor
u 3 LL u ARCHITECT'S DECLARATION
ty:O g 1 mdersland my pan,shall M used n public records
3�
u n c o Licensed Prolcssional
' 0 4
OWNER BUILDER DECLARATION
I hereby aft inn that I ren exempl from IM1e
n ' Contractor for IM1e
folowing mass .. Section s>and io Code:Any city o,county
sF❑ which ts permit m,mn,.me 'rep sae,demolish,
e li h o as any structure
t e. I. q .thapplicantlo. M1pe n filesigned Ilemm
c. tnih llcen dp aotoftA nsofC wct Lc V (Chpter9
_
C Sq".Ft..FloorArea.> a Valuation
(commencing ' th1 t 7OWI of Div's a fthe B sine. dPr fs
esso Code) I v 1•t .,Ir - r Y •'! 1
or that he,s exempt therefrom and the bass for the alleged eaempuon Any violation 3 5 7 0 3 0 5 6'. 0 0'
of Section 70315 by any applicant for a permit subjeco the applicant o a civil penalry-
'of not more than five bundred dollars($51)(o. APN Number Occupancy Type
❑I,asownerofthepropsry.ormyemployeeswithwagesastheirsolecompensation, 502 — FINAL PLUMBIN ENERGY
-win do the work,and the structure is not intended or offered for sale(Sec.7044. 506 - GAS TESTk aired Inspections -'
'Business and Professions Code:The CmaracmC,License Law d«s na apply m an q I7 +
owner of pro,,,,Who bolds or improve,thereon.and who d«s such wo,k himself 507 — FINAL PLUMBING
Or through his own employees.provnot Nat such improvements are not imended or ..._.. .-
offered for sale.IL however,the building or improvement is why within ane Sear of _...... _... _ Ir
completion,the mmerrbuilder will have the burden of proving that he did nut build or
improve for purpose of sale.). �/��
co E mther of the property,am Business a cmnroessi withadc:)do Com ica 's ' PQs E®
License
the project(Sec.
appl 7f1W.Business and Professions Code:)The improves
tmcmrn,
i
construct
Liana Law Dees not apply ns an owner with
property who builds si improves t-to fM
i .and who contracts for sued projects with.commctor(s)liccnscd.pursuanl.m the -- JAN 0 3 2002 .
Contractors License Law. .
Oram exempt antler See I .B&PCfor his rcsmnDate
Owner
WORKER'SCOMPENSATION DECLARATION BUILDING
t 1 hereby affirm under Penally of perjury one of the following doolairtions:
O 1 have and will mainmin a Certificae of Consent to self-insure for Wmker'n
Compensation, as provided lot by Section 3700 of,he Layout Cade, for the
performance of 1M work for which this permit is issued.
_ ❑1 have and will maintain Woiker'$Compensation Insunecn as trquited by Section
3700 of the Lahor Code,for the performance of the work for which this permit is
issued.My Wearkc"Compensadan Insurance earner and Policy nambe arc:' _ ._,
. Cu 'ts' t ' Policy Nn: rI's ., i
'CERTLFlCATION OF EXEMPT ION FROM WORKERS' -
_._. ... COMPENSATION INSURANCE.. .. .... .....
'(This section need not be complete if the permit is for one handed dollars
011007 ter less.)
Lit1 certify than in the performancework for which this permit it issued,1 i•+b t ..t I+.•^ +.
not employ any person in any mannernner so as to become subjectto the Workerscmin lCalifornia,DateA '
' CPP pnsOt
cicantion Laws of... _ ... _. - : . ... _.. ._. . . . . .. _ .._ ... .- .
NOTICE TO APPLICANT.If,after making this Certificate of Exemption.you should
become subject to the Workers Compensation previsions of the Wbm Code,you must
O forthwith comply with such provisions or this permit shall be deemed revoked.
.-. .-. . . .. . _.. _. __.. . ..
..^�s s'd 'CONSTRUCTION LENDING AGENCY
"I hereby uffnn,na,thele is a commaciinn lending agency for the performance
r of,he saNama which,his permit is issued(Scc.3097,Civ.C.) _ ..
.... .. ..:.-
U:.O Lcndm's;Addrtsa
L certify tha 1 have mad this applic nom and vain IM1m the above infmmation is
as
[r cbrrtn:1 agree to comply with all city and county ordinances and state laws relating
[) to building construe ion,and hereby omhoriae representatives of this city to enter upon
kT] the above.mentioned pmpnty far inspection purposes.
(Ws)iii to save,indemnify and keep harmless the City of Cupertino against
G. Vl liabdities.judgmems.costs and expenses which may in any way seem'against said
C,7 Z City in consequence of the lamming of this permit.
APPLICANT UNDERSTANDS AND WI LL COMPLY WITH ALL NON-POINT"' Issued by: Date
SOURCE REGULATIONS,
Signature ofnppfcarlContractor Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the mplicish or forms bottom g accapar,store or handle ha,",rdous maims) Type of Roof ..
as deft ad by the Cupertino Municipal Code Chapter 9.12. d Ne Hea1N and Safety I „ ,: l 1 :.: ) s
Cd 355321 )
[3 Yes
No: - s,�` t,sf.
-All roofs sball.be inspected prior to-.any.roofing,material being installed _. ._
Will the applicant or future building occp I use equipment or devices which If a roof is installed without first obtaining an inspection;Fagree to remove
main hassurdeu coma i .dfind b, he By Arm Ail Quality Mnegemwn
District? all new materials for inspection. Applicant understands and will comply with
oY. 0 N - - all non-point source regulations..'.... -
S.� 1 have mad the hazardous nationals requirements under Chapter 1195 of the
California Health&Safety Cama,Sections 25505.25533 and 25534.1 understand that
,,tire
building does not curtendy have a tewm,that it is my responsibility to notify the +.
ocdpam of the cyuimmems which m6s1 be met It.,to issuance of a Cenificatb of
Occupancy. Signature of Applicant Date
Owner or authonzd agent Due All roof coverings to be Class"B"or better
4' 4 ..
OFFICE .. .__. ..