03010125 CITY OF CUPERTINO �• �� y)1"
BUILDING DIVISION PERMIT CONTRACTOR INFORMATIQN:
I«ia .. ..
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT NO.
709 STENDHAL LA oinioi9.�;
OWNERS NAME: 17614 NATIONAL AVE APPLICATION SUB DATE:
fik VERONICA LAGRANCE 01/232003
orONE: (510) 293-9901 SANITARY NO. CONTROL NO,
ARCIIITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
0
Oo LICENSED CONTRACTOR'S DECLARATION
�U 1 hereby affirm that 1 am licensed under provisions of Chapter Y(commencing Job Description
¢w with Section7000)of Division 3ofthe Businessand Professions Code.and my license is
<n inrmlfnreeanderreeL REPLACE WATER HEATER
z0}pLicense Class ue.a
0 Datc Contractor
(50 GALLON GAS) F11YALE®
F=F
g
u ARCHITECTS DECLARATION
Nyglundcrstand my plans shall Mused as public rcnnds
3FEB 0 5 2003
.. Licensed l'mosmional
FLLO OWNER-BUILDER DECLARATION
e00 1 hereby affirm that 1 1. exempt cram Ne Contractors License c Law for the BUILDING
a a p O folwhich
re requires
a(Section]1131.5,Business and improve,
demolish.
Cnde:Any city err county
w$ which requires a Permit w consuucl,oiler,improve.demolish err repair any structure
prior br its issuance,also requires the applicant for such permit in file a signed statemenl
That he is licensed pursuant to the provisions of the Contractor's License Law(Chapter9 Sq. Ft. Floor Area Valuation
�$ (comencing with Section 7")of Division 3 of the Business and Professions Come)or
— Nalmm is exempt therefrom and the basis for Ne alleged exemption.Any violation of $695
Section 7031.5 by any applicant for a Permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not mom than Eve hundred dollars($500). 37542030 . 00 P Y YP
❑1,as owner of the pmen
py,or my employees with wages as their sole compensation,
will do the work,and the immu e,is not intended or offered for safe(Sec.]044.Bmiow g���yyyy���s{.,���¢y,�p
and Professions Code:The Contractors License Law does not apply m an owner of 5 02 - FINAL U1v1131N1`i e ORGY
property who builds orimproves diercon,and whadces such work himselforflrough his
Own employers,provided that such improvements are not intended oreacred formic.If, 506 — GAS TEST
however,the building or improvement is sold within one year of completion,the owner-
builder will have The burden of proving that he did not Wild or improve for pullwsc of 507 - FINAL PLUMBING I,
ask).
❑1.as owner of the properly,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and PrOceasinns Cndc:)no Contractors Li.
cense Law Uses not apply to an owner of property who builds or improves themm,and.
who confmcu for such projects with a contractor($)licensed pursuant to tM Contractors
License Law.
❑1 am eacron under Sec. .B&P C for Nis reason
Owner Date
WOR K ER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of the following declarations:
I have and will maintain a Cenificale Of Consent To self-inmte for Worker'sComped-
tion,as provided for by Section 3700 of the Lamor Code,for the Performance of the
7M037�'00
rk for which this Permit is round.
1 have and wilt maintain Worker's Compensation Insurance,as required by Section
of the laher Code.for to performance of Ne work for which this permit is issued.
y Worker's Compensation Insurance carrier and Policy number are:rrier. Polity No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COM PENSATION INSURANCE
('Itis auction need not be completed if the Permit is for one hundred dollars IS HHB
or less.)
1 cenify that in the perfnrmuncc or the work for which this Permit is issued.1 shall not
employ any Person in any manner su as to become subject it)the Workers'Compensation
Laws of Cali fora a.Dale
Applicant
NOTICE TO APPLICANT:IL after making this Ccoiliatc of Exemption,you should
warriorsubject
comp Its the Worker's Compensation provisions oe de labor Cnde,you man p
zO forthwith mnrPly with such Provisions or this permit shall Mdremed revoked.
= CONSTRUCTION LENDING AGENCY
(-� I hereby affirm Nat there is a construction lending agency for the Performance of
Cat me work for which this permll is issued(See.3097,Co,C.)
QLender's Name
z Lender's Address
U Q 1 certify that I have read this application and sone that me above information is
L6 F correct.l agree to comply with all city and county ordinances and state laws relating To
0U building eonswction,and hereby authoriec represenutivesof hisoky to enterugm the
W above-mentioned property for inspection purposes.
G (We)agree to save,indemnify and keep harmless the City Of Cupertino against
lr N liabilities.judgments,costs and expenses which may in any way accmc against said City
U z APPLICACNT of
AND WILL COMPLY WITH ALL NON POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature nl APPIicanUCOm Datee
HAZARDOUS MATERIALS DISCLOSURE handl Type of Roof
Will the applicant or fume building recupam scare or handle hamNnus material
as UcfsneJ by the Cuprnino Municipal Crate.Chapmr 9.13,and the Health end Safety
endo, 0 an zss3z(ayr All roofs shall be inspected prior to an roofing material being❑Yes E]No P P Y S g installed.
IrdneWill the applicant or future building Occupant use equipment of devices which If a roof is installed without first obtaining an inspection, I agree to remove
mil havallons air contaminants as derincd by the Bay Area Air Quality Management all new materials for inspection.
s
istrict/
❑Yes ON.
1 have read Ne hazardous materials reyuimments under Chapter 6.95 of the Cabot.
is Harlin Code,Sections 25515,25533 snit 25534.1 understand that iftM building
not currently have a tenant,that it is my responm m sibility nouly me cacupaof the
quirements which must he mel prior to imunce of a Crnificam of Occupancy. Signature Of Applicant Date
wner ma duffs cd agent Data All roof coverings to be Class "B"or better