02080085 (2) ,:CITY OF CUPERTINO
BUILDING DIVISION •PERMIT CONTRACTOR INFORMATION:
BUILDING ADDR S' PERMIT NO.
10511 LRRY WY JUST WATER HEATERS INC 02080085
�7 HAROLD M AND DOLORES M1764 NATIONAL AVE APPLIC8W7s MtY002
PHONE: - SANRARY NO, CONTROL NO.
(510) 293-9901'
z Z ARCHITECDENGINEER: •• BUILDING PERMIT INFO -
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Job pp P[ion
��zol Ihereby af�rmthat lamlicensed under provisions ofChapter 9(commencing REPLACE WATER HEATE�CrI
F_t with Section]000)of Division 3 of the Business and Professions Code,and my license
la,y is in full forceml effect. _
.°'i.� Licenu Class Lic.x
tDatelr'.r, Churl
"13 00 :'Yr 4 "+ ARCHITECT'S DECLARATION.
•1 understand my plans shall be used as public records
p'p Licensed Professmwl
OWNER-BUILDERmptfrom
DECLARATION
r+�1 m _. 1 hc¢by affirm that 1 1. exempt from tM Criminal's Co License taw five rhe
�C?z0followingmaven(Section 1 ]onstru Business and Profession Code:My city structure $670
COs which tequr es o Permit r construct.alter,Improve,demolish or rtpau any swcture
3� ',pot t tsuantt lortq th applicant for such permiuo flees gned scot t - -- ---- -- - - -- ----
p yeti,, ....... .-_....
Pubbeslen"dp'rtuuM t61h pmvivanx of the ConuacmrsLicenm LeW(Ghpier9 .,,f. 1�.._z3164270X1bQ10Veas4 h`I Valuation
'ch
c mmenc swith S'cr,gn]000)°1 Drvrs an7of the Business and Prpfeesion Code) Y Ir 'Y::^, , ;l l_)`I,+'
or that he is exempt shcrefrom and the baso far the alleged excmptioA.Any lot'too
rof
"and
4031.5 by any applicant for a pcnnir mbjecss rhe epplicam m e civil peruhy
or am reore than five honoree em�ars(ssIXB. 502 APNBYINAlEr PLUMBING ENERGY Occupancy Type
0
1,as owner of the Moperry,or my employee:with verge:ntheir son compemotion. 506 - GAS TEST
will do workend rhe swcmrc is nor imm�ded'or°RemJ for sale(Sec:]DGI,"
Busamess'uaJ Professions Code:The Commemr's License Law aces nm apply to an 5 — FINAL P nspectioils-
., owner of progeny Who builds or improves ihcrton,antl who does such work himself
through'is
own pl ya proviJ 1 th t s h p m m re not intended or .: .
efferan or
sale
IL B' r the tiudd g .. p vemem Id with n one Year of ...•...._. .. . .._ , .._._ -- ---, ... ...---. .
o completion the ownerbutlder will have the buNen of proving tha he aid not Wild or
impulsive for purpose of mle.lC ^
._..._..._._._Mope Y .-......_exclusively_ _. gwi ....- __ _Ir�.1��1�1�16�..._.......__.._'.....__. ._...... ...... ..........._ ._____ .._.
co 1,us owner of rhe n,am Businsscontracting with licensee Contracts r actor a
newel Lathew
project(Sm. to a Busies end enyProWho
ho b Code 1 The improves
unclear, rl ,
License low does f apply man owner of groped who) Ids or d,prnva thereon. ...AU.G-2. 7..2002. .
%and C.rir4ho contracts for such:Protects.with a<onwcmrfs).bceasca.pursuanuo the .._ .._.__._..._..� .., _. _
`.Citi ctt'a Liccrle La _ .. _.. .._ ... . ___ .f1 .,.II.
O f am a crept under See,t B&P C fur+h s reason
bale's; Data BUILDING
WORKER'S COMPENSATION DECLARATION
nv l hereby affirm under penalty of perjury one of rhe following dechrauons:
5. OsI IW16'end will inamoon ViaCertificate of Consent to self-inure for Worker's
C rfnpenaatlon, use,provided for by Section 3]00 of the Labor Code, for the
pp col iznce of ilia wmk for which this permit is issued_ '
111 have and wiif mituros a Worker's Compensation It..are,as requimd by Section
3]00'of the Lubor'Cak%for the performance of the work for which this permit is
issued.My W6rkela Coaileron,ion lnsumnce comer end Poljcy number
of i "r a .. . ., ...-.-
Ce PubcY No: . .. ..
3CERTIPICAnON OF,E'Elvhn ON PROM W.RKBRS_y �y.v. f„
SOMPENSATIONINSGRANCE
1
to t_(Tfi s met tin need not be completed if the permit is for one hundred dollars
(81001 o�IeoJ ,,
p 1'clonythmiallue,serforcurnme.of the work for where the permu a
shall not employ any person m any manner m as to become sobject to rbc Workeri
s
Compensation Iowa of California,Data '
..
Alpli&m
OTU
NOTICETO APPLICANT.
OAPPLICANT:IL after making they Certificate of Exemption,you should
become su Ocomply
the Wo pr Compvn err , p visions of the bur Cale,you must Q •forth tl c imp plyy with such provisions or garcon shall b deemed revoked
r"-I• 't1 '' �'N CONSTRUCTION LENDING AGENCY u
��ai r the
' the k for-which tthhisnpermit cosedt cu.I1ndCi,agCenc)
Leder Name 4 . _.' ..—- ... --
Lenders
Address, - - l7/bJ`n(/,�'l/ •, �-
V"� �' I cenify"a"I base read this application and sate tbut the above information is
W.i F.r tames.1 agree m nrmply with ull cite and county ordimu ces and sum Iowa relating
0•U mtiuiI'm car ro"ion;and herebya authorize representatives of this eity,to corer upon
�+;rW ' the. tae mentioned pinged for inspection purposes.
" .(We)agracrosave.iMemnify and keep harmless the City of Cuperii;against
rp liabilities,judgments,costs and expenses which may in any way occme agi rst said
> 6,7}Z City in consequence mshe gmming of this permit.'
APPLICANT UNDERSTANDS AND WILI,COMPLY WITH ALL NO•Y-POINT
SOURCE REGULATIONSIssuedb t
ZSUDate
Signature pr Applicant/Contractor;•;,, \Dote' Re-roofs
as def ed b t "HAZARDOUS MATERIALS DISCLOSURE
„)
Will the app] ant rfutu¢h,ildiga p ,score banJl<haraN us men Type of Roof -
y he Cupertino Municipal CoJ Ch par 9,12 and the Health and Safety - t
'cnae seroma zss3zfal )1 # x_'All roofs shall..be inspected( �rior to.an .roofing.material.being.in
OY. S ) ❑hos „ o. Jxt {, Yl Y 14. . Ap
. .. ..: prior y stalled.
iWill the applicant u fuer Wilding pant use cgmpremordnive which If a roof is installed:without first obtaining an inspection;I agree to%'re'move
arrin hiclardmi, it contaminants as defined by the Bay Area Air Quality Management
Damct all new materials for inspection.,,Applicant understands and will comply with
°Y ON. all non-point source regulations. „
- 1 have read the hzaa dom.muteLi, r q immani under Chspar 6.95 of the
CrilifnarmaFficalth&5 f ry Code,Sections 25505,25533 and 25534,1 understand that
', rhe Wildingof the
does not currently hich ro ,be rend is my rsuance bilary tetifi tat rhe --
6ecupint of,tie requircmen¢which must be met prior to issuance of a Certificate or � •
0 apan`Y Signature of Alicant _ _ Date
.. ,r � -, .r Dam.. . ..._ . ..,
`! owne mroantgdamage t All roof coverings to be Class B or.better
OFFICE
..-.... '. .... _. _. .. ... . ....._.._., _... . . .. ._ ._.