02050040 CITY UILDINGON UDPERTPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT N0.
6199 SHADYGROVE DR JUST WATER HEATERS INC 02050040
OWNER'S NAME: APPLICATION SUB DATE
BRAINARD LORETTA L AND ROBER 1764 NATIONAL AVE 05/ 07/2002
PHONE: (510) 293-9901 SANITARY NO. CONTROL NO.
n O O ARCHITECr/ENGINEER: BUILDING PERMIT INFO
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LICENSED CONTRACPOR'S DECLARATION
5 1 nemb affirm dial I am Licensed
finder f cna ler 9 mnmmenc;ti Job Description
p , REPLACE WATER HEATER
._Cto wish Seclionl7 BB ofDivisionJof the Business and PmfessionsCode.end mylicense
;y is in mu force and effect, (4 0 GALLON GAS)
0 u License Clens Lic.a
I L s_ Dam Contractor
0< ARCHITECT'S DECLARATION
1 understand my plain shall be used as public remNs
t
C0 Licemed Professional
e LL OWNER-BUILDERIinexempt
front
DECLARATION
= 1 hereby affirm rM1m I am exempt frznn the Contractor
License Law for the
h'Z< following reason.(Section 7031.5.Business and Professions Code:Any lily or county
Se.R p which requires a format to consumer,alter,improse,demolish,or repair any structure
6
3ec pdonol ' lai aq ll pphusur forsucnpernt m fleasgned sutemme
that he.-recessed pursuant ladle maroons of the Contractors License Isw(Chapter 9
morn g m Section 7010) r Dicusiou 3 of he Business and Professions Cnde) ; '(1 : a'n> Sq. FL Floor Area f
m
or at he is exempt thm g
erefroend the basis for true alleged emlthim.Any violation w - 'k Y k s I .1
of Section 7031.5 by any applicant for applicant a permit subjects the applicano a civil penalty ,
.of not mere than five hundred dollars($500). APN Number Occupancy Type
01.as owner of property.or lily employees with wages as their sole compensation, 502 FINAL PLUMBI G ENERGY
will do the work,and the slmemrc'is not intended or offered for sale(Sce.70,14, 506 - GAS TES1;;equired Inspections
Business and Professions Code:The Contractor:License Law does not apply m an
owner or property what,hands.1 impmvn oiem—,tad who does such work himself 507 - FINAL PLUMBING
or through his own employees.provided that such improvements art not intended or _
offered for sale.If,however,the building or improvement is sold within one year of
ompinioq the owmer-builder will have rhe burden of proving mat he did not build ce
improve for purpose of sale.).
co 1,as owner of me Property,am Business a comranisi with Ii Th contractors to -
icewa thedoes
project(See.
appl]Ota,Business end Professions Code:j The improves
tin neon,
License Law toes not apply roan owner of progeny who milds se improves thereon,
.and who contracts for such pmjecu with a commnorfs7 licensed pursuant to Ne _ ..
"
Contractor's License Law.
❑tem
exempt under Sec. .B&P C for this reason F I N A LE D
..
owner Dart ,
WORKER'S COMPENSATION DECLARATION MAY
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1 hereby affirm under penalty of N perjury one of the following declarations: 1
❑ 1 have Dad will mainmin a Cenlficam of Consent to sclf.im,an,for Wndcr's BUILDING
Compensation, as provided for by Section 3700 or the Labor Code, for the
performance fine work for which this permit is issued.
❑1 base and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is
Picked.My Worker's Compensation Insurance cancer and Policy number are.
Caricc. r 1 , :. it i 1...,Policy No.: •' . ... . t...
CERTIFICATION OF E%EMMON FROM WORKERS(' .•) ' S, } 1( f i) y t ;' h„its ( — ,••t,N�, .t
COMPENSATION INSURANCE t' _
(This section need not be completed if the permit is for one hundred dollars
o I00jorlcx,) .
1 certify that in the perhurounce of the work for which this pemtitis Issued.1
man - - - - • It - - - - --
shall not employ any person in any ner so as to become subject to be Workers
Cam'trounon Laws of Celifmmia.Date
Applicant .. .__.. ... _. .
NOTICE TO APPLICANT:If,after making this Certifcam of Exemption you should '
Z beconm subject o the W'orker's Compensation provisions of the Labor Code,you must
Q Q fonhwith comply with such provisions or this permit shall be deemed revoked.
r
CA CONSTRUCTION LENDING AGENCY
rFL'� 1 hereby effimt that them ro
is is nstrumen lending agency for me pdo
crmance
r of the work for wM1eh bis permit is issued(Sec.3(197,Civ.C.)
Q Under'a Name - . - .. .. _ . ... _ .. ...
Q.Z Lender's Address -
U Q , 1 carry that I have read this application and state that the above information is
Ga Est 'amer 1 agree to comply with all city and county nrdinnnces and state laws reletting
Q U to building convection,and hereby aurhorim representatives of this city to enter upon
ry r�
the above-memioned property for inspersion proposes,
rr. (We)agree to sate,indemni fy and keep harmless the City of Cupertino against
Ill liabilities,judgments,costs and espousal shach may in any way accrue against said
U � City in consequence of the griming of this permit
'APPLICANTUNDERSTANDSANDWILLCOMPLYWITHALLNON-POINT Issued by: Dale
SOURCE REGULATIONS. - Y•
Signewm of Applicama Cunlrecoo ”" Date Re-roofs
" HAZARDOUS MATERIALS DISCLOSURE
Will;be applicant or finale building oedupam afire or handle hazardon,..,coal Type of-Roof _ .. _ .. .. ...
ant defined by the Cupertino Municipal Cade.Chapter 9.12,and the Heave and Safety .i .. i •} ;
Code,Section 15532(x1^ '
0Yes 0N 'j'; '.� ..
_. _� All roo•fs sliall,be.inspec[ed prior to,any,roofng material being installed..
will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to'remove
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management
Districro tea oNo all new materials for inspection. Applicant understands and will comply with
- all-non-point smince regulations:.
"49L
1 have read be hazardous materials requirements under Chapter 6.95 of the
eron.Health&Safety Code,Sections 25505.25533 and 25530.1 understand that
hxi lding does not currently have a tenant,that it is my responsibil lty to notify the
pant of the requirements which must be mel prior m issuance of a Certificate of
- ...
iously - Signature of Applicant Date
er m aammned engem Data All roof coverings to be Class"B" or better
'.:. .
:., 7 OFFICE - ..