03010126 CITY OF CUPERTINO _.f
BUILDING DIVISION PERMIT X,CONTRACTptR�INF 'RMATION:^
lakalr.. ,, ..>s,,.
BUILDING ADDRESS' JUST WATER HEATERS INC PERMITNO.
22325 REGNART RD 03010126
OWNER'S NAME: 1764 NATIONAL AVE APPLICATION SUR DATE
JACKSON JAMES E AND PATRICIA R 01/23/2003
apZONE. S I O 2 9 3—9 9 01 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINHER: BUILDING PERMIT INFO
BLOC ELECT PLUMB MF.CII
o00 LICENSED CONTRACTOR'S DECLARATION )Ob Description
U F 1 hereby of0fm that I am 1 licensed under od Poimv of Chapter and
si, p
with Section 71XX)nl Division 3 nl the Business and Pm@ssinnt Code,and my license is
inlnufnreeandeffet,. REPLACE WATER HEATER �����E'®
FRq g Date cleat Lie.a (7 5 GALLON PROPANE)
r Date Lif'.0 ter
m ARCHITECTS DECLARATION FEB 2 4 2003
Kz 1undcfaunJmy plansshall he TSmard.1 public records DECLARATION
KOyU
Rio I.trcnseJ Pmlcssinna
KRio JJ that I a OWNER-BUILDER Dr the Co TION
8 a 0 1 hereby affirm that 1 1. .Bfirm from the Cnntmcu o :Ad,a Law lin the BUILDING
to—p0 followwhich re uirenn.(Sermon 7031.5.Business and improve.
demolrcsish,
Code:AnY oily of county
°' $ which its isea a permit ro aims the ahem improve.demolish,or repair any structure
Zy
poor to issuance.also reyvircslhe applicant for such Permit to file asigneJ statement
t—p
that he is licensed pursuant to the provisions of(be Commences Life use Law(Chapter 9 Sq. Ft. Floor Area Valuation
�$ (commencing with Snmion 7100)of Division 3 of the Holmes,and Prmovsinns Coca)nr $219B
that he is exempt thcmfrom and Ne basis 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 e
not more Ban five hundred doaara(gsDn. 36639001 . 00 P yTYP
I,as owner of the property,or my employees with wages u Bator role compensation,
will do the work.and me stracmm is not intended car offered for sale(Sec.704,Business
and Professions Code:The Content Lima.Law does not apply to an owner of 502 — FINAL pptWp JJqjelgqqtRGY
property who builds or improves thereon,and who dcessuch work himself or through his
own employees,provided that such improvements we not intended proffered for sale.If. 506 — GAS TEST
however,me building or improvement is sold within one year of completion.the owner. 5O7 — FINAL PLUMBING
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑h as owner of the progeny,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Cust The Commences Li
cense Law does not apply to an owner of progeny who builds or improves themon,and
who contracts for such projects with a contrachubd licensed pursuant o the Contractors
License Law.
I am exempt under See. .B 4,P C for this rwsnn
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of me following declarations:
I have and will maintain a Certificate of Consent In set binsum for Worker's Camped-
trump,as provivMd for by Section 370(1 of the Labor Coca,for the performance at the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,m required by Section
37(0)of the Labor Cale,for me performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissection need not hi,completed ifthe Permit is for one hundreddollam(k I1X)
less.)
I cenify that in the Performance of the work for which this permit is issued,1 shall not
employ any person in any manner m as m become subjecuo me WorkersCompensation
Laws of California,Dalc
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the faMr Code,you must
OO forthwith comply with such provisions of this permit shall be deemed revokd
e
E n CONSTRUCTION LENDING AGENCY
[r I hereby allifm Out marc is a constmaTinn lending agency lite the performno.ol
the work for which this permit is Issued(Sec.MAP,ON.C.) V
W Q Lender's Name
C
z Lender's Addicts
U
C.) t7 I certify mat 1 have mad this application and auto that the shove infamminn is
W U comingcon tr to comply herebyth authorize
andriz county ordinances ivesOf and smu lawsent r upon to
the
QU athosengndindection.and hereby of this city to enter upon rbc
W above-(We)areifsoproperty for inspection l keep br
(We)agree m save,indemnify and hick hay in an the City of Cogent s id City
U Z incoixopue ceofth.granting
reuand expenses arit. may in any way nccmc against said City
V z inemnsCAN'Tcof UNDERSTANDS
this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signawrc wApplicantiCivanactor Once
HAZARDOUS S MATERIALSDISCLOSURE Type Of ROOF
occupant
'
Will the applicant or future building tecupam score or handle M1avarduus material
as do Med by fhe Cupertino Municipal Calc.Chapter 9.13,and the Health and Safely
dale.seeder zss3z(ar!
❑Yes 0 N All roofs shall be inspected prior to any roofing material being installed.
Will the eppneaat or future building«apant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
mil hazardous air contaminants as defined by the Bay Arca Air Quality Menagenteot all new materials for inspection.
District'
❑Ycs ON.
1 have read the hvafdous materials requirements under chapter 6.95 of me Califor-
ia Hcalm A Safety CrvJe.Sections 35505,25533 and 25534.1 understand mm if the building
does not currently hose a tenantsp
.mal it is my feonsi hility tonotify the oecuPant of the
myuimmeme which must he met prior it)issuance of a Cenincwe of Occupancy. Signature Of Applicant Date
n
Iownee or with wd agcnf Data All roof coverings to be Class "B" or better