02080060 CITY-OF CUPERTINO
<< Bun_niNC IVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
20699 SHELLY DR JUST WATER HEATERS INC 02080060
APPLICATION UB DATE
`�1g'sLVRALD JAMES H AND GILBER 1764 NATIONAL AVE 0813/ 2002
'PHONE: (SIO) 293-9901 SANITARY NO. CONTROL NO.
n-ZZ iARCHITECf/ENGINEER: r BUILDING PERMIT INFO
kP wF BLDG ELECT PLUMB MECH
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Z LICENSED CONTRACTOR'S DECLARATION Job Description
Ihercby affirm that lam licensed under provisions of Chapter 9lwmmcncing REPLACE WATER HEATER
pmtwwith Section lOW)of Division Jof the dosinesa and Profess ions Cafe.and my license
Lmefall fnmeandeffeet.
pu ClFINALE®
M
a a Liceass Lic.x
�E i D Date Corrins,
W 3 u Fn ARCHITECT'S DECLARATION OCT 1 0 2002
t g - 1 unda
ersnd my plans shall Ise used usas public rcr
cos
�Y
w i O O I iimm d Prime si...I
s. MOWNER-BUILDER DECLARATION
u�M—' I hereby affirm that 1 am exempt from the Contractor's License law for she Bl, tz�f NG
I;Z a , following rcamn.(Scotian 107 L5,Business and Professions Cade:Any city or county
F s a whmh req arcs a pans t t construct
r 1¢c i npmve demobs
h.or repair nny swnurc
pmj3s�.phot rt. ,sols No to'
applicant
for such perm nafileawgrted . ......that he ala«vea puts sea mthe pro men,the cnntmcmra uanae ltaw lcnapmrq f e 3,5 �t0�lpor�pea,,•�4 , ( - Valuation
(commenc n8 ith Secu ]WU) IDvis on Jof the Rusmcss and Profess tins Cale) (`,,' 1- ,. _ �, ,.;(,--,, '1: 4,Y.`• '
or Our
he is exempt,dmishom end the basis for the alleged exemption:Any violation -
-or Scuiiod 1031.5 by sons,applicant fora pert subjects the epplicem to a civil penahy-
ofout m„relot.five hundred doyass(SNan. 502APNPgMha PLUMBIN ENERGY Occupancy Type
OL as owner of theo rt,or sd r employees with on as their sole cora tion, 506 - GAS' .TEST I
pr per p r g penia
wo ure me wok-,and me ade: ri Is am intended terse Law doe sale(See ]f an 507 — FINAL PL ]TaGnspeetions .
Business and erfa Who
b Cafe:The roves tcmr's License Law docs not apply to an
owner of property Who builds or improve at such improvements end who encs m n work himself
or
,
or throerect fo bis own employehowever, provldcd that mn ementis slart in intended or _ _
offered for sale:If;bowever,the buildin i is wld within one car of _ .. .. .__.._ __..._.. .... _
completion,the owner-builder will have he burden of proving that he did not Wild or (Y ,
improve for purpose of sale.). _ I
❑
[."i;owner of the property,,1 xcsinessly d P.fr ng with licensedcontractorsCimetors's
License
the does
n Tapp.]Oats,Business and sny whops ills or The improves
thereons
Licenu I co docs not apply to an owner m Pro ntr who halide or Improves thereon,
I ,Cm who cummns fnr.mch pmjttm with.a rnmmnorts)..licenud.pursuant to the ._ - _ _ _ ._ ... . ._. _. :........ ... .. ..._..__ ..... ._-.......__..... .. ...
El I imctor s pt an&Law, -
" [71am exempt under Stt:'� '� ,B&PCfor this reamn - ' ' 1�_ •'��I
0 wineDate
WORKER'S COMPENSATION DECLARATION
.,. . . 1 hereby M.under penalty of perjury one of Ne following dedarsomi,i
5 a
❑ 1 have and will maintain Certificate of Connt to self-insure for Worker's
Compensation, as provided for by Section 37W of the Labor Code, for the
'pidormmtee m the work for which this permit is issued.
El 1 huve'and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Cade,for the performance of the work'for'which this permit is -
-: [: issued:My Worker's Compensation Insurance carrier and Policy number me:
l.
Catera :ee •t
Policy No: lt ..r• An - .S aril. i,,.l PJ t L
CERTIFICANON OF EXEMPTION FROM WORKERS';;
COMPENSATION INSURANCE _. ... .. _. ... ........ .._
(Thissection need not be fiomplme it he peri is for me hundred dollars
($100)or less.)
1 certify that in the performancenn the as to b co eM1 this permit a issued;l _ a
shell not employ any penton in any manner m as m become subject to the Workers a
Coiripcnution Laws of California.Dae
Applicant
NOTICE,TO APPLICANT:if.after making this Certificate of Exemption.you should '
become subjca to the Worker's Compcnmtion povidone of the Labor Code. no mast
Q fmthwith comply with.such provisions.,,his pemtit shall be deemed revoked.
�'N a CONSTRUCTION LENDING AGENCY
_^ I hereby affirra h ih t themusd(Se, lending agency for the performance s A
of th li f h ch th parol t s ssued(5<c JW],Civ C)
f:endcrs Name __ - .. . . _ .. .. . .. ._r ... ._...., _. .
7,Z Lender's Addres.eI• ,� t
r'..1' Icenify thmlbave read Chia application antl was rhuuhe above infortnmion is
W E., correct I agree to comply with all city and county ordinances and stare laws relating
Q.,U to building construction:and hereby amirmi. ,maralutim,of ON cityto cnmr open
W the jowe rentioncd property for inspection purposes.,
iq (We)agree to sive,indemnify and keep harmless the City of Cupenino against
r'0 liabilities,judgments,costs and a,saxes which may in any way acerae against said
V-z City in consequence of the granting of this permit.-
' i APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLN0N-POINT Issued b � Date
SOURCE REGULATIONS, . 1 y
Signature of ApplicanUConametor Du¢ Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the dhcard or houre building uccupam some or.handle Isomplow mateml Type of Roof ---- ..
as dein dby the Cuperum Municipal CW Chapter 112, d th Health and Safety
Cade becwas 25532( )' 1 n';Y ! :• +' "• "-'.'a'I1 1 M1 e .• .
❑red^ ono' - - . 7 :.All roofs shall be.inspected prionto any roofing.material being.installed..
Will the ppl< t or future buildg resultantuse eq p t or devims which If a roof is installed without first obtaining an inspection agree to remove
emthaz rem Contaminants as defined by me Bay'AreAir Quality Management
Dian,,❑ - Cl No all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
I have lead the hazardous materials rc,mmucems under Chapter 695 of the
Coliform.Health k Safety Code,Seen..,255B5,25533 and 25534.1 undersand that . ._. ... .. . .
if the building does not currently have a tenant.Nat it is my responsibility w notify the
paupers,of the requirements which must be tact prize m issuance of a Certificate of
Occupancy. Signature of Applicant - Date_
Owner urmmnrieeaagent Date All roof coverings to be Class,"B"or better
_ OFFICE : -