02020126 (2) CITY OF CUPERTINO;=. ,iyn `- •'
.PIALDINGnrvtSton�;;�'.,�. � PERMIT'-' 'CONTRACTOR.INFORMATION: _._ -._... . . .... _
d
-- BUILDING ADDRESS: •s,s-'.. •, PERMIT(i,'`-.•.
10833-:, NORTHFIELD SQ _JUST- WATER'_HEATERS `INC ' 02020126
�• OWNER'S NAME: ' - _ _ - -- - - - - - APPLICATION SUB DATE
< kATHERINE, WAGNER 1764 NATIONAL AVE ' 02/28/2002
PHONE: SANITARY NO. CONTROL NO.
(510) 293-9901
D O O ARCHITF.0(ENGINEER: ' - BUILDING PERMIT INFO
v_ - BLDG ELECT PLUMB MECH
I—I I-. L_J L_I
baa
v=Ni 2 LICENSED CONTRACTOR'S DECLARATION Job Description
1 must,affirm that I am licntscd under provisions of Chapter 9(commencing
?„ wdmsatmn7Boo)ofDiviamn3onheBu:messandP mssion,Code,andmylieen REPLACE 40 GALLON WATER HEATER
[m^; is in full fume and effort. -
z z< Lice Lie..a
O n V nate"a Class—' Commaor
ARCHITLCf'S DECLARATION'. .
,�� -'I unacmm�d my plans shall be uud es public rtcords
2n,y
i_ g o Licensed Prnlcssinnal .• -
1. n OWNER-BUILDER meC DECLARATION
o a 1 hereby affirm on 1 1. camp[ s an tM1e Cumrals Cas LiAny C Law for the
a,?0 following uimsa retaioI 7o3su Business arta ve,demolish.
Code:Any city or<ounry _ - •.structure $494
-
e' that e 1 nod rum to 9 dieProvisions or lh C mictorl Livens s awe(Cutemen[. - - -- - - -— -e'.3 which u r n consumer.At ve deg[ I ss l; le (Chat 9' ,�• Valnall011
t 9 � Bo mapplicanti .n repair r
(comma ing withwh en 7") f D tion 3 pan Bminet yw p;femtons aae)
of that he is exempt themfsorit and the basis for the allegeJ eaemptwri.Any violation
of Section 703 P.5 by any applicant for a permit subjects the appli cant a civil penalty- "
of mom than five bonarta atoms S5oo). . ' . =' :iPN 1Qccupancy Type
-- - • r • •. ....
- S0 - PLUMBING : BNERG ;. ,
OSI,as owner of Ne,mpcny,m my employees with.....as their sole compenmtion.
w,It do the work,'and the�suncmm is not inmribid m offered for side(Sev.70114.
Business and Profesnoo Code.no Commoor's License Li w.d.es not apply to an 5 0 7� - FINAL PE@ MjnU(gspections' " -
-� - owner of property Who builds or improves Ihet<on,and who docs such work himself -
or ored f h his own uw ove,<s,pmvldin that such improvements within
not intended or
- Jffema for awe.H.n.w<v<r,me Wilding �i.� tier a.la wnnin one - r'
g e improvement y<ld o
-
completion o h hlJ will hue to burden (P proving did to IJ or
sup I PuTo,o Ofsale.).
-
❑I s owner oftb pro,sor,p I. ly contracting withlicensed confusionto.
constrouct.h p j t(Sec.7044 Business and Professions Code:)The Contractor's
V� +
1-n L J t apply rpm) P P y uiltl p Ihrcon
rad.who c Vat f a 1 d p uam to.Ihe . . .. 1 ... .. . .. ..-
an uwnctr nr n n,n
- such ens with co tna r(s)
Coo [ Is U Icon Low. /
Q I pr der Sec ,B&P C I this rtason t
Owner D¢ '
}- WORKER'S COMPENSATION DECLARATION -
f) ' I hcrebr affirm ruder,pcnalty ofperjury on<of the following declarations:
❑ I have and rill maintain a Cedificute of Con¢tn to self-insun for Worker's `
Cma,mumien. as provided for by Section 3700 of the Labor Code, for me
_ pedomiantt of the work for which this permit is issued, ,
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Labor Cale,for the performance of the work for which'rhis pcmn,is -
issued.My Workers Compensation Insurance Inner and Policy num6ei are: '- _ - _ _ ---
,.,. ... e. ..•rY __ _
Cem '.'. PoIICYN . . -r.• I a t..r.
"CERTIFICATION OF,EXEMP IOY.FROM WORKERS ° t• ik -� kL. .. i lJ.. 1, ;-d s ,s h
' COMPENSATION INSURANCE" -a s'
.. - .. .I-.. .....-__r._ ...-a..._.
fie
(TI is sect nn'naJ not be co nplemJ done Permit is for one hundred J.Ilan
f '
(SIM)or less.)
_ v
.t I certify thal in the Performance or the work for which this permit is issued;I -
,hall not"ploy any person in any manner an as m become stiffest to the Workers
Applicant on Laws of California.Dam '
_ 'NOTICE TO APPLICANT:IL after making this Certificate of Exea,sidnyop should
p comply with provisions Comps o permit
of the Labor Cada you must
Z Wchwithc subject the Worker's Compensation permit
O forthwirh4om 1 th such or t shall be deemed revoked.
CONSTRUCTION LENDING AGENCY - - - -- - - - -
1 herthy afilrm that them is emastractiOn fending agency for the pc 8mmoncc
6Y' 'of th k for which m ,e 't' ii sued(Sec 3097,Cis C) '
�.Q Lenders Name`- - .t . -.. .. - .. .... . ...... . .. ..__ ... ..._. .. -. .. .. _.._.
LenBer's Addis. -
U' I ccnify that I have read this application and state that the above information is
mane,I agree t.comply with all city and county ordinances,and state lows relating
U rebuilding conswnion:and hereby eudlurim mpresentxtives oftioncity[center upon
rhe nbcmonW
ovemipmpcny for inspection purposes. s
y' (Wit)agree m save.indemnify and keep harmless the City or Cti'penino against
r V] liabilities,judgmenm,costs and expenses which may in tiny way accrue against said
U Z City in consequence of the granting of ibis permit ' '
^' APPLICANT UNDERSTANDS'AND WILL COMPLY WITH ALL NON POII.'f' IssUedb Date
SOURCE REGULATIONS. y'
Signature of AprucanUContraaor . ' , .Date.:.[..' Re-roofs
HAZARDOUS MATERIALS DISCLOSURL t
pJl Nc applicant orf m Wddmg.ec pant sort handl haiaNoutin fatal Type Of ROOF .- - '•
as defined by}he Cupertino Man cited Cad Chapter 9 13 and the Health d Safety
Crete:,sco oh 255RIe) I 'yx t'sy ( .r t .Y`' c. s \ tfl..., a ,-"g} , _ ..
❑Y a• 0N ('.. t .pll,roofs shall be inspected_pnor to.any.roofing material,being installed. . . . . ._.
Will the applicant or future building occupant use equipment or devices which' If a roof is installed without first obtaining an inspection,4 agree to remove
ems hnnrdous air conmminunts as defied by[ho Bay'Area Art Quality Management,
Dir I all new mate
t e' . mate. m_
.Ap
_ plicant understands,and will comply withnas ,
❑ all.n.on-po.re[sourcereg..ulations. . -
yas✓ I have read'the'hSnNoue mme'dals requ irements ronder'Chaptei 6.95 of the
Califomin Health'k Safety Code,Sections 25505,25533 and 25534.1 understand that
if the Wilding does not currently have a tenant.dim it is my responsibility to notify[he -
oecuptint of the requirements which mus.be met prior 1.issuance of n ??oleate of
a' ,Occupancy; •,..Ia
et. .. - Signature of Applicant Date .,
. Dat= All roof coverings to be Class"B+' or better'
Owner or Influent aeon.: •'
OFFICE