03010010 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CQNTR.AC OR IN"�,&CtRMATION
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT NO.
10737 BROOKWELL DR 03010010
OWNER'S NAME.: 1764 NATIONAL AVE APPLICATION SUB DATE
TRACEY PHILIP W ET AL 01/03/2003
HONE: (510) 293-9901 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
00 LICENSEDCONTRdunderSDECLARATION JobDescri tion
U I hereby affmt Nn 1 am f0w Business
under and
Prodma of Chapter 9(commencing p
with Section]II(Itp of Division 3 of the Business and Pm(cuinm Code,and my license is
„ m ton fnree and effect. REPLACE WATER HEATER wwgg g� �q ��ee
OZSa LDi. Claes Cmarractor (40 GALLON GAS) FINALED
s- ARCHIT,C'S DECLARATION
F=
a2,I< 1urs
ndcunJ my pleus+hallbeused as public records JAN 1:7 2003
U
Licensed Professional
OWNER-Bxempt frDGCLARATION
1 hereby.sect that I atm exempt from the Cssionsc Liana Law for the ®�I���IY�
_p O fallowing roazoa t 7031.5,Business andmpr improve.
de Professions Cm le:Any tiny or county
which its isaaPermittouirsthe after,improve,demolish,ore a sig anytateawre
prior to issuance,aolmntto ft the of for such Pctor'to Nese signedstatement
that mencccnsedPustion7 )ofDivisio of the Gameness License Law(Chaptersode)9 Sq. Ft. Floor Area Valuation
�$ 'at he is exemptng Section r and the
Division r of aged Business and t Professon.Any vi Code)or 4 01
�.. Net he is exempt therefrom and Ne bssia for the alleged exemption.Any vitiation of
Sudan 703 1.3 by any applicant for a permit subjects to applicant to a civil penalty of APN Number Occupancy Type
not mom man five hundred do0an($50IB. 36921005 . 00 P y YP
❑1,as owner of me property,or my employees with wages ss their mlc compensation,
will do the work,and thampostue is nm intended or offered for sale,(Sce.]MC,Business ,j$,p�{U{' I,t{$�7 rr.n.�
and Professions Code:The Commuctors License Law docs not apply to an owner of 502 - FINAL PrsCJIv A V e LTi\`7 GY
property who builds or improves thereon,end who does such work himselfor through his
own employees,provided that such improvements are not intended of offered for sale,If, 506 — GAS TEST
however,the building or improvement is old within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of 507 - FINAL PLUMBING
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors no
construct the project(Sec.70*4,Business and Professions Code:)The Contractor's Li-
cense Law does not apply m an owner of property who Milds or improves thereon,and
who contracts for sun projects;with a contractor(s)licensed pursu+m to the Contractor's
License law.
❑ I em exempt under Sec, ,B A,P C for this reawn
ON DECLAR
Owner Data
SA
WORKER'S COMPEATION
1 heffi
thereby arm one of penalty of perjury oof the following declensions:
1 hove and will maintain a CenlGcale of Consent 0 self-imum for Workeri Comped
radon,as provided for by Section 37M of me{YMr Cade,for the performance of the
work for which this Permit is issued.
❑I have and will maintain Worker's Compensation Insumnce,as required by Section
31Q)of the labor Code,forme performance attic work for which this Permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
oris section need nm becomplmod if the Permit Is future hundred dollars S fall
of less.)
I cenify that in Oc Performance of the work for which this Permit is issued.l shall not
employ any person in any mortician as to become subject to the Workers'Compensation
Laws of C.lifumi..Data
Applicant
NOTICE TO APPLICANT:If,arm,making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisiou,of the Labor Code,you must
>OO forthwith comply with such Provisions tar Or.Permit+hall W deemed revoked.
q CONSTRUCTION LENDING AGENCY
Ihereby affirm than there is a construction lending agency for the Performance of
pi the work fur which mi+permit is issued(Sec.309],Civ.C.)
WJ 0 Lender's Name
a.7 z Lender's Address
V O 1 certify Out I have mad this application and sum that the above information is
U., F correct.I&guru to comply with all tiny and county ordinances and cute laws relating to
CV buildi ng construction,and hereby authonve representatives of this city to enter upon the
sh
W shove-mentioned Pr.,ny for inspection purposes.
gys (We)agree to save,indemnify and keep harmless the City of Cupcnino egainsl
C,) liabilities,judgments.costs and expenses which may in my way aamc agamassaid City
V 7 in consequence of the granting of this permit.
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
Re-roofs
Signature of APplicaHAZARDO Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or(Muni Municipal
Co e,Chapter
store or handle Heallousd material
as define)by the 32(a)l nn Municipal Coda Chapmr 9.12,mJ the Health and Safety
Coda,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑Nu
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
mit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes EJ No
1 hove mail the hazardous materials requirements under Chapter(.95 of the Celifor.
Ir
ia Health a Safety Cole.Sections25515,25533 and 25534.1 undersand that if the Wilding
oes not currently have a tenant,that it is my respromot iliny to notify the reconfirmof the
c quirememss which must be met prior to issuance of a Certificate of Occupancy. Signature of Applicant Date
Owner m sun xtowd agent Dam All roof coverings to be Class"B" or better