00120016 (2) Y {
CITY;NAME,
PERTINO
BUI 'DIVISION 'PERMIT CONTRACTOR INFORMATION:
BUILDINGS: ( '' PERMIT NO.
OWNER'S APPLICATION SUB DATE
{ONE: , t- - SANITARY NO." CONTROL NO,
d,
91 VI)
G Q O ARCHITECTIENGINEER: BUILDING PERMIT INFO
rvnq BLDG ELECT PLUMB- - MECH
E= LJ 1=1 Imo,
ZGW w LICENSED CONTRACTOR'S DECLARATION o0atthatItan censeddanderprovs f Chapter 9lcr mmencino s , s - < -Job Description
th Section] 007oD m 3 of he Bu dPMM,d.m,Gxlc,andmyhcns '
s f II f and erre h -
s.m� L,a Gla; ' " REPLACE 40 CRLLON. 6RS WRTER� HEATER
Lie:3 w m Data -Contmemr . . • _
ARCHI'TECT'S DECLARATION' -
C 1 understand my plans shall be used as public recordsce _ r -
ar
OO Lbarnesl Professional --
°�oat OWNER-BUILDER DECLARATION '^
u3I I h by affloor that I act ecconarid For. he Contractor's License' Inn,for the _
Cfollowing rc" (Section 7031,5,Business and Profic,snum,Cod .Any city or county' '
O which,naluires a permit to construct, II t p x demolish, pn' y samcluare
naf m farear c is Mahone,the it hp 'nolle a sign l:plenen ✓
that" licensed Pt to tile provisions ofthContractors LL (Chapter 9 - `Sq. Ft. FloorArea • Valuation"
(commencing with Section]IXm)of Division 3 of the Business and Francesconi nesconi Code) ' _ '"
or that he is exempt therefrom and the basis for the alleged exemption.Any violation _
.= of npp
Section 7031.5 by any lleaat lora purmil subject,the upplieant m a civil penalty
arnot nmm than live hundred douma($500).'. - , APN Number ; -Occupancy Type,
❑1 own"r f thep p y r toy mph Y with .g a.the i pe. n, c
will d the k d h o m I t d d r tt eJ f (S 7004, .,
Business and Professions C de The C n t r s License Law does not apply to an ,Required Inspections '
owner of property Who build m
m, im" rc
eIheon and who does such work himself
throuhisownerideyees pmvldelthat suchimprovementsare not intended or 502' — FINRL .PLLIMBINC ,ENERGY
offered per sale.If„hower,evthe building m improvement is sold within one year of '
impletion,I"ow"a-builder will have Inc huNenoff oro g that M1edid no '506
t bride, — CCAS TEST
� .
Improve for purpawofsaleJ. ”
Ed 1.as owneroftheproperty.anx usively contracting with licensed conarreffirso, 507 FINAL' ,PLUMB'ING
cons(met the Pioneer(Svc,70441 Business and Professions Code) rhe Co amemr's- -
License Law does"not upply m un"wool of property who builds or improves therm", •• _ _ '
and who contracts for such projects with a commcmr(s)licensed pursuant to the
Connector,License Low..
'El 1 am exempt under Sec. B&P C for this remron
Gore, Data -
WORKER'SCOMPENSATIONDECLARATION _
I hereby affirm under penalty of perjury one of the fallowing ded.nnion:: - n s '
❑ 1 have and will maintain u Con,mate of Consent to self-insure far Worker'{
Compansmion, its provided for by Section 3900 of the Labor Code, for the '
Emormanee of the work for which this permit Is Issued
101 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor C de,for he pert onace range wh
e work for im his Permit is
tied.My Worker's Compensation Insurance currier and Policy nhmbar are: '
CameoPolicy No.:
CERTIFICATION OF EXEMPTION FROM WORKERS'
- COMPENSATION INSURANCE I, t
_ (This section need not be completed if the permit is or are bmalred dollars t
(4110)or less.) .
_ I certify that in the performance of the work foewhieh this permit.is issued,I , i
s.
shall not employ any person in any manner so as to beenme mover to the Workers'
'Compensation Laws of Calirotuia Data .a ,
Applicant
NOTICE TO APPLICANT:If,alter making this CeBlliwle of Exempiium you should
become ecoe subject m he Worker's Compensation us
pention pmvilim,of the Labor Code,you mat
Q O Ihsnhwith comply with sneh provisions or this permit shall M deenned revoked. . - -
N -CONSTRUCTION LENDING AGENCY. s
a1 h by irtion, a that Ih i f ding.,.ay for the perfutmn me
W of run work for which his perm"',issued(See 7097,Cie C.) e ,
Lender's Nunn,
`yyy❑' Q LeAdd
nJcr's Address
_ Q u I ecr ily that l b I th' xpplis i ward milethruOu,iteree inforroulasov,
correct 1 agree to comply with all city and canary- nnurace and state Ids ref w g - • - s
Q [) to building ammmction,and hereby tiuthanzcmprescnmtives of this city m enter upon
[[��]
flocaboscamentioned property f p 1 on purposes.
(Wedagrem to indemnify and keep harmless the City fCipnln)against ( - •-
F V) lihb I Ic',judgment:,costs and expenses which inay in tiny way starme against said - -
V ,Zy
City In cansequ.nce of the griming of this permit :' -
ti 'SOURCE
ANT UNA3RSTAb DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
Signature of Appi canueomractor Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant slow or handle hooblitrs mmerad ..Type of Roof
ax defined he the Cupertino Municipal Code.Chapter 9.12,ind the Health and Safety, n "` 1, ,
Code,Section 25532(.)^
❑Ye,.,; :o No All roofs shall be inspected prior to any,roofing material being installed'.`
Will he app0emm ar wtnae bnutrnb oedtipnm use cornmeal or donarx which If a roof is installed without first obtaining an inspection,I agree to remove
it heralds.,air cnmaminants as delated by the B6y Area Air Quality Management ,
ianiae • all new materials.for inspection. Applicant understands and will comply with
0 W °No all non-point source regulations.
1 have read the recruiters materials requirements under Chapter 695 of the
Califerin Health&'Safety Cale.Serious 25505,25533 and 25534.1 understand hat w' -
ifthe building does not currentlyhave amnunhthw'n is my respansibllitymnmifY the .•
xcupam of the rcgniremem,which muss Ie mel prior a+issuance sof n Cenifema of
°carp°°`, Signature of Applicant Date'
Owner or wumoriaea agent Date All roof covering's to be Class"B" or better
-OF FICE
00► �,001 �
—City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 10767 Linda Vista Dr. Date: 11/28/00
Owner's Name:---Smith Robert
Phone No.(408)446-4790
APN#: 356-07-013-------------- Project Valuation: $ 856.89--------
Building Permit Info: Bldg___------- Elect------_-- Plumb___ X___ Mech-_—__---
Job Description
Replace 40 gallon gas water heater.
Contractor Information
Company: Just Water Heaters Inc. Phone: . (510)293-2012
Contact Name: I Fax: (510)293-2022
Address: 1 764 National Ave. E-mail: permits@justwaterheaters.net
City,State and Zip: Hayward,CA. 94545
State Contractor's License# 591329 Exp. Date: 3/31/02
Worker's Comp#: 03KR0001018 Carrier: Clarendon Exp. Date: 4/1/01
Credit Card Information
Credit Card #: 5474-6331 -7168-6326
Name on Card: just Water Heaters Inc.
Expiration Date: 9/02
Visa ❑ MasterCard
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