01050174 (2) CI HUoFUDN
PERTNO
tN O - 'PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.,
"aHUNTERSTON GL -JUST WATER HEATERS. INC. 010501.7_4, •-,
r OWNER'S NAME I APPLICATION SUB DATE
1764 . NAT'J,,OIsIAL•sAVE;e
PHONE: SANITARY NO. CONTROL NO.
p z Z ARCHITECT/ENGINE.ER: BUILDING PERMIT INFO
(�Om OOC BLDG ELECT PLUMB MECH
yZLL 1=1 I� IJ 1�
Z S y Z, LICENSED CONTRACTOR'S DECLARATION Job Description ,
O Z O I lncruby.Ifnn tom I.m licensed a id........to.,of Chapter 9(cammencing
l,y.Fw with Sadon 10ad fD,.odb3.fine Business sad Professions C.dyandmy live d -
3 u. is in full force and direct.
Sw a Lianacm.. ra -,REPLACE:: 40,r'GALLON,;,WATER;�:HEA,rER. fr
a U Dane Contractor
ARCHI'NS71"S DECLARATION
or C 0 Ivndersmnd my.Ions shall be used as public records -
�A G��fNAL Mo
L
OWNER GUILDER DECLARATION
m'u. I hereby d m Ilial 1 eml t farm tl Contractor',L L draft, - -
I"ZQ fold , (Section 7031.5Biomass and Professor,C,AAn,ad,or county ���
F ❑ which q. a p I t a Ile p de li I r pair m
y mewrc 18 2001
3� pr t .I y n applicant f h Parini[ fl signed 6 d st tement
thI h fwanted n t 1.toprav,ohn,ofh Ciournalm,Lwanse L (Chapter9 Sq. Ft. Floor Area - Valuation
(enmmencin,with Section 9000)of Doo.vine 3 of Inc Business and Profess o ns Cale)or mm he Is astran duration,and We basis for the alleged exemption.Any violation 01 Ruff _
of Soc ion 71131,5 by any appl loam fora permit subjects Ibc applicant too civil penalty
fit., m I d a dollars tS5a0 APN Number Occupancy Type'
111,a o r l he property,or my ani Y ith wages as(bear sI 1 savor, M222032
will do the k I the structuret intended or offered f (Sec.9044, - -'
Business und Professions Code.The Complaint's License Law doest apply t.an , Required Inspections
owner fp pnyWn builds thereon, d h d :: h work himself
or t gh h. pfd that h huprodenients are nott dee
or 502 j'F&NIAL-rPLWMB1NG. ENER{3Ybv1-
offered for sale.lir lardweb,the building or intpm.claim i,.ala within one y,r of
completion,merwnerwdd,r will have me bamenaf pronto,that he did am build ar 506 — GAS. :TEST.
improve Gupurpnse of sale.).
❑L.sowneronneproperty,amexclusively contracting with licensed commrm..m 5,07-'._—tE.T-NAL.GLUMBI;NG• r
construct the project(Sec.7044,Business and Professions Code:)The Contractor's
License Law docs not apply to an owner of property who NIHCU or improves thereon,
andwho compacts for such projeem with a contractors) licensed pursuant to the
Centmemrs License Law.
C,I in,exempt under Sm. ,B&P C for this reason` ,
Owner - Data
WORKER'S COMPENSATION DECLARA9'ION
I hereby alliin under penalty of pajary one of the following declarations:
❑ 1 have and will maintain a Cenifcate of Consent m self-insure fm.Worker's
Coaapensaton, to provided far by Section 3700 of the Labor Code, for he
performance ill the work baredual,this permit is ,,.ad,
01 have and will maintain Worker's Compenxaach Insurance,as required by Section
3900 of the Lah a Code,for the pat blame.1 he work far which this Fermin is
,sued,My Workers Compensation Insurance carrier and Policy hander er are:
Carrier Policy Na:
CERTIFICATION OF EXEMPPION FROM WORKERS'
COMPENSATION INSURANCE _
(thi.section need not he completed if the permit is forme hundred dollars c -
($Ilq)orlessJ
,1 certify that in the performance of the work for which Ihis permit is issued,I '
shall not laundry any person in any manner so as to becomesubjecl to the Workers
Companmtinn Lows of California.Data _
Applicant -
NOTICE TO APPLICANT:If,atter neklng this CenlEeme of Exemption. ...should
Fecosu
mebjecuns
n the Workers Cnmpeminn Nrokiremol be Lahm Ccac,yrounin
Q Q forthwith comply with such provisions or this perandd 01 be deemed revoked,
Z r
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them W isennednSce. lending agency for the perfirtmana of the work fm which his.,mutt iss:sued(Sec.3119],Civ.C.)
A lender's Name
Leader',Add, xs _
V Q Irerifyflm l have dead this application and xhrm thus lheubole information is
GL [~a worn.I agree to comply with all city and county ordinances and state laws relating
Q V to building construction,and hereby actio.:ze representatives of this city m enter apron '
the onov>mentiooed propany for inspection purposes.
(We)agree to save,indemnify and keep hararess the City of Cupertino against -
N h
liabilities,judgments,costs and expenses which tinny in any way„arae against said
U Z _Clly m omam der/olid im ming of this par it - -'
'+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b Date
SOURCE REGULATIONS. y'
Signature of AppftcamfCommmer Date Re,roofs "
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or f tune indent,cecnpart store or handle hazardous material Type of Roof
as defined by the Caperhum Municipal Code,Chapter 9.12,and the Heakh and Safety
Code,Search 25532m)? '
0 Ye` - [I No All roofs shall be inspected prior to any roofing material being installed:
Will the applicant or from,building rampart use egmpnlent or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hazardous par containments as defined by the Bay Area Air Quality Management
Didn't? all new materials for inspection. Applicant understands and will comply with .
❑Yea '❑No all non-point source regulations.
I have read the hnzanlo is mmcn.Is requiremmhts under Chapter 5.95 of the
California Health&Safcry Chre.Secdnrt 25505.25533 and 2553E I understand that
11'the building does hum andaully haver¢rant,that It is my resprnsdality to nnlfy the -
occupant of the requirements which most IN,met prior to issuaneeofa Cenificme of
Occupancy,
Signature of Applicant - Date
Oscar,or o.d,odeed agrnt Dale _ All roof coverings to be Class `B" or better -
OFFICE