02020129 (2) CITY OF CUPERTINO ''•=•' '- "'
BUILDING.DIVISION PERMITCONTRACTOR INFORMATION: . .
BUILDING ADDRESS: •. .. PERMIT NO.
20249 NW. SQ, JUST WATER',HEATERS. INC, , , ;,. ,02020129
~ DS _. .._ : � t.__.-1764'- -NATIONAL AVE AP 01
S E CATION US DAT
WUTININ 2/28/2002
PHONE: - - SANITARY NO. CONTROL NO.
(510) 293-9901
o ARCHITECT(ENGINEER: BUILDING PERMIT'INFO
re- BLDG ELECT PLUMB MECH
L'J L-'J L._1
f «
Lm that ID CONTRACTOR'S DECLARATION
•�v� 1 thereby alRrm that I am licensed undo rcha ter v uninmenem Job Description
prod Prens o p g
?w_m isinfllforeandofDivision3ofthe��sinessvndPmfnsionsCWe.antimyliccnxe REPLACE 40 GALLON GAS WATER HEATER
i x s,-, i.in Inn firma and mbei.
a Licence Clasz Lic.tr /
0 a`O Wm S DELLA _
5 3 Ia ARCHITECT
um DECLARATION
On
I uindenuW my plain.hull Ik•usce as public records r
3 O O Wccnsed Profcssianvl
a.' a ON NER BUILDER DECLARATION
I '
=' 11 byih t 1 ;n r from the Contractor s License Lax for rhe
?a following ui (S S ii 7031.5.Basinosand Professions C Cute An,mry ter county
EsxrC ..,which requires a permit to t malter.improve,demolish. repair ny.nuam
.Q
2pncr1i ;....nor.rilsw requiresthe
,pi anfar such peimult'o filensmgned nammi - .
�3- that he sl emJ Pursuenn the pr" nsofthe Cnnwmory L;cenu law(Chap; 9. :, 1 Valuation
ecom ncng with Secton]1100)of Division 3 of the Business mid Pryfess acts Code) �S}3�(]�
m that he it exempt therefrom and the has,,for the alleged aempuh Any violation-of Section 703 1 i5 by any applicant for a Permit subjects the..plicate te a civil penalty-
of net mom than roe nanarce aad:n,(ssm). 50�PN"iThL PLUMBI G 'ENERG1Qcc pancy Type
O 1,a
...at of the property,m my employees with wages m their sole compensation.
II d the rk d Ne amemre is nm t d J' R d for sale svr.'?W;' ..
d ti e. 1 d ereu ass Cale'The Ciiii r I 1 w doer not apply to an . .... __...5 07 - ' FINAL-'Pt.1tAiS.lil40pections. _• - ..... ...__ ..... .... ._._
r of Property who builds or raided that
such.and who east such work n ed or . . ..
orthrnagM1 his own employees. building
that cepr improvements art not intended or
:oRcred for sale.If,knsdvcr,the buiteing or imprav<mem is sold within ane Year of -
oniplmion,the owner-builder will have the buMen of proving that he did not build or
improve for purpose of mler)
•' ❑1axwner ot_he.ropenYir exclusively
contracting
ontruting w_ith l.licensed_n.ued_contractors mr . . ..... ...... .. ._. _. - ._. _
imorconstruct the does (Sec.]to a Business and Professions Chep The Contractor's
'- Liccnsc law docs not apply man owner th property who builds se improves thereon,
..an arracu contiaas for ouch.projects wiiM1 a.commnottx)licensed!Pursuam�o.thc _._.._..... _ _ ___.._.._. _... . _. _ _._ .._._ _. _ .__..._..... ..
01 ma cora Liana low.. ---
OleincnemptunderSec. ,B&PCfar this reason
Owner Date" -
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty o1'perjury one of the fallowing declarations: -
❑ 1 have and will maintain a Cenificme of Consent to self-insure for Worker's
Compensation, as provided 1'nr by Section 37W of the Labor Carle, for the
performance of the work for which this Permit is issued. i
❑1 have and will maintain Worl n'.s Cnmpensvtion Insurance,as rtquord ey Section
37M of the Labor Codd,for the performance of the work for which this Permit is -
issued:My Worker's Compensation insurance came,and Policy number are: .. "' 1 .t
. rat .,.�. . .. ....
Cants -r: t(':Policy No - -
'I CEIT1�FICATION OF E%EMPOON FROMWORKERS( L1 '�' rk.�r.
h
COMPENSATION INSURANCE" nFi..
rfis sea an need no
be completed if the permit is for ox hundred dolls ,. f•. . .
' ..I .: . .".. ....
r 1 ceM,I that in theperformance nyance work for dons,object
t or J I
.hhll not cmPloy any personnn anY manner so as to become- b)at to the Workers - "" - _ "' - "'s•` --__ _. _... .. .. ..."
Conircmmioh Laws of California.,Date - -
.. 'Applicant-
NOTICE TO APPLICAN I.IL afrer making his Cenifieme of Exemption,you should
become subject m the Workei s Compensation provi.ions of the labor Code,you..at
Q forthwith comply with such previsions or this permit shall h deemed revoked. -;
CONSTRUCTION LENDING AGENCY,
a.> 1 hereby affirm that then is a cons taction lending agency for the perfommnm
of the work for wn ch his promi is i.sued(Sc6.309] Civ C)
� 0' L'e"Jcr's Name
A. .._. ... .. .!n ' ._.... .... . __..__._....._ '-. - __._.. ..._.._ ._ ... ...... .... ...
Le
.D;Z nticr'a Address
'V-C) Ianiry ihmlhave and this application vnd state shut the above infotmmion is
W.E. Goner,1,ague to cep,dy with.11 city and county ordinances and state lawn relining
O C.) to building constriction.and hcieby authorise representatives ofthis city to enter upon
Lr] the above-mentioned property for inspection puipous.
y: UMO agree tattoo,indemnifyind keep hmmless
CW the City of Culirman against /f_ilt UI/
rteliabilities,judgments,cosm and expemex whichmay in any way accrue malnst,did
U Z City in consequence of the from v
granting of this per ' ''"-
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITHA1.LNON-PO Issued by: r Date
SOURCE REGULATIONS.- y'
SignaturP,4fnpprcaocantraen, . .' :' Date'„', Re-roofs
HAZARDOUS MATERIALS DISCLOSURE -
.”. Wlldic applicant or future buldm8occupant smeorhandle blinarchmaterial Type of Roof-'. .. _ :,..... -• _. _-. . ._
as dkfindd by the Coisdirm Municipal Coar.Chapter 9.12,and the Health and Safety.
Code Section 25532(a), N
All roofs shall be mtspected,prior to.any,roofing material being installed. -
"t Will the pantusccqup t a.epr,-wmeny If a roof is installed without first obtaining aIt inspection;Lagree to remove
emit haaardous air contaminants as defined by the Bay Aka Air Quality Management
Di,rnda all new materials for inspection..Applicant understands and will comply with
❑Y
13 No all"non-point source_ regulations:,•.
hese'rcud the hrecolds Immen. .,armments ontl Chapter 6.95 of the
California HealthA,Safety Cade.Sections 25505.25533 and 25534.1 undemand that.
- if the building does not cunemly have a tenant.that it is myrcsponsibility to notify the
opum of the rcquimearmi which nmst be me,prior io issu..re oro Certificate of
a
cc° apo"`y Signature of Applicant Date
Owner or amhnd,ea ager:, - rare All roof coverings to be Class "B" or better
-.� - - OFFICE.