02020125 (2)CITY0FICUPERTINO'..
:TI;BUILDING,DIVISION•'- _ PERMIT"
.BUILDINGADDRESS: - -
i+' i22-3'4'9','-JANICE,-AV' -
r'" 'OWNERS NAME::(. ti' ^•i •, -^-.. ,..•
''WAR.KT'-MANTRV."
I
ARCHITECTIENGINEER:
,
+ LICENSED CONTRACTOR'S DECLARATION
1 hereby M. that 1 um licensed under provisions of Chapter 9 (commencing
with Section 7800) of Division J of the Rosiness and Professions Cade. and my license
is in full farce and eff«t.
License Class 1 Lie is
Da, Contractor
ARCHITECTS DECLARATION
I
I undenwnd my plum n),all be uwd as public rceords
Llc n'ed Pruressm.l
` OWNER- oonnR R m the CoATION.
Lniner adTrw that 1 1. uemps from the CosionsC r :Anye Law for the
folloxmg reason f3enion]Ul LS. Business and Professions Cade: Any city or county
of not more than Ove hundred dollars] 85
I v ,_iT; il 71t u.. _. ,C IL-. ,:
CONTRACTOR INFORMATION:
JUST WATER,.HEATERSr..INC.^
........ ....... ..., ..,.._.......__.......» .., .._ ..... A
1764` NATIONAL 'AVE'- -
(510)293-9901
SA
10. 1 !.
a','t n02020125
PPI:ICATION SUB DATE-
02/28/2002''
ATE 02/28/2002''
BUILDING PERMIT
BLDG ELECT PLUMB
I
Job Description _
REPLACE 50'GALLON GAS WATER HEATER
or mrougr his on employees, pmmdcd, Pad such tmproyements marcor, intended or.
off c tl tor'sale If. hawcvcr, the building of improvement' is sold within one year of
completion; the owner builder will have the bur of proving that he dud not build or
improve for porpnse of vola) I• .
$833
MECH
vafuauon _ .._.... . .
ENERG1Qccupancy Type
pEUMiFIk4igpections
ti,
.Q l as, weer pmpeny, y contractors to
t
prtheoject
construct the project (Sppl 70sa, Business d Professions Cwcenwise
Professore Code:) These.
,
_
License Law docs not apply to an owner of pmpeny who builds or improve thereon,
pro the .,
'
.;=7
...and who mnwnx for such Pmjeelswith It commaorls),licenscd.pursoanl to the
Cimwaors License Low.
❑ lam exempt under Sec. ,B&PCfor his mason
r
. _.... _....... ... _ _ _I_..
..-..... •. ..._._ .. .. .. _._. .._._..._ _
..,Dore a, .• , .v. ..
r
WORKERS COMPENSATION DTCLARATION
I'
APR O 1 2002.
T herebyIlmor under pc by of I:rjuoy one of the following deductions:
�•
❑ I hiri rid w II m Immh a'Cenificme'of Consent' to self insure for Worker's
Compensation, as pro dad for by Sen n J]00 f th Labor Cod,for the
gqC pJ
BVILLJ117-
�
_ -
perfawance of the wok forWhich dii, perrind is bounce.
1.
, -
❑ 1 have and II maintain Worker's 6ntpin,miom Insurance, az rtgmrtd by Section
37W yf the'Labor Codlot she perfutimanct, of the wok for which (his permit is
Ihsssbed MyWorker's C mpcnvauon Insurance c ic, and Policy number
Caner 1 ct'YI "Polcy No: „1.t
CERTIFICATION OF,EXEMPfION
's { rs s' g ':,> Z
-. f f ! / 4 ! s j - ' -'' -
FROM WORKERS
1'
,.: _ t. . t • . .t, . z s;
'T" COMPENSATION INSURANCE ' "' • -
did; iambi need nod be completed ifflic permit i.s for one hundred dollars
d II
.,'
(Slip) I s) u t d i tk
o
l t i
Ir mfy that in thepert a Gc or the wofk f -r 1 ch'dh pc d I issued 1
.. •._ _ _' , _ .''�
" ""-_ "
ssholll 1 rept y'any'persnn In any mann r so see hector . ub3 cd the Worken
i' • y ;ti. "
'
ompensahon Laws of Cobrom a. DareApphou
"
'NOTICETOct APPLICANT: If, after king this Cen Certificate on you6u
t ..
Q 0
bac me s bl uo the W Ael Cont,
Wmk LyWr
Provisions of the Labor Cade, you must
must
forth
ioso, trandom
nh comply with uch prouans pemdu shell- deemed.evoked.
1.I,
CONSTRUCTION LENDING AGENCY.
Ih rcb Rtrtn thin the civ aconnmcu n1 nJing ugc yfN pert
Y
+ i
Gass �ti
hdh perm. s auW (Sec 3097 C'v C)
,;.
Lcnd'r Name
Z
Lendc sAdd sa
I
V 0
< 1 ccnify i have
-'
'r3't tr
' CLU
thin read This application amt slam thauhc above information is
,correct. 1 agree to comply with all city and county, ordinances and nam laws mining
•dobuilding "olnmumioaand,
-
.
be property for puposemetives of Nis city blender upon"
for I m0dt..e
dike purpose,. msec.,.
I _ /j _
.
0.
F P.'
t I two agree to militantly
.<'.+'es,j agree ly an harmless the City of Cupertino
l against
/y't'A1 f/M'/t/�
rn
V
judgments, costs hi
expenses which, y n any ay accrue against said
st
in c
consequence R
I
eand
City
City sequence n8 this h nit
APPLICANT UNDERSTANDS WILL
'
D COMPLY N'ITH ALL NON POINT'
ULATIOTANOS'AND
SOURCE REGULATIONS.
ISSDCd by: ,Date '
n.. - -
-
SigumureodApplicart,Q 1 to _ •, Dine-'
Re -roofs -
-
- •;4 - HAZARDOUS MATERIALS DISCLOSURE t;' ",.
Will dlieapplicant orfuwre bu'Idmg accupam sole or,handleheurdous martnal
Typeof ROOF....
as defined by the CorcornoMn pal Code Chapter 9.12,and the Health and Softy:
Cod Sect n25532(a)
'V5 t r d a
4,,;, „_,. t•.a ..' '-'
y ti •..
{..ii r�i': (41v S.: r'u-7
.s I!]Yi pN' i
w B i',r ,
v
. —All. roofs shall,be respected prior„to any roofing material.being, t'nstalled..
Will theapplicant rfuture building c p I use equipment o devices,'which
defned by
If a roof Islinstalled:without first obtaining an inspection;-I'agree, to remove
amid hazardous air commitments as the Bay Area Air Quality Management
District -
-
all new materials for inspection.; Applicant understands and ivill comply with
❑Yes j- ❑No -. r .. ..
. „i.
,. .. _.
m
all n66 -point source iegulaaons -1! ...,.
' 4 have fwd Ise meionsl2 rc 6.95 tithe
25533
- -
.'
CaliforniaCode, am2550At
5, and 255 4. 1 un
understand that
ofSafetycuremlyhaveSec
dolth es itis yrespo3a.1
buildingi(the dromfircunen0 have tenant, nim- fa 'Y,
Y Yre p nnhl to notify the
- --- - .._ ... .... _...._ .. _. ... .. __ ..
pea mannereu r2 cols which uil be recd n to issu rice f e C rt' Ecate a0.
Parc q
Occ p , 11 .1 ' Y`
i"'
Signatureof_Applicant Date
,Owne orauthonzed agentAll
Dae ,. ,
roof coverings to be Class "B" or better `
OFFICE