02100112CITY OF CUPERTINO
Al, im'
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:,
BUIIl)6(&1)I)RM11LKY WY
JUST WATER HEATERS INC
PERMIIN®2100112
DWdBILSABACK JENNIFER M AND RUSSE
L1764 NATIONAL AVE
APPLB`N1TVY`T!91 2002
40NE:
S l0 2 93 — 9 9 01
SANITARY NO. CONTROL NO.
ARCIIITfiC7TlENGINEIiR:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
0 0 0 0
LICENSED CONIRACTOR;S DECLARATION
I hereby after 'her 1 am licensed under pron,bitaor Chart, 9 lcnmmencingREPLACE
WATER PA 1rFtion
with Section 71gIB of Division 3 of the Business and Profession e, Gnand my license is
in leluoeraodeBccl.
(50 GALLON GAS) FINALED
License Class Lic. p
Dale Contractor
ARCI IITT;CI'S DECLARATION
1 my shall he used as records
r%003
ppR 1 5 L
understand plans public
I-munmd Prule,amal
OWNER BUILDER DECLARATION
1 hereby affirm that 1 a exempt from the Contractors License law for tbe
BUILDING
following reason. (Section 7831.5. auxins and Professions Cdde: Any city or county
which requires a Peron or enn.ances. alter, improve, demolish, mer repair any grimmry
$900
prior u) its issuance, also requires the applicant for such permit o Glc a signed statement
Sq. Ft. Floor Area
Valuation
that he is licensed purtnunI to the provisions 9f the Contraii Lice Bac Law (Chapter 9
(commencing with Section 7001) of Division 3 of the Business and Prolevuions Code)or
36219001.00
Nal he is exempt dtetefrom and the hnls for the alleged exemption. Any violation of
APN Number Occupancy Type
Section 7131.5 by any applicant for a Permit subjects the applicant to a civil Penalty of
not more than five hundred dollars aBgB.
502 - FINAL PLUMBI G ENERGY
Lnowner of the pmperry. ser my emPloyms with wages a[their sole compersvlion,
will do the work, and the swarm is not intended or offered for sale (Sec. 7(144, Business
and Professions Code: The Contractor's License law discs not apply to an owner of
INAL ffiffff6iqections
507 - FINAL
property who builds or improves thereon, and who deessuch work himself ordmough his
Own employees, provided that such improvements are not intended or offered for sale. If.
however, the building or improvement is rald within one year of completion, the owner-
builder will have the burden of proving Nat he did not build or improve for purpose of
sale).
I] h as owner Of the p opedy, am exclusively cuntracung with licensed contractors In
consumer the project (Sec. 7014, Business and Professions Code:)The Contractor's Li-
cense law docs not apply to an owner of property who builds or improves Iheteon, and
who contracts for such projects with a Coolant licensed pursuant o the Contractors
License Law.
1 am exempt under Sec. . B & PC for this critical
Owner Dat
WORKER :S COMPENSATION DECLARATION
1 herchy action under Penally of perjury one of the following dcclaratintls:
I ]have and will maintain a Certilicale of Consent o self-ihtsnre for Worker's Compere
cation. n provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, res required by Section
3711() of the labor Code, for the Performance of Ne work for which this Permit is issued.
j
My Workers Compensation Insurance Cartier and Policy number am:
Cartier: Pugh, No.:
CERTIFICATE OF E%EMPr10N FROM WORKERS'
COMPENSATION INSURANCE
(his suction Decd om becompleted done permit n for one hundred dollart (SRp)
or less)
I Modify that in the performance of the work for which this permit is issued, I shall not
employ any pe Orion in any manner so as u) become subject n the WorkersCompensation
Laws Of Call no. Dale
Applicant
NOTICE TO APPLICANT: I. after making this Cer iticate pf Exemption, you should
been concoct to the Worker's Compensation provision rat the Labor Code you must
forthwith comply with such powninns or this permit shall be deemed revoked.
CONS rRUCI'[ON LENDING AG17NCY
1 hereby anion that more is a contraction lending agency for the performance of
the work fur which this Permit is issued (Sec. 381 Civ. C.)
lends,',
n
Lender's Add. Address
I certify Nal I have read this applicroor and suite that the above intimation is
correct. I agree to comply with all city and county ordinances and scale laws relating to
Wilding COT%Lox ion, and hereby authorise mpmwnLatiWS of this city to enter upon the
ohnvementioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities. judgments, costs and expenses which may in any way accom against said City
in consequence of the graining of this permi t.
APPLICANT UNDERSTANDS AND WILL COMPLY WITII At.[, NON-POINT
Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Type Roof
Signature Ofnpplicarm untractnr Date
I IAZARDOUS MATERIALS DISCLOSURE
of
Will the applicant or future building neca,mi .sore of handle m.dous material
as defined by the Criterion Municipal Code. Chapter 9.12, and the health and Safety
;
code, Salic 25532107
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes ❑No
`_ If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant orfuture building Occupant 9.uewiin entordevia,which
not haeuNous air contaminants as defined by the Ila, Arca Air Quality Management
all new materials for inspection.
District!
Dyes C] No
1 have read the hesaNnus materials requirements under Chapter h95 of thc Califor-
nia Health & SafetyCdC, Section 2.5.505,25533 and 255:50.1 understand that ifthe building
Itienot Currently hive a cement, than it Is my responsibility Ill notify tic Occupant of the
recommentawhich mug hemet poor to owners, ofaCemficaeofaiuPan`�y
Signature of Applicant Date
- ' All roof coverings to be Class "B" or better
comer or authodxed agent Dae