01060058 (2) OF
CI cut NG DI ERTONNO PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21080 RED FIR CT JUST WATER HEATERS INC 01060058
OWNER'S NAME: APPLICATION SUB DATE
ELLIS LUCY A 1764 NATIONAL AVE 06/11/2001
PHONE: SANITARY NO. CONTROL NO.
(510) 293-9901
O O O ARCHITECDENGI,NEER: BUILDING PERMIT INFO
pt— BLDG ELECT PLUMB MECH
yi L.-1 LJ I_J L...I
as
Z S = LICENSED CONTRACTOR'S DECLARATION Job Description
IQ
O Z—D 1 hereby ummt mvt I am licensed undo provisions of r,Cade9 fcommennng
F_�tu with fathomad)effect.
Division Lafthe Hominess and PrulcssionsCWe.and mylicense
a I is in full fame add effect.
E.�a License class Lie.a REPLACE 40 GALLON GAS WATER HEATER.
O O Dole Contractor
Q ika t; ARCHITECT'S DECLARATION
U.ON g 1 understand my plans shall be used as p.hire..his
ate,p O Licensed Professional
e� OWNER-BUILDER DECLARATION
e u�
in o' 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
t_a a following mason.(Section 70311_Bnaness and Professions Code:Any city or county
I D which requires a x,mrit n)construct,alter,improve demolish.Or upir any structure
a5$ .prior to its1 o tire'ppl A tt lk r In t1 'R d 'terse,.
ilt-Wd t all. i tt Itl. , ' f heci ,I (cnnyer9 SCI-F61710ofAfea37r :*.f 'i V )O., $63'Aluation
crag v ih Sc no,7W0)of Division I nnhe Past,a and PmfessioConde) Q ; .,S f`s k. t v i., r.:: : v ' 1
Cor that he is exempt therefrom and the basis for the alleged exemption.Any violation
of Section 7031.5 by any applicant for a Permit ubjects the applicant to a civil penalty
,of namnrethan five hundred dollars(s5o0). 359eMY40M) it x ' Occupancy Type
01.as owner of theproperty,or my employees with wages as their sole compensation.
will do the work.-sed thee-stmeturc is not intended or offered for sale(Sec.70,14,
Business and'Proessimss Cade:The Comm ror's License Law does not apply to an 502 — FINAL PLtMl999Vs&SMGY `
owner of property Who builds or improves thereon,and who does such work himself I
or through his wn employees.provided that suchimprovements tire notamended or ___506_. — .GAS-,.TESrT-
offorod for sale,If nn e e the building p tit i Id tb' year of
yeof ,
nmPll the wneoloddr willhave the boder ofpr var,In.,he ea mild or 507 F.a�r +�A�r�I NG I
rp
improve for puose of.ale.), G.V ttJ t
_ ❑Lre,owner prthe ject(Sec.7044. usineselycontmmssionshllcensThe,Comcmrsto APR ---4 - 00
onswa the project(San I.a mine,o and cal,who
Cade:)The Contncm e. 2 2 2 ,
License Law d......pply m an owner of property who builds or seimproves Herron.
.i .. ,Co who comromse Law.such projects wim.a conuanogA licensee pursuant to toe.
_ Cntractors Littnu Law.
❑I..,exempt under Sec .B&P C for this reason
BUILDING
DIV t'
- 'Dao'
T 'r- WORKER'S COMPENSATION DECLARATION
�. 1 hereby affirmunder Penalty of perjury one of the following declarations:
❑ 1 have and will maintain is Certificate of Consent to self-insure for Worker's
Compensation, as provided for by Section POP of the Labor Code, for the
performance of the work for which this permit is issued.
I
❑I have end will maintain Worker's Compensation Insurance,as requite)by Section
PDO or the Labor Cade,for the,performance of me work 4,r which this permit is
Y Compensation Insurance carrier and Policy number am: -
issued.M Walker's Com tion
Ca f„CEIGIFICAI`ION OF EXEMPTION FROM WORKERS'i 4.�7 a
COMPENSATION INSURANCE_ '
r i t s t(Ihisumion need oat be completed if the perms ie fo one Hundred dollars I'i ., ')\v t-.\\ 1
(SIOO)orlestj ,
1 certify ihm in the performance of the dark fur which this permit is issued,1
m employ any per»n in any mintier.so as to beme
cosua I.the Wuderi
Compensation laws of California.Date
Applicant.. .__._..
NOfICE TO APPLICANT',If,nater making this Ccnllicutc of Exemption.you should
besubjectai theta k ' Cmpmt p ms of the Labor Code you most
Q O (trth to ply with h P lions o th p t I shall be dec n d revoked _
.. _.. _ .. _.. . .. . _.. _._ _ ... _ .. . _. _
""CONSTRUCTION LENDING AGENCY
71 hereby affirm that theins a construction lending agency for the performarae - t
of the work for which this permit is issued(Sec.3097.Civ.C.)
a.❑ Lender's Name. -
.,Z LandeCs
V � I certify that I have mad this application and state that the above information is
fi (.. correct.[agree to comply with all city and county,ordinanees and Coate laws relating
..:Q'V to building construction.and hcr6y outhbrize re,rewen(mi-I of this city to loner upon
F-;4 the above-mentioned property for inspection putpgaes.
.O. (We).911c octave,iadeinnify andkeep harmless the City of Cupeaino against
'Vl liabilities,judgments,costs and expenses which may in tiny way acerae against said
U.Z City in consequence of the granting of this permit.',
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINT - Issuedb Date
SOURCE REGULATIONS. y'
Signature of Appliever/Conuacar I Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE '
Cdefined
o$ed by the Cupert or future ni boldonna e.Chapter
store m.handle Health
Safety - Type of Roof
Will
nz
y the Cupertino Municipal Code.Cha. 9.12,and the Heahh ane Sofcry
On 2553'_( 1 . ' . '.. �� � ,
0Yes•' oryn' All.roofs shall be inspected prior to any.roofing.material,being:installed..
Will theapplic to t t ebulld B I occ I apant t:se equipmeat or devices which If a roof is installed \Jith'out first obtaining an inspection;Fabibe.to remove
earl hicturdar,aircot dor,definedby tM1 Ry Area Air Quality Nang mcnl
Dimd,t, - all new materials for inspection._Applicaitt understands and will comply with
6 Yes ' - . ON. all
non-point source'regulations.
I have mad the hudado.,mate Is requirements und< Chapter fi 95 of the
California
Health&Safety Cad Sections 2-5505 255)3 and 25534. understand that
iftea building does c tlytr at t tett tYresponsibilityt Quay the
occupantorthp requiremem<wtisF semi be met prior toissuance fa
-
Cenifficaue of
°"Cope°"`Y' t - Signature of Applicant __ _. Date
Owner or aamonzee agent - Date, All roof coverings to be Class"B" or better'
OFFICE