03040008 (2) CITY OF CUPERTINO ''"''-'' ''dam^"
'r� t
BUILDING DIVISION PERMIT 'ACU* 1 TRAC,0R W'2 N AT10N -
-I BUILDINGADDRESS: PERMITNO.
20044 NORTHWIND SQ JUST WATER HEATERS INC 03040008
OWNER'S NAME: PERMIT 65UEDATE
DOLLY JAIN 1764 NATIONAL AVE 04/01/2003
E: SANITARY NO. CONTROL NO.
(510) 293-9901
CHITECf/ENOINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
00 LICENSED CONTRACTOR'S DECLARATION
6 F 1 hereby afros that 1 am limaed under provisions of Capra 9(ammcncing Job Description
wlthScetian 7000)of Division Sof the But.ate Profcsdons Cods,and my Imat.is �^�a we
L.fall iame Chase etten. FIN p LE®
Dan.ecw. Lie.is REPLACE WATER HEATER r ,Y/'1
Deo
ARCHITECTS DECLARATION (40 GALLON) APR 1 7 2003
1 mberuand my plea m.11 W used u publle wards
5 wer Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby afford that 1 em exempt form Ne Coronaries License Law far the BUILDING
0 O following recon.(Section 7031.5,Balance and Professions Cade:Any city or county
$ which require•Permit to coaRat,alar,improve,demuikh,or repel,any atrature
Sq prior In its issuance,dto requires the applicant forsuch Permit to Ole&signed statement
£ that he is licensed pursuant In,the provisions of the Conflacclor's License:Law(Chapter 9 Sq.Ft.Floor Area Valuation
y (commencing with Smtht 70D0)or Division 3 of the Business and Professions Code)or
Ther W Is exempt therefrom and the basis for the rousted exemption.My violation of
Secdon 7031.5 by any applicator for a permit subjocts the applicant to a civil penally of APN Number Oce panty Type
not mom than S.hundred dollen(SSW).
0 1,n awner of due property,in my employca with wages u Or*sole compewtion, -Airqpor-A no
will do the work_and the stroame boot intended a offered for sale(SO.7044,Business Required Inspections
and Professions Cotte:The Conuacmh License Law dos not apply m an owner or q p
property who builds or improves floamn,and whodoessuch work himselfor Waugh his 502 - FINAL PLUMBING ENERGY
awn employ=,Provided thaauch Improvements en notlnlended at offered for ask.If,
however,the building or improvement Is mid within one year of completion.the owner- 506 — GAS TEST
Wilda will have the bunch of proving that W did not build or improm for purpose of 507 — FINAL PLUMBING
0 I,as .Or of Ne property,em exclusively contracting with licensed contractors to
construct the projoet(Sec.7044,Business and Profusions Code:)The Contractor's Li.
c roe law dans not apply to an owner of property who builds or improves thereon,and,
who contracts for such projeea with a contractor(s)licensed pursuant to the Conlnemes
License Law.
0 l am exempt under See ,B&PC for this wan
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby afllrm under Penshy of perjury one of the following doelmdonse
have and will msintan a Cerifiate of Consent m self-Insure for WorkeYsCompen-
on,as provided for by Section 3700 of the labor Cade,for the Performance of the
work for which this permit is fussed.
❑I
hesnit will meinain Worker's Compensation Insurance,a required by Section
370(of the labor Code,for the perfamanee of the work for which Nu permit is ismed.
My Wor ms's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mss section recd not lee completed If tie perm0lsfmoa huMmddnllan(5100)
or Ica)
I carry that In the pedarmenco of the work far which this permit Is Issued.l shell not
employ any person in my manna W as m became subject to the WaherS CompeaAdon
Laws of California.Data
Applicant
NOTICE TOAPPLICANT.eIf,after compensation
this woos or of Labordiodyoushoo
become hobject
mp m the Woher'o Compensation povisioa of the hear Cattle,you most
.J 0 forthwith comply with such provision or this Permit be domed revoked.
'� '--' CONSTRUCTION LENDING AGENCY
[-wr Iheroby affirm Net then I.samvuetinn lendingagenry for to performance or
a work for which this is issued(Sec.3097,Civ.C.)
Le q
W 0 Lender's Name
.7. z laedela Mdw /
U Q 1 cenify that I have mad this application and state that the above Information Is
Wf'" co ma.I egme to comply with all city and county ordinances and also laws misting m
DU building construction.and hereby authodm mpresenlstivice of Nis city in ewer upon the
W shove-mentioned proPerlY fm Inspection Purposes"
, (We)agree to rave,indemnify and keep hermless the City of Cupertino against
cn Iiabllltia,judgments,costs and expenses which may in any my accrue against said City
(„) 2 In consequence of the granting of this permit.
G APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. .
Re-roofs
Sigaidurecil'ApplicartuCanuactorAZARDOU Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant o forum building e.Chapter
or handle Health
meadal
Or defined by the Cupertino Municipal Codc,Chapter 9.13,and the Halm antl Safety
Code. 35531(x)7
Ov. OND
All roofs shall be inspected prior to any roofing material being installed.
Yes
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I humorous air contaminants M defined by the Bay Ara Air Quality Management all new materials for inspection.
uict7
0 y ON.
I hentreed the hmardrosm Her nquimmcnuundc,CMplsr6.95ofthe Offen.
Iroqni.H.Ith&S.felyC�,Sltd.25505,25533� 534,Iinderrundthatifthe building
s nm currently he.n to-M that ItIs my responsibility to nosily the aaup.,of the
uintents which mal be met pdorwissuanceora ccnl0cemaf occupancy. Signature Of Applicant Dale
Owner or euthodmd agent Dam All roof coverings to be Class oBo Or better
CITY OF CUPERTINO
�(�... • WATER HEATER . 3 �Io e U
CUP`ERTINO PERMIT APPLICATION FORM
APN# 3(' 06-3 r
,3 Date1611°3
Building Address:
Owner's Name: Phone#
aT
J�j--of�73
Contractor: .. , Phone: License#:
/rS7L 1U1 rev -ct� L�r� S� 2,0/2
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb Mech ❑
Job Description:
Residential Commercial , ❑
Cost of Project:
Strapped On Platform Li Bonded
New Location ❑
Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE . Plumbing Permit Issuance PLUMBING
BENERGY Ener y BUILDING
BUSLIC Business License BUILDING
# 2