03020004 (2) CITY OF CUPER'I'INO -'.
BUILDING DIVISION PERMIT CO RXC kT4V6RMATI0N �",�'�.
BUILDING ADDRESS: MUST WATER HEATERS INC PERMITNO.
10181 MACADAM LN 0';02QQQ4
OWNER'S NAME: 1764 NATIONAL AVE APPLICATION SUB DATE
DAVID WITT 02 03 2003
40 ONlit (510) 293-9901 SANITARY NO CONTROL NO.
A R C I IIT!Cf/ENO INEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
M.I 0
pupil LICENSED CONTRACTOR'S DECLARATION JOb DCSCTI I
K U F 1 hereby affirm bar I am licensed under provisions of Chapter 4 nommem'ing p ar ��
�¢w with Section 7( XB of Division 3 of be Business and Professions CaNle.and my license is
r<<�„ mrmlrnrecanderreet REPLACE WATER HEATER.
zoq: License Class Lic.ar
oN � Dam Contractor (50 GALLON GAS) APR 1 7 2003
ARCI IITECTS DECLARNHON
-a I understand my plans shall be used ns publie records
c p6V
ti3u. Limmsed Professional
ma, OWNER-BUILDER DECLARATION BUILDING
vy� I hereby affirm that I am exempt from the Contractor's License Law for the
x+600 following reaynn.(Smmm 7031.5,Business and Prnfcssinns CoJh:Any city or county
aWe 22 which requires a Permit to construct,inner.improve,demolish,or repair any structure
prior to its issuance,alar,requires the applicant for such Permiuo file a signed statement
�s< that he is licensed pursuant to the previsions of the Connectors License Law(Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section 7011 of Division of the B usiness and Professions Code)or $657
y 9 that he is exempt therefrom ethe
had be basis for alleged exemption.Any violation of
Semon 7031.5 by any applicant for a Permit subjects the applicant to a civil Penity of APN Number Occupancy Type
not more than five hundred dollars($5)(B.
❑ L o the work.the property,or my employees
ntendedwith offend wages ns rheir sole(Sm.compere tins,
36901057 . 00
will dothewnrls Codec he ctureContracuns not' Lice sofaw foraide ot apply 71146.Business ge����j j y �yp�g
anJ Profession Cade:The Contractors License Law does not apply to an owner of 5 02 - FINAL YLUl�lk3 SLV Ue L�'N h'RGY
propertywho builds i ed that suchicon,and who does such woe himselfor edBrough his
own empmycea,pmvlar imprvemintisod wneamnetiear of c or offered for owner• 506 - GAS TEST
however,the building or den of
is hale within one year of completion.the owner-
builder will have the burden oT proving that he did not build or improve for purpose of 507 - FINAL PLUMBING
sale.).
❑1,as owner of be property.am exclusively contracting with licensed contractors no
consuum be project(Sea.7614,Business and Professions Code:)The Contractor's Li.
cense Law easy not apply to an owner of property who builds or improve;thereon,and _
who contracu for such projects with a carnations)licensed pursuant to the Cosbsecur's
License Law.
❑ l am exempt umda Sec. ,B Ac P C for this rcnnn
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following declaruions:
1 have and will maintain a Certificate of Consent to self-insure for Worker's Campen-
sarian,as provided for by Secure 371k1 of be Labor Cush,for the perfom Tom of tbe
work for which his Permit is issued.
Cl1 bane and will maintain Worker's Compensation Insurance,as required by Section
70
31 of the Labor Cale,for me performance of be work for which this Permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Cnrtiee Policy Na: _
CERTIFICATE OF I'XEMPI'ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed ifft Permit is formic hundred dollars(S IUD
in less.)
I certify chat in the performance of the work for which this Permit is issued,I shall but
employ any person in any manner sr as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption.you shimW
become subject to the Worker's Compensation provisions of the Labor Code,you must
0 zforthwith comply with such provision or this perm it shall be deemed revoked.
z , 1, -
CONSTRUCI'lON LENDING AGENCY
[r I herchyallirm that Berens actmwuetion lending agency lirthc Performanccol
ai the work l iuwhich thispermiiis issued(See.3097,Civ.CJ
6Wi Q Lender's Name
z Lender's Address
U 0 1 certify that 1 have read this application and Buse that the shove information is
W f-r torten.l agree to comply with all city and county ordinances and sum laws relatingm
0 building construction.and hereby authome representatives of this city to enter upon the
r V4 atom mentioned property for inspection purposes.
(We)agree to save,indms
ei ly and ImP harmless the City of Cupertino against
ti N liabi litres,judgments,costs and expenses which may in any way game against said City
U z in consequence of the granting of this permit,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature ol'ApplicantiContractor Date
HAZARDOUS MATERIALS DISCIASUType of Roof
Will the applicant or future building acupam store or handle
hanNom material
as dclined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
ctWh,Sc mar zss3z(a)1
❑Yea 0 N All roofs shall be inspected prior to any roofing material being Installed.
Will the applicant or future building oempanr use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
it hasardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
WriO7
❑Yes 0 N
leave read the hamajous materials requirements under Chapter 6.95 of the Cal ibar
I Ri llh K Safety Coke,Sections 255115,25533 and 25534.1 undcrsmnd that if the building
lido,.,
not currently have a tenant,that I is my respmaty m i hit inotify the occupant of On
olrements which must W mel prior it)issuance of a CeN(ieam of Oecapascy. Signature of Applicant Date
Owncror malim ace agent Doc All roof coverings to be Class rBa or better