01040087 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
JUST WATER HEATERS INC 01.040087
OWNIiR'S NAME: APPLICA'I ION SUIT UAE'i
_ RSMITH 1764 NATIONAL AVE 0431.8/2001
�!PHONE: SANITARY NO. CON 11001,NO,(510) 293-9901
C m% ARCHI I17MIIiN IINIM.R' 11'111,DING I'IiRM1f 1'I'INFO
O O HLDG ELECT PLUMB MECH
F 1=1
F LICENSEDCOMRAC'I'OWS DECLARKI'ION Job Description
1 hereby alfirmnnm 1 an,licensed under provision,of ChaPmr 9l commencing
with Section 70lB of Der,ioa Sof the B.,inesx and Pmfosions Code,and my license
< is if fulltmae.antlelr'e°'' REPLACE 40 GALLON GAS WATER HEATER.
r O U Licenxc Class. I.ic,M
Dale Contractor
t�i 3 a h ARCI11'rFCI'S DECLARATION
F NO 5 1 amtemm�d my plan,enu11 be arced as nunlie records
ofO O Licenwd I`ndosion l
Is.A OWI CK-BUILDER DECLARATION
ul=' 1 hereby affirm that I'un,em In f it,the Contmmur'x License Law Pur the
H Z Rdlowing rc a(Scc,inn 7031.5,Btu and Pbucs ma Cost,:Any oily u linty
E S G which nyuirts a permit w consumer,after,e,improve.demolish,or repair any%lumnam
nag prior to its issuance,also reyuim%the applicant mrsueh permit to file a signed vimen,em
that he is licensed pursuant to the pmvisum%nt the cmmrrma:s License Law(Chapter 9 Sq. Ft. Floor Area ValuatiOfl 1�1
(commencing .III Section 7WU)or Drf,inn l nrthe liusin..and Prom,,iu I,Code) $l
or ma he is exempt themm n,and the basis for the alleged exemption,Any s'inlaion
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
,It net more man live hundred doll.,%(s51O). APN Number Occupancy Type
❑1.axnwnerufine,rn pert.orm , loeeswithwaesasdmnsolecm„ tion. 37515021 . 00
i r remployees g pen%a
will du the work, i nt t cm n,intended er otlknd f l (S 7MJ,
Bn%, dr t..' ed lin c ,mmnr'1.,.enw o: d t rkhim+an Required Inspections
f, 1 ny.,Ic l IIimprove,thou, ,+dwhne 'I work Blot
I,,thnmgh his ow nn,ploytts.ppm'Jul but wch n,pmven,p,r:are not intendivil or 501 — FINAL PLUMBING ENERGY
offered for sale.If,however, Im Wilding or improvement is Sold within one year of
,ilAcdon,the ow Ger-haimer will have the burden of rpming that he did not build or 506 — GAS TEST
m a
IIIlprwe n+r p,Imn'e nraale.). 507 — FINAL PLUMBING
01,as owner of the prnpery.am exdu%ivdy contracting with licensed contractors to
Gama the pmjcct(ape.]O4y Rumness and,ny,hio,h code:)The improve,
I mor'.
construct
who
:Ica ones ran apply bI un owner of a conlr who halide s improves thereon.
and who c,Liter,fur such prnjccrr with a u+mrmmr(q licensed purxunm to the
Contractors Licence law.
D I am exempt,order Sec. .II K P C for this reaso
(lwncr Dam
WORKER'S COMPENSATIONsperp,
lyIfCLARA'nON CJ
I hereby utlirm under penally of perjury one of,he following Jcelnmtione, y/
❑ 1 have and will maintain it Cenikatc If Convert as self-invert lint Work,,
Compemxaium, a, provided for by Section 3701], of the Labor Cade. (or the /
perli+rnmove of the work lirt which this permit r issued.
❑1 have and will nvaimaln W..k.1's Cumpenxmion Insuravec,as required by Section
3710 of the Labor Code,for the performance of the work for when his permit i.
sued.My Worker'%Compensation Insurance carrier and Policy number are: `
Camier: Polity No.: � p
CER I'R9CAT[ON OF IiNEMITIUN FROM WORKERS'
COMPENSATION INSURANCE I 7 LJ
(Ilii.seear„nmxl nn,be cnmpldml if Ina purn,i,is for one hundred dollar' '
($100H.,les'.)
I terry rant in the perfnm,aucc ut the work Por which Ibis permit is isw<d,i
shall no,employ any perxnn in any n,anver su as In hceomte'abjoa m the Wnrkcic
Compensation Lau'ofedhornia.One
Applicant
NOTICH'10 APPLICANT II:after Imnking Ilii,cemilicate Ills I?xemp.ion.you should
beeon,e%abN1r,the workers Corm minnprnvi'imI,of Lad,...Code,you nmsl
Q O forthwith comply with such provisions or this pem,it shall he deemed mucked.
CONS'[RUCIION LENDING AGENCY '
a ' I hereby ul(Inn,bm llmm I,a.nmmtctlon tend'mg agency for the la+lo nmax
of the work for which this penal is fared ISec.3097.Cm C.)
L Q Lender's Name
U 7 Leader',Address
U Q I verify that l have rend this application and mac thm,he oMrve inlormalon is
4s, F. cures.I agree m comply with ILEI city and roan,o ximaree,and shim laws mining
U to hullding uramedon,and hereby autharile mpmxenative%of this city ,I enter upon
^�a W1 III,ulervcmenlinncd Pmpcmy nv ingaction'Unf—c'.
e. a We)agree to cave,indemnify and kccp faintness the City of Cupemnn against
lin lethilitice,jndgmcm.,car,and eapenw%which may in any way m,nm again,,said
U 7 City in con'enacn«of the gra,mng of this urtua.
r SOURCIANTNDERSISNUSAND WILL COMPLY toI'HALI.NON-POIN'r Issued by: Date
Signature of ApplicandContractor Ume Re-roofs
HAZARDOUS MAI URIA1 S DISCLOSURE:
AM he apowam nr mtare buidin,cer.,a n smm or handle haaardous mmcnal Type of Roof
e.defined by,he Copeman Municipal Code.Chapter 9.12,and he Health and Smut,
Cade.Section 2553200)!
❑Yes El No All roofs shall be inspected prior to any roofing material being installed.
NSB the applicant of future Wilding occupant use equipment 't device%which If a roof is installed without first obtaining an inspection, I agree to remove
emit harallous air co,naminanr%as derived by the Bay Arca Air Quality Management
Diemen all new materials for inspection. Applicant understands and will comply with
0r°° 0"n all non-point source regulations.
I have read,he hreardous materials requirements under Chapter 6.95 of the
G,tit'omia Health Ie SAtcry Lode.Sactiulls 25505,25533 and 25534,1 understand that
o the Killing docs Bat cmmiuly have:uenant,that R is my iespom,oil ty In hairy the
cury m of the requimmen,s which,Gua be fact prior to issuance of a Certificate of
Oc'r'ncy� Signature of Applicant Date
G.enernraathorimdageat Date All roof coverings to be Class "B" or better
OFFICE