02110046 crry of cuPECONTRACT
BUILDING DIVISION
stoN PERMIT � fORJNFQRMATION ^,
6ul5)gdrMA9DI&HADYGROVE DR JUST WATER HEATERS INC PI-RMrrN02110046
oW@R'gb&A:RY FREDERICK A JR AND B R1764 NATIONAL AVE AppCIcATITI1YU)81tI 2002
41 IONIC: 51 0 2 9 3—9 9 01 SANITARY NO./ CONTROL NO.
ARCIII'ILCr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
.0'z LICENSED CONTRACTOR'S DECLARATION y p
.Cup Ihenchy affirm that l am licensed under lariwComoof Chapter 9(eommmeing REPLACE WATER H ATS ll°n
-Z. wish Secdon]IXXp of Divirion 3^I the Business and Pmfes: and my license in
m ten Inree and effect. (4 0 GALLON GAS)
0 Z License Class Lie,M
r Zr, Doc Contramnr
ARCHITECTS DECLARATION
g a< I mederxtaml my plans shall be used as Public records NOV1, 2. 0 ?n 2
Oyu
�LL uO g Licensed Pndcssim it
OWNER-BUILDER DECLARATION
aY 1 hereby allind that am exempt from the Cnntra[I I��gIBc
re 00 fellnwingncason.(Section]1131.5.Business and Professions Crrtic. y .(fie
n'a6f sa which rryuir a p:onio tar cuns,ma,doe,improve,dcmoliah,or repair any orad $1067
w-'^ prior m is issuance.also requiresfhe applicant for such Eximul to file asigneJ statement
'-?< tharMislicensed purnanitothe Pnaveoini nnbeConfuse 's Li«aseLaw(Chapter9 Sq. Ft. Floor Arca Valuation
ea (commencing with Section](XIB)(it Division 3ofthe Business and Profeui^nsCode)it, 37540013 . 00
y 2 Nm he is exempt therefrom and the basis for Or alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant fo a Civil penalty of APN Number Occupancy Type
not mora Out five hundred dollars(sSXp. 502 - FINAL PLUMBI G ENERGY
❑1,resowner of the pri stty,or my employees with wages as their sale compensation.
will do the work,and Inc suuctum is net intended or offered for sale(See.]IISC,Business 5e6 'E
p�k1��{,.lsaSp
and Professions Code:The Contractor's License Law does not apply m an owner of 507 _ FINAL dy4f�dIJiQ,b ections
progeny who builds or improve thereon,end whodoes such work himseffor though his
own employees,pmvidcd Out such improvements me not intended orortered formic.If,
however,the building or improvement is sold within one year of completion.the owner.
builder will bare the burden of proving Our he did Can build or improve for propos,of
sale I.
❑I,as owner of the property.am exclusively contracting with licensed contractors to
Conswct the project(Sec.7IW4,Business and professions Code:)T o,Contractor's Li-
cense Use does not apply to an owner of progeny who builds or improve thctean,and
who contracts for such projects with a Contracmgs)licensed pursuant o the Contractor's
License Law.
I am exempt under Sec. .B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent o sell-insure for Worker's Compete
sa um,as provided for by Section 3700 of the lalnr Code,for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance,ex required by Section
37110(if me labor Code,for the performance of the work for which this permit is imai
My Worker's Compensation Insurance Caner and Policy number arc:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
foie section need net he completed If IM permit is future hundred dollar.($100)
or Icss.)
1 certify that in the Performance of the work for which this Permit is issued.1 shall not
employ any Person in any manner se as become Subject n the Workers'Compensation
Laws of Caldradi t.Dale
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject m the Worker's Compcnediun provisions(it the LaMa Code,you must
0 forthwim comply with such provisions or lois Permit xhollbe deemed revelod.
z O CONSTRUCTION LENDING AGENCY
E1hereby affirm that there is a Construction lending agency ter the performance of
> ,he work f or which this From it is issued(Sec.)119].Civ.C.) —
W0 Lender's Name
G lender's Address
U Q I certify mal 1 have read this appliea m.and state that the aMrve information is
W F correct.l agree to comply with all city and county ordinances and nil¢laws relating to
OUbuilding conswctinn,and hereby authari¢representatives of this city to enter upon the
above mentioned polarity for inspection purposes.
t�" a (We).goes to save,indemnify and keep harmless the City of Cupertino against
F' lay liabilities.judgments.cost and expenses which may in any wayacaueagainn said City
U in com"tonae of the granting of this Permit.
'-' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE.REGULATIONS.
Re-roofs
Signature of APPlicaDam
HAZARDOUSMAnDISCLOSURE
Type of Roof
Will the applicant or Ir building occupm nam or handle material
as defined by the Copedinn Monicipal Coda Chalcr 9.12,and the Width and Safdy
"JaLcude.Savo�Ycr 25532(a) ❑Nn
' All roofs shall be inspected prior to any roofing material being installed.
s
Will The applicant or future buildingoccupanl use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
'mit haiardous air co ntrionants as defined by the Buy Arca Air Quality Management all new materials for inspection.
District]
C3 Yes L]No
I hive read me ha ardous materials requirements under Chapter 6.95 of me Califer.
ria IIcalth&Safety CodeSeedons 25515,35533 and 25531.1 on&k, dthat if she building
doe not currently bac a Cram,that it is my resp nvibility,,notify the acupmt el the
equiremeenv which must he mm Poor it)issuance of a Ccnlfiete of QerPmeg Signature of Applicant Date
owner(it aamerned.gen, noes All roof coverings to be Class "B" or better