01070028 (2) CITY OF CUPERTINO
EImLUING DIVISION, . ' • -PERMIT CONTRACTOR INFORMATION: -
:BUILDING ADDRESS:. : PERMIT NO.
— —
. 10652 GARDENA CT JUST' WATER' HEATERS INC 01070028
oN �sT. . . .. .. ,.._,- '.r . r,.c '. .. _. APPLICATION S D
NE�I liARRY / ATE . . ...... ...... —
1764 NATIONAL AVE
10 2001
PHONE: -
(510) 293-9901 SANITARY NO. CONTROL NO.
7Wj ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Job Desch tion
o heeby a�m that I am licensed under provisions of Chapnr 9(commencing REPLACE GAS WATER HEAP)ER.
ioof vssicenseis in full forte and effect.
LicenseCims Lic.Y
k Date Contractor
F u p�+ '+ - . ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
y<f
a ii o is Lensed Pmfesstowl _
=n OWNER BUILDER DECLARATION -
y
I hereby affirm that I am exempt from the Contoodor's License Low for the f
!=z a
following reason.(g coon]031 5 Bus nc nd Pr f. Code Any ry ounty -
rma to consuuel.eld m ro - d 1'h,or re +t
to h o onwhich remits, Pc P Parstructure - .. .. - $680 :
' - -
w3 ,.pri t ire caul orc9 the applicant ofor Contractoruch permit s
is signedChapeent.
thot]t shenxd purelint to the pro sons.3 Contractor L' Le ons C erg
(eo m mg wvh S<t ]000,) f D'vis'on 3 of the Eusiness and Professions Cade) ^ ! 1 ' 3 _ V'6-V/�C.6qa S +"h}i 'h j Valuation
If of he is ex'enipi th tefor and the bass for the dlegdd exembnon.Any violation °"
of Set 9031.Stinny onliwnt for a permit subjects the applicant to a civil penalty - - _
or of etnanfee wnareaaou 1($50H.
LEI
PLUMBIN - ENERGYOccupancyType
X01 w ne of the property,or my employes thwages a-their sole compen5 r n: ! " 506 = GAS TEST
-'will tl the vrrkmd the stionlare is not intended or-offered for sale(Sec
sadProfessionsCode: ComfortLicense La d n t an f507FINAL.. PJit rkBlfs ec[
ions
'. -.ovine f property Who builds
orm h eo d seen
work
hielf '
or through his own employeesprovided tl at inch'improvements am nt intended or
offered for sidIf,how the building - - - __ __. .... _ ...
B P met la th one Y f
mf theowner-builder 'illi [h Lard fpo ' gtM1 thedd not build -
improvePurpose fml ).
❑1as a wo e r oRh e pre
n7a esI elyc t mmg 2hI need fr, t
vin -
n th p le t IS ]014 B and Profession,ss o C de)Th Cnmac t
License Law does not apply t no
h y p ,
ad who contracts( such ujctst
ommnar6s1.1' nsed.punuant.m the
C. tis LccnseLa
❑ - - ...-.
-: ... 1t mPtuntler Sec ' "`' " "'''-,',B&PCfonhis revson ,• "• ,..;•,;,
Date
WORKER'S COMPENSATION DECLARATION
Phereby affirm under petmlty of perJury one of the following declarations:
1
^O I have'und will maintain a Conilirl4c of Consent lm'mlf-insure far Worker's S `
Compensation, as provided far-by Section J]00'of-the Labor Cale, for the - `
- - performance of the work for which this permit is issued..,
111 h d will riatudiihn.Workers Camiuiryoioa Insuran- required by Section '
3700 f the Labor Cod f theperf rman f the ark'f which this perm r i.- -
issued.MyWorkers Compensation Insurance comer and Pole ii - - - -
Cerner ._i.t "Polar
-CERTIFICATION OF,EXEMPTION FROM.WORKERS(' -' '-1."4� .i:i 1 f. ' f4Fd. s_
COMPENSATION INSURANCE
1111i sedition'ne d not be completed if the Permit is far one hundred dollars -
» t 1
I ttfY thato the pop c fa workfwh hthspe tis vs a 1
shrill t mel Y'a'"Is-- any nae n o t be come-object to the WorAers' "' -' - -- -- - •-ti. :
Comp neat nn'Laws of Cut ifom ia.Date'-
...) APPlicdm_
NOTICETOAPPLICANT If,of..mkgth.C rtific t of,-xemFlt -
yen shyuld -
z bec me, bled m the W k r-C pe. t pm ' s of the Labor Code you oust
O forthwith comply with such provisions or this permit shall be deemed revoked '
N.'~" v+;, .Ili by affrm th NSTarstconst
of the'work for viii ch tM1 t le dnga n f th .- - - -
� CONSTRUCTION LENDING AGENCY "
IYj', 6e Y Pe fomi'nc<
ssuW(S 309] C.C.t
..Lend s Name..-... _._. -_. ... ..._. . ._ _. _ ... .. _. .-. .. .. ..... ... ..
;D Lender's Address
- -
Uz •
co. I cemify that have read th -application d state that the bove onfiernaraid,:s
E.. rtet f e t o plY th all c tY and county dicta c ❑ ret I . f luting
D,C) tob la ng t to adh by authorizerepresentatives of this city to nth, pen
the alms,rainioned pro,orty for p C an rp es
F.,.O. 1a e t indemnify. 1,lace,phma theway
fC P n' ganef
'rn Ctheadline,indictmentsrose, a pe c li may m any y -rue.,amt,aid
U-^ Clry As.ey NDERfth grin KDWILL ret
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL'NON-POtNT
: SOURCE REGULATIONS:. 4 Issued by: Date
Signature of Alplmant/Contrxctor, .Date: Re-COOTS -
Cot HAZARDOUS MATERIALS DISCLOSURE I
•'deW II to aper vm f t building ac p nt do orhandlen m 's mat -1 _ Type-of Roof ..
f d by the C Pertto M n leIC°d Chapter912,and theHealth d Safety.
Code,Section 255) (nl
, No 'I it
AIL roofs shallbe inspected prior to.any roofing material being installed.
`t11 Will he applicant t i future building' p t ee equ pine t d 'mc wit' h Ifo root 1$ ]ns[alled without first obtainin an inspection;'Irartree'to remove
th d ore utca-aefned by over HayArea ItyNI evitt,e m g p e
°isi f1 all new materials.for.inspec[ion..,Applicant,understands and will comply,with .
°w °N° all non point source regulations -�
a
have read the ha,moli terou's monourement,order Chapter 6.95 of th
C I if a He lin&Safety C d Sections 25505 2553) d 25534 I nderst d Nm
o'co,iam Idngdoe' tc nentlyh a tuthan my rep bltyt tit'th - - `-' - - - -
oc
cupthe requ remenw which moo be
be met prior m iwuunce of a Cenifeme of
Occupancy.:. . '.
!, _.. .. .... _ . .Signature of Applicant _ - - . Date
own« t o�xea ugen . Date„., All roof coverings to be Class B"or better
OFFICE..