02080064 OF
CI BUILDING DVIISIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT N0.
10751 SANTA LUCIA RD JUST WATER HEATERS INC 02080064
APPLICATION,UB DATE
'59MM SMITH 1764 NATIONAL AVE 08/13/2002
?HONE: (510) 293-9901 SANITARY NO. CONTROL NO.
O O ARCHITECT/ENGINEER: g BUILDING PERMIT INFO
w BLDG ELECT PLUMB MECH
aDE u u o I' -I
Bad
Z S m Z LICENSED CONTRACTOR'S DECLARATION Job Description
OZ—G Ih<rtby apron tnatlam littnscJ under provisions of Chapter9(comm�encing REPLACE WATER HEATER
F O1 It: wire Section70001of Division 3 often Business and Professions Cod<,anderylicense
I is in full farce end edea.
¢ a Liccnsc Class Lic.x
0 a L' Date Connector
u3.c.fn ARCHITECT'S DECLARATION
S 1 understand my plans shall be unit as public records
for
ne z O O Licensed Professional
K
OWNER-BUILDER DECLARATION
w m I hereby of i.that I am exempt from the Contractor's License Low for the
H Z< following ren oat(Section 70315.Business and Pimm.ion..Cale:Any city or county $820
p which requires a permit to construct her,improve,demolish,or repair any.inicten
—�
prier to its'. Iso requires the applicantfor such permit to file a signed statement ....._.-
n.a�
hit he failed pumounint to the provisionsoffae contractors License Law(Chapter 9 34*&*019ecfr@fya; ;'y ; Valuation
(cora ncin,wosSwan,7")ofDvnon3mitre Business and Professions Code) t r„R x z.._ A-. r:Ys 1..1•s..a IS,
or the he is exempt thcmfmm and the basis for the alleged ciemption.Any violation
of Section 7031.5 by any applicom for a permit subjects the applichat of a civil penalty
of not mom than five hundred doll.(S50(h. 502APNN!J4QJVL PLUMBIN ENERGY Occupancy Type
0 1.as owner of firm proPerty.or an j employees with wages an thmi,sole owerapersaims. 506 — GAS TEST
will do the work and the strecmr<is not intended or offered for sale(Sec.711,14,
Business and Professions Codw The Contractor's License law does not apply to an 507 — FINAL P LPAfil W([hspeetions
owner of property Who builds or improves thereon,and who does such work himself
or through his own employees.provided that such improvements arc not intended or
offered for sul<.If,however, he buildin t is sold within one ea of -
g nr improo f pro y
completion,the paPiwn<r-builder will have the burden of proving the he did not build or
improve for purlarse of sole.).
o I L as owner of the P ; Y Y N . . . ...... ... . .... ”. .,.. -. .. .. ._ _.-... _ _. .__.......
rt I t lh I' mJ connectors to o X200[
incense the roes n (sec Ito a Busies. and erty w ons Cmdal The ve&Semen, n
License Law d«z not apply m an owner mf progeny who solids se improves Ihereun,
.. _end who License
for sato projects with.a contractions)licensed Pursuant tm.Ue . . - _.. .. - _._ -_.. ....... . - �'
_147. - .... ._ ........
Col am ese Lioende see . . A DItl G
❑lam exempt under Sec. �� .B&PCfor this reason � r. 9I'V\/7
Owner Dae
WORKER'S COMPENSATION DECLARATION
1 hereby aRrm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Coolers to ulBinsum for Worker's
Compensation, as provided for by Section 37W of the Labor Code, for the
performance of the work for which this pcmrit Is issued.
_ 01 have and will maintain Worker's Compensation Insurance,as required by Section
3700.1 he WMa Code,for the performance of the work for which this permit is
Issued.My Worker's Compensariun Insurance camier and Policy number are: •, ,
Policy No.:
. ) l .. - .. ..o,.
•si
.CERTIFICATION OF EXEMPTION FROM WORKERS'' . f�• + i. 1", T •,i s. 134 G •.i.. L s: 7••Jif
COMPENSATION INSURANCE _— .._.._._"_...__.....__.___._.-_._.. - ..._.____.__ .. ... . _...—..,.
(This semis need not be compercil if the Permit is for one hundred dollars I - -
(S 100)oz less.l
1 certify that in the performance a of the work tar which this cttopermit e iss rke,I •,.. 91.•'.. "
shell notation L any petro any manner so as m become subject to the Workers' "
Compensation Laws of Califomia.Dine n
Applicant
NOTICE TO APPLICANT:if,aper making this Certificate of Exemption.you should
QQbecame suhlcct to the W k .C penmt p is of the Labor Code,you must
forthwith comply with suchprovisions or this Permit shall be deemed revoked.
uz"' Vi CONSTRUCTION LENDING AGENCY
a.; I hereby affirm bar thonsbua s n lending agency for the performance
W,r sof the work for which this Permit is issued(See 3TN7, is.C.)
Name
Q Under',
Adyes, lhav<rcal this application and
ofia die to- -
a' Lender's Addrcsi
_ U Oterrifyinformation is �
fi F correct.1 agree to comply with all city and county rd' relating
to building con.tm<non.and hereby nation.repro. Y tint r open
�s'[y the above-entioned prope fy for inspection purposes. e
(We)agree ersave,indemnify and keep harmless the City of Cupertino against
V1 liabilities,judgments,costs expenses
and which may in any way acerae against said
UZ city in consequence of the graining of this permit '
.s" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issuedb &JO Date
SOURCE REGULATIONS. Y<
Signature of ApplicanVCaodector Date Re-roofs
,. HAZARDOUS MATERIALS DISCLOSURE
t will inti appuca t r future building occupant 96M or handle hazardous nataial Type -
asdelmedb the Cupertino'Munim Cale Chapter end the Health and Safer 1
Code.Section 25531pal P t Y s a. •a 'n r' } sat5..:;," IVS IVTi4i
❑Ye.' •' '❑No ., i- I �, , ; I All roofs shall�be.inspected.prior,to.any roofing material-being installed._1'. Will the,applicantorfutvmhuildingoccupantumequipment.,devices which If a roof is installed without first obtaining an irispection;'I agree to remove
emit hazardous air contaminants as defined by Ne Bay Ana Air Quality Management
District^, all new materials for inspection..Applicant understands and will comply with
- ❑Yes 0 N all non-point source regulations.
1 have read the hazardous materials nquinment.under Chapter 6.95 or the
California Health h Safety Cede.Sections 23505,M533 and 35534,1 understand that -
,If the building does not currently have a tenant,that h is my responsibilitym notify the'
occupant of the requirements which must be met prior to issuance of a Ccr ifiate of
°CeY"ney' Signature.of Applicant _ Date
- r owner.,authorized agent Date All roof coverings to be Class "B" or better
- ,. -OFFICE ' _ _ ,_ • ,