01050085 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS PERMIT NO.
18315 CHELMSFORD DR JUST WATER HEATERS INC 01.050085
OWNIR'S NAME: APPLICATION SUB DATE
AKA GARY 1764 NATIONAL AVE 05/09/2001
HONE: SANITARY NO. CONTROL NO,
(510)293-9901—
QCmCZ ARCHITECT/ENGINEF,R: BUILDING PERMIT INFO
t2 w— BLIIG ELECT PLUMB MCCH
v i of
H L LICENSED CONTRACTOR'S DECLARATION - Job Description
p 2_p I lac chy ulina than I fon licensed..,for Provision,of Chapter 9(aemn"m in,
s. with Scctkm7000)of Divisionlofthe HueinevanJ Pmfessi...Code.andmylicensc -
in fill force and effect
.
L`ieen,e Cm,, LIc.N REPLACE 50 GALLON GAS. WATER HEATER.
y 3`a N Dano Cmm�ctm
ARCINFEC'I"S DECLARATION
(_
0. 1 understand my Plans shall be used us Public recnnlx
u Z p Licensed Podecsinnd
OWNER-BUILDER DECLARATION -
I hereby aflirin tout I um exempt 1) it the Contmnar's Licennu Luw fnr the
F¢ inhaling nasnn.(Sooting 70315.Rosales,and Pndessinns Code Any city or county
,F M which requim .
v a Permit In con%ame :dlcr,improve dcmNish,or repair any,immure
a, pontoons ismance.also requires the applicant for such pemniuofilea,i,nedamenvort -
that he is licensed pursuant to the Provision,ofine Contractors License Law(Chapter 9 Sq. Ft. Floor Area Valuation
(fon cin,wish Seeiun 700(pufDo,kon3of the Bit......and Pmfn.I".,Code)
or tom i,exempt therefrom cad the basis for the alleged eaemption.Any violation $831
of Sectio 70315 by any applicant for a pemdt subjects the applicant to a civil penally
It not nonan than five handled doll..,(ssw). APN Number Occupancy Type
❑Ln,owner of mo pmpeny.or my etty,loyer_,lab wage-to then olo.mnpea,mian. 3752201!7,: 'IPI
will do the work,and the structure i,not intended or offered for sale(Sec.70,Ls. ..
Business cad Prafeuian,Cada:The Coatmanr,License Law doe,no,:,poly tI an Required Inspections
ow r or property Who builds or imes provdivorce,tend who does such work himself
r through his ren employers.pmv,ded that such improvements an not intended or 502. — FINAL PLUMBING ENERGY
offered for ode.If,however,the building lir bnpmvmnem is sold within line yen.of
Impletion,the owner-builder will have the burden f proving that he did not build or 506 — GAS TEST
io
mprn,e for Fortino nrmle.). 507 — 'FINAL PLUMBING
0 L as owner of the property,am inclusively ematmeting with licensed am,m mita m
et the pmjem in
(Sol.7014.Bmce,and Pmfc,sio I,CaIcJ The Contractor'I
Lnsmiean,a law does not apply to an owner of property who builds(or improves thereon,
and who comfort,fill such Innjcn,with a m una,em s)licensed pmuam to the
Cnnr ers License law. \/
❑1 aam exempt antler sec. .R&PC Ratio,reason 1V\
Owner Date
WORKER'S COMPENSATION DECLARATION O�
1 hereby affirm under penalty of perjury one of the following declarations:
t7 I one and will maintain a Cenifieure of Consent to self-if,me for Worker's
Compensation, as provided for by Section 37M of the Labor Code, fnr the
,erfnmruhce of the work for Is lot,[,This punnil is need.
01 hove and will maintain Worker's Cnmpcnsa,ion Insurance,as required by Scsr)on
3700 IdIhe Lul,or Ced ,tis the pifnrmance of the..,it fnr which this permit is -
,sued.My W Re,,0movenaation Insurance currier and Policy number are:
Carrier: 'Policy No.:
CERTIFICATION 017 EXEMPTION FROM WORKERS'
L'OMPEN'SAI ION INSURANCE , '
(This ref,ort need n i is mmplcted if the per nit is io Inc hundred dollars
f$10)orless.) -
I con,,lin in the Pcrfounurec al'the .,it For which this permit h issued.I
,hall not employ any person in any manner so as to became subject to the Workers
Compen%rao.Law,of Cnlifomia.Data
Applicant
NOTICE TO APPLICANT:IL suer making this certifieme of Exenption,you should
bnnesubjen wthe Worker,Cnmpense, so
a prolkionf Ibe Labor Cndc,you must
O 0eforthwith comply with such im visinns or this Pont shall M deenned mocked.
z .
CONS'TRUCT'ION LENDING landing
AGENCY
a (hereby affirm that there isaamw (So,. lending agency for the pefunnance .
U Beth,wank tar whish Iii,Format is is,tad(Sm.9097,Co,,C.)
0. Q bender's Name ,
tJ z Ixnder'.v Address '
U O 1 cenify that 1 have read this application and%late that the above info.mmbn is
�. tw correct,I ugreo it)cotnply with all city and conany....nm,acs and Beam laws mining
O V rebuilding conswclion.and hereby amimia.epresenutives ofthis city to enter open
y z the abuwmendnned property fnr in,pecGon ii-f-Iv.
F., p. 0`10agree,to save.indemnify and keep hamnles,the City of Cupertino against
U (Z) liabilities,judgments,cost and cepenses which may in any way accrue against said ,
Citymclow,-ossuf rbc grutningof this Fanta. .
^n APPLICANT UNDERSTANDS AND WILL COMPLY Wn'H ALL NON-POINT
SOURCE REGULATIONS. Issued by: Date
Signature or Applican/Contmcrer Date Re-roofs
I[AZAR DOUS MA'I ER IALS DISCLOS U RE '
Will the applicant ar lame buildingWeapon, ,an,lir handle Invention,maerad Type of Roof
as defined by the Cupertino Municipal Gid,Come,9.12,and the Health and Safety
Cuda Section 25532(u)7
oye, oNo i All roofs shall be inspected prior to any roofing material being installed.
will the uppllcont or future building occupant use equipment or devices which If a roof is installed without first obtainingan inspection, I agree to remove
mit hilarious air contaminant as defined by the Bay Area Ai.Quality Management P g
'nithilariousall new materials for inspection. Applicant understands and will comply with
°Yc, 11 No
all non-point source regulations.
I have read the hamrdous materials requirements under Chapter 6.95 of me
Califamia Health&Safety Code.Seeing,25505,25533 and 25530.1 undersand that
if the bn'ddin,doe,not emocatly,bavn a ani-,m.,ha,it is my ,rc,pon,ibiiry w notify the
occupant of the requirements which mus,be met prior to issuable of a Certificate or '
Occupancy. Signature of Applicant Date
Dwnmmnammired a,mn Date All roof coverings to be Class "B"or better -
OFFICE