02110122 CITY OF CUPERTINO
BUILDING[)]VISION PERMITCONTRACTOR INFORMATION:
4
BuIQ) PsGLENVIEW AV JUST WATER HEATERS INC PERMITN®2110122
GW[NIFERAJA KARNALA 1764 NATIONAL AVE APPLICATI.NIS11D UY2002
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IFZONE: (510) 293-9901 SANITARY NO./ / CONTROL NO,
ARCIIITECT/ENGINIiHR: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
0
X00 LICENSED CONTRACT'OR'S DECLARATIONp
I hereby affrm that l am licensed trod,previsions of Chapter Y(commencing REPLACE WATER J�AefS�T [iOn
with Sullen 7flXXE of Division 3 of um Businessand Professions Code,and my licensc is
y in fall how add effect. (50
LON GAS)
ZaIccnscClass Lic11Ot2Dam Contractor NHLE
®
aaPm ARCHITECT'S DECLARATION
'C� 1 understand my plans shall dcbe used as public records DEC
2002
'apwV 0 5
rxii3ar Licensed Pnssinnal
OWNER-BUILDER DECLARATION
g�y I hereby.(fere that 1. exempt from the fermis ns Co Licence Law far the 1
a6po which followingreason.a.permit
71131.5, t.alters and improve.
demolish,
Any city teounty
rem BUILDING 892
whleM1 requires a permit m nmstruct,alter,improve demolish,nr epulr any s¢ucwre
F�vy+
prior o its issuance,also requires the applicant hasuch arrouto life u signed statement
SSma
that he is licensed pursuant 3691otheprevisions(iftheContractor'sLicenselaw(Chapter9 Sq. 1 Floor Area Valuation
y+Fnt (commencing with SectionRlfO)ofDivision3oftheBusinessandProfessionsCode)or 1027 . 00
]hut he is exempt therefrom and Ne basis for the alleged exemption.Any violation of
Section RU 1.5 by any applicant for a Permit subjects the applicant m a civil penalty of APN Number Occupancy Type
ae more Nan five handed dollars(SSW). 502 - FINAL PLUMBING ENERGY
1,as owner of the pmpedy,re is employees with wages as their sole compensation,
will do Professions
and the he Contractors
tended License
offered does
apply 8144,Business e��y� j�y�p
and Professions Code:The Conuactnr's Liccn:c Law docs nnl apply m an owner of 5 0 7 - F INAL L Nffv '1 cact)ons
property who builds or improves thereon,and who does such work himself or through his
n employees,provided that such improvements am not immuded aroRered for sale.If.
however.fee building or improvement is sold within one year of completion.the owner.
builder will have the burden of proving that he did not Mild or improve for purpose of
salt.).
I,as owner of the prolixity,am exclusively contracting with licensed cnmfactors on
cnnsuucl the project(Sec.71144,Business and Professions Codeq The Contractor's Li-
cense Law does not apply to an care,of property who Milds or improve,thxenn,sad
who contracts for such projects with a contracuu(0 liecared rumored to the Contractor s
License Law.
0 1 am exempt under Sec. .B&P C for this moon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a CerliEcem of Consent o self-insure for Worker's Compere
amino,as provided for by Section 3700 of Nc labor Cute,for the ficifmmance of the
work for which this permit is issued.
I have and will maintain Workers Compensation Insurance,as required by Section
37(X1 of Ne Leber Qxde,far the re fmarnm a of the work for which this Permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Curtner: Policy No.:
CER'T'IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nm M complemd if Ik permit is for one hundred dollars(glial)
less.)
T cenify Nat in the performance of the work for which this Permit is issued.I shall not
employ any parson in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenifcam of Exemption,you should
become subject ua the Worker's Compensation provisions of the labor Code,you must
OO forthwith comply with such provisions Or Permit shal l M deemed evoked.
z CONSTRUCTION LENDING AGENCY
[-t .N. I hereby drum Nat Nese is a construction lending agency or the performance of
rt i the work far which this Permit is issued(Sec.3017,Co.C.)
GA Lcndcr's Name (Y1
z lundcr's Address r ✓'1
U 0 1 cenify that 1 have read this application and Stam that the above orma ra ion is
1,, F correct.I agree to comply with all city and county ordinances and Stam laws elating to
O U building construction,and herchyamhomc repeecatatives of this city tocnmr upon the
above-mentioned property for inspection purposes.
a
(We)agree to Save,indemnify and keep harmless the City of Cupertino against
y liaemnse,romemcnq co odic,ex penscs which mayin any way ammc againstsoil City
U zhis pi
APPLICANTCUNDERSTANDS of IAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaoYConwnor [)am
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicam or fumre Wilding Occupant store or handle hamldous maerixl
as defined by the Cupertino Municipal Code,Chapter 9.12,and the health and Safety
code Seefon 255321x)1 All roofs shall be inspected prior to an roofing material being Installed.
❑ra ❑No
P P Y g g
Will the applicant or future building Occcupantuse equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
mit hazardous air comamiwnls as defined by the Bay Arca Ail Quality Management all new materials for inspection.
Distnet?
❑Yes 0 N
I have read the hatsudous materials equircmcnts under Chapmr 6.'15 of the Calilim
non 11.16A,Sadly Code,Sections 25505,25533 and 25534.1 undersand that if the building
docs not currently have a tenant,that it is my responsibility to nobly the account of the
requirements which must he met prior to issuance of a Certificate of Q:cupancy. Signature of Applicant Date
Owner or authorized agent Dam All roof coverings to be Class"B" or better