01030192 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
If UI LII INC,ADURISS: PERMIT NO.
77r-,yj ngnrRmt\inF Pi JUST TER HEATERS INC 01030192
OWNER'S NAME. APPLICATION SUB DATE.
Pr=ARD "ll I TAM Rhin MnSAED 1764 IONAL AVE 03/30/2001.
PHONE: SANITARY NO. CONTROL NO
BUILDING PERMIT INFO
0,--O ANCIIRIiCIIIiN(il Nlili R'. PLUG ELECT PLUMB MECH
�w—
a;G u u cl u
i7 h j LICENSED CON'T'RACTORS DECLARATION Job Description '
o 7 H 1 demby atfmn ram 1 am Iicen,ved antler ennt , of Chaplet 9(tori omncng
O Qp "...r, W with Scc'dnn]IM111)ol'Dv nnJul'the lluancnn:n,J 1'mlmns G,dc,and my tic
<y i.v in lull livcc unA dretl.Isi
�:W Lmen.ecla.n ue.n REPLACE 50 GALLON GAS WATER HEATER.
x O o.V Hart, Contractor
al 3 c,u ARCII n Cris DECI1\RATION
I undcntand my plats shall M:rood as Public mulJr
wc,p p larenved i'rofiewwnd
o OWNER-BUILDER IIBCLARAI]ON
uY1— I hereby nllirm That I ash cncmpl front the Contractor's License Law lir the
H%< following reason.(Section 7031.5.Levine,and P vicsoons Code:Any city or county
which nyures a pemhit to constma,alter,improve,demolish.or repair any swcturc _
c t-m
prior to its issuance.ala requires the applicant for such pandit to file a vi
d3— that
ththeiarcensedpur.aannnmeprosmoniofdieContractorsLicenseLaoChapter9 Sq. Ft. Floor Area Valuation
(commencing wish Section TXXI)nr Division Jnr the Ravine,and 11 rev.iona Code)
r,bar he1p thereinto,its I the basis r the alleged evempit,,Any violation IK I P49
of Secdod 70tole
7031.5 by any u,h,ao,iem
nt a prit eunjwie the applbam u,a civil Anally
of nor mme0em five hundrel dollar.(s50p). APN Number - Occupancy Type
❑1.as owner of the pmperty,or my enhployees With wages as their sole cmnpenw(ion. .�
will do the work,mal the suunum is nor intended or offered for sale(Sec.W,1,1.
Ravine,and I'n fir..ion.Code:*1 he Contractor v License law tone,not apply man Required Inspections
,,w r ofproperty who nnilds e,or bnprovthereon.and who does.vach work him.elr
r in.ndgn tuition mnployee, I led mal su,h i...prnveaLLnl,are tort intended it 106 — SEWER & WATER
,Jared for sale.It.however,the hulldiog or ingmwenmml a,old Wihln no yc:d or
iInt,letna.henwoO.nuim.,w;ghave the burden ofproving hathedid not buimnr 202 — UNDERFLOOR PLUMBING
mprove for pi rpnw of sale.).
❑1.asn„nerufhepmperty.nit,e,el-wel,eumran.,with licensed contmctnr.tn 301: - ROUGH y PLUMBING
construct he project(sec.7W4,Rus ,and Profess ns Cede:)no Cmnmm 302 — TUB & OR SHOWER
ie, a Law doer on apply to an owner nr property who muds or inhpm es hereon.
and won muaew lot -ch ptgieCn With a i taloc,nrfs)rcco—I I,u nam m ate 502 FINAL PLUMBING ENERGY
-
Contmelo,.1 cense Law.
❑I am oward under See. .N&P C lot this notion 506 — GAS TEST
Owaer Dme 507 — FINAL PLUMBING
WORKER'S COMPENSATION DECLARATION
I hereby a0imh under pcnnl,0 pe Jnr,o,no nrdw Inllnwing decLoan
don,
:
❑ 11 ' na L rlcd C n to .Il'. I' WodeLc
m
Copo i provided 1 by Sect YNXI f Labor M Cost, fur the
peau nn, ,rk bar
ithich his .it i. 1.
O 1 not, II unitition.Walker*,Conniption Insurance. eq hod by Section
J]W of the
Lahor Code,lot the perlonaturat,of the work for which the permir hs
issued.My Wnrkure Compcnsuiuvh Insurance chhniur and lidiry number are
Currier. Policy
. CIiR'19CAOP EXEMPTIONFROM WORKERS'
COMPENSATION INSURANCE
�G•C/
/
!/
(nis,caion need nal he conhplcted if he Irodil is for one hundred dollar. /0
IS 100)or leve)
I certify than In fhe Ixd ornmme of the wol,I,,,which this hermit is Isucd,I
,he][nm enq,loy any pecwm in any manner ho a,In necome siib nal It,the W..wri
Compen.a(ion law,of California.Lane
Applicant
NOTICE TO APPLICANT:it.alter making this certificate of Eaanp ton,you should
7 bea,ma wbkeno the Worker',ComPenution provisions of the labor Code,you tra
O forthwith comply wIh such pro mmn,or tau pain I shall be leaned revoked.
F ^ CONS'I'RUCI'I ON LEND]NO AGENCY ,
C I ,1 hereby uilinn that there is a aon.maion handing agency for the perfonnanm
s: of he wad lin which his permit i.issued(Sec 3(hG.Civ.C.)
Q. Q lan4r's Nvme
z Lender's Address
V O I cattily Thur 1 have lead(bl,appl'mm'mn and.urate Ihat the above infonnallnn ie
or...1.1 ugma Io enmply with all oily nod County ordinance,and state laws relating
O U tonuilding eo ourtedon.and booby atmmdu repnncnmtivev of his city maser upon
tlie.1ane-nmmionoil p,,,,dy forn,pevtal pr,ow,.
F a (We)agree(o save,indemnify and keep hmmlem Inc City of Capita m again.
On liabilities,judgments,costs and cspanmd which may in any way teems against said
U Z_ City in aonvapmnce of the granting of this sandhi
SOUAPPLICANT AND WILL COMPLY WITH ALL NON-POINT Issued by:. Date
Signature of ApplicmNContmctm Ume Re-roofs
DISOSURE
Will the.,Ii.... flm(are building u
ding tvdxrERw 1pd mstore handle M1vallous material Type of Roof
as defined by the Copedino Municipal Code.Chapter 9.13,and the Health and Safety
Ctdo.Section 25533(11'
11 yes ElNo All roofs shall be inspected prior to any roofing material being installed.
Will he apphcao,or Lure building occupant use equlpmeni nt devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit h tijoha.,air c nlaminmt,a,defined by(he Pay Area Air Quality Mtmugement
District all new materials for inspection. Applicant understands and will comply with
o Yes 0N all non-point Source regulations.
I have read the coo dour mmerials tequitemcnu under Cheaper 695 of the
Culllania Ilett&safety Code.Sections 25505.25533 and 25531.1 undersnmd(hill
d the bnllding does not utmtmly have it enuall. hal It In my te,to oihility m nndry he
ccupnnl of flue olaorcou"a,wbieh mu.0 be area prior o,imuunre of a Cenillcate or
DCepaa`y' Signature of Applicant Date
Owner or aurhmired agent Date All roof coverings to be Class "B" or better
OFFICE