03090205CITY OF CUPERTINO�
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BUILDING DTvlslory PERMIT
��N�RAC" ThR INFOXtMA'TION-
C�
BUmDING ADDRESS:
JUST WATER HEATERS INC
PERMITNO.03090205
OWNER'S NAME:
1764 NATIONAL AVE
PERMIT ISSUE DATE
SMITH DONALD W AND BERTHA M
TR
09/24/2003
NE
(510) 293-9901
SANITARY NO, CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERM IT INFO
BLDG ELECT PLUMB MECH
o 0 0
LICENSEDCONTRACTORSDECLARATION
I hereby Lm Chapter 9
lob Description
affirm that 1 am licensed under provisions of
that I under (commencing�B
with Section of Division 3af me Business and Profcaaieu Code, and my license is
F11Y w LE®
In ndri
REPLACE WATER HEATER ems»
w.C1skndarfe0.
Licence Clens Lic. #
Dam Contactor
(4 0 GALLON GAS)
ARCHITECTS DECLARATION
NODI 1 0 2003
1 understand my plana.hall bo mud as public records
B�'ar45aIL\�
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 exempt from Nc Contractor's License Law for the
. :
reason. (Section ] 1. Business and ore Co de: Any city or wooly
which requires a
whfolich re construct, ve de
aIle[ improve, demolish, or repair any ammnmm
carps
e. aul ora
prior to its censnec,alsort to the the applicant for such petor's fir ssigned nammem
the
of the Law
that he islicensedwdparsuant7")of
Sq, Ft. Floor Area
ValUati0$645
eBusinmfandProe
]00d of Divisionr or ssors Code) or
(commencing with Division Calc) or
exeandon.
mf� me alleged
Net he is exempt Nsrt(rom and IM buil for Ne alleged exemption. Any vielatian of
Any
- - 3 AM MY Ser 0 0
QCCU Type
ParaC Y-
Section ]031.5 by any applicator for a permit subjects the applicant to a civil penalty of
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not more Nan five hundred dollar (g500).
-- -
❑ 1, as owner of the property, or my employees with wages as their tole eampensidon,
cLftRGY
will do the work. and the swmmrt is not intended at offered for sale (Sec. 7014, Business
and Professions Code: The Contractor's License Law dor# not apply to an owner of
property who builds or improves thereon, and whodoes such work himself orthrough his
502 - FINAL YL' Ik31 N'G
own employers. provided that such improvements are not intended oroffered for ole. If.
506 — GAS TEST
however, the building or improvement is sold within one year of completion, the answer -
builder will have ti¢ burden of proving but he did not Wild at improve for purpose of
507 — FINAL PLUMBING
ss[a.).
0 1, as owner of the progeny, am exclusively contracting with licensed centimeters in
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construct the project (Sec. 7044, Business and Professions Cade:) The Canmacter's Li
cense Law does not apply to an owner of progeny who Wilds or improvu theater, and
who contracts for such projects with a cormactof(s) IicenYd pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. B & P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 thereby M. under penalty of perjury ore of Ne following dacla t ti u:
1 haw and will maintain a Cenifcam of Consent o sol f-insum for Worker'sCompen-
tion: M provided for by Section 3700 of the Labor Code, fm Ne performance of the
work for which this permit is issued.
❑ I haw and will maintain Worker's Compensation Insurance, u required by Section
3]00 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mcu.seclion need mat W completed irlbe lermit is fromm hundred dollars ($10D)
or less.)
I comfy that in Nc performance of me work for which this Permit is issued, I shall and
employ any person in any manner toss to become subject to be Workers' Compensation
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of me Labor Code, you must
forthwith comply with such provisions or this Permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 heathy aRnn that there is a construction lending ageay rot the Performance of
me work for which Nu permit is issued (Sec. 3097, Civ. C.)
LenticYI NameLemica's
n
Add.
I .neat I haw read this application and nam char the show imistinn is
carmtt I agreee to comply with all city and county ordinances and care laws b
r upon
and herebymateriaereoreunaliws of this city bcarerulna Um
alerva-mentioned
above-mentioned property forimnify an
lumpy.
to saw City ity
agree co taw, indemnify and keep harmless
w m against s id
nju expresses; which may in any wets aeruc against said City
Iiaconsequenc
ofgreeting of
of thegranting SA Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
A APPLICANT
Issued by: Date
SOURCE REGULATIONS,
Re -roofs
Sig.... or ApplicaRDam
US MATE RIALS DISCLOSURE
HAZARDOUS
Type of Roof
Will the or forum Wilding occupant rare m handle an material
Health
u defined by the Cupertino Municiptl Code. Chapter 9.I7. and the Health and Safety
a Cupertino
out. Section 25533(.)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yea ON.
If a roof is installed without first obtaining an inspection, I agree to remove
Will me applicant or rulue Wilding occupant use equipment or devices which
It haa#Nous air contaminants as dchmal by the Bay Area Air Quality Managcmcnc
all new materials for inspection. e
smict?
DYcs ON.
- v{
Y
imal7MunderChepmr6.95 of the Califon.
1have afet Kele, SN,nsma5505,
53 ifthe Wilding
ria Realmo Safety Code. Sections,25505,it
myrspons534.l. rodimMe
dao cat cunencly have a mnanl Nn il'u my responsibility m notify the ¢cuPut of the
mquinements which must W met prior b inusnee or a Ccalrnam oroccupaney.
Signature of Applicant Date -
All roof coverings to be Class "B" or better
Owneroraumon,edagent
mm
t
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%-(ty or Cupertino tsunuiny rermit Appiicarion
E -Mail
jobsite Address: 10396 Anson Ave.
Owner's Name: ---Smith Donald
Phone No.(408)255-1795
APN#: 326-41-054
Building Permit Info: Bldg -----------
Date: 9-24-03
Project Valuation: S 645.00
Job Description
Replace 40 gallon gas water heater.
Contractor Information
Company: just Water Heaters Inc. Phone: (510)293-2012
Contact Name: Dulce Fax: (510)293-2022
Address: 1764 National Ave. E-mail: permits®justwaterheaters.net
City, State and Zip: Hayward, CA. 94545
State Contractor's License # 591 329 Exp. Date: 3/31/04
Worker's Comp#: 1626288-03 Carrier: State Compensation Insurance Fund Exp. Date: 4/l/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679
Name on Card: Just Water Heaters Inc. # Z 3 ZS�
Expiration Date: 9/05
Visa ❑ MasterCard X b
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