02110037 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CON TRACTOR INFORMATION-
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BmI GRBLMS FORD DR JUST WATER HEATERS INC PERMIT NO 2110037
OWtITUN&A-SING 1764 NATIONAL AVE APPLiCATT115 UgT)t2002
41 ZONE: (510) 293-9901 SANITARY NO. CONTROL NO.
ARCHIIECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�00 LICENSED CONTRACTOR'S DECLARATION
<-uIhereby affirm matlamlicensed under previsions ofCmNrr9(commencing REPLACE WATER �SR! Fi]tion
F¢pt with Section]INMBm Division 3 of the Business and Professions Code,and my license is
N<d in full force and effect (4 0 GALLON GAS)
n? License Class Lie.as
r I_a Date_Common,
ARCHITECPSDECLARATION
Y C I undersmnd my plans shall be used as public records
OyU
3 a Licensed Professional
=og OWNER-BUILDER DECLARATION
<T I hereby affirm Thal I am exempt from the Cuntraanr's License Law teethe
i poo following reason.(Section 7031.5.Business and Professions Code:Any city or county
;e m which requires a Permit to consume.alter,improve.demolish,or par,any stucmm $764
n'—" prior to ids issuance,also requires the applicant for such Permit o rile a signed statement
t=i< that he is Licensed pursuant tofM1eprovisions ofthe ContractorsLicevcLaw(Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section of Division 3of the Bminessaod Pinfeadons Code ,,
'10 s g r 36209009 . 00
3� Nat be u exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects fre applicant o a civil penally of APN Number
Occupancy Type
net more than r hundred dollars(x5110).
❑1.asowner ofbe,propeny,orm employeeswithwagesastheirsatecom 502 - FINAL PLUMBI G ENERGY
Ypcnsiness
will do Ne work,and Nc sWclerc is not intended Lir offered for salt(Sec.7044,Business 506 GAS Te
and Professions Code:The Comrenofs License Law does not apply to an owner of 507 - FINAL Ingections
prune"who builds or improves Nemon,and who does such work himself or through his
own employees,provided Nal such improvements are not imended mothered for sale.If.
however,she building or improvement is sold within one win ofeumplelion,Ne owner- I—��r�
IYA\VII r,���D
builder will have be burden of proving Nal hFe e did not Wild or improve fur purpose of
sale.).
❑1,as owner of Ne property,am exclusively contracting with limexed convaccum to NOV 20U2
construct the pmjen(Sec 704E Business and Profusions Code:)The Contractor's Li- e
cense Law does not apply to an owner of property who Wilds or improves dormer,and.
who comment for such projects with a contraaorod licensed purmantto the Cormactoi s
License Low.
0 l am exempt under Sec. ,B&P C for for mason BUILDING
Owner Dow
WORKER'S COMPENSATION DECLARATION
I hereby al mai under penalty of perjury one to the following declarations
o / -
1 ome and will for by
a tion 37oa of Consent m sc de.fore for Worker's Compere
soden, r provided for rm Section 3]4p of one lahor Code,for the peRomtantt of the
work for which Nis perms is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section V
3700 of the Labor Code,for the performance of the work for which this permit is issued. L
My Workers Compensation Insurance carrier and Policy num her am:
Carrier, Policy Nn:
CERTIFICATE OF ESXEMPTION ATIONINSFROM WORKERS'
COMP nlilw it INSURANCE
[rnixsemirm need not Wcomplcadifthe yermitisfmone hundred tlnlhrs(S)00)
or less.)
I certify'that in the performance of the work for which this permit is imucd.I shall not
employ any pecam in any manner sen as to become Subject to the WorkersCompensation n
Laws of California.Date •1.(w//
NOTICE
1 G
NOTICE TO APPLICANT.It.after Compensation
this Cisions of of Exemption,you ushould
Applimost
becomesubject comply with
it Worker's Compensationermit hal of the mMn Cium you must
Oz forthwith vnmply with suchprovisions er this PermitshallWdccmcdrevekcd.
'ZE'O CONSTRUCTION LENDING AGENCY
F l for whaOirm Nmmit i isucil(See Construction lending agency for the performance of
7
Sa Nc work for which this permit is issued ISec.trio],Cm.CJ
{L Q Lender's Name
z Lenders Address
U O 1 certify Nat 1 have read this application and some Nat the above information is
Fcorrect 1 agree to comply with all city and county ordinances and state laws relating u,
OU building conwuainn,and hereby amscom repmrintatives of Nis city to enter upon the
(y
above.ms.judgments.oned estrty for inspection purposes.
4. (We)agree to save,indemnify and keep harmless the City of Cupertino against,
h incotsequenc of
grasand expenses
Permit may in any way amroc against said City
U in consequence of the granting of this permit.
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REGULATIONS.
Srgnamrc of ApplicanUCuntraaer Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building necupi m someo,handle moundous mamrial
a'"
tied by he Cupertino lomoripul Code.Chapter 9.12,and the Health and Safety
y,.,
CNc.Se 25532(a)7
70wor ❑vex ❑Nn All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use e If a roof is installed without first obtaining an inspection, I agree to remove
,
mid hazardous air contaminants as defined b the Ba Area Air
nT devices which g p
r r Quality Management all new materials for inspection.
District?
❑Yes 0 N
I have mad Nc havallou.s materials myuircomms under Chapter fi95 of the Cali Or-
aflealN&Siody Code.Sections 25915.25533 and 25511.1 undersand that if do Wilding
oes not"ountly have a tenant Nal it is my maryrmi hit try m nntily the recupunt of the
quiremno.which mertWmrtPoor missuance if.Cent ticks, ifoccupancy. Signature of Applicant Date
otauth.,ixdagenl Date All roof coverings to be Class"B" or better