03110039 I CITY OF CUPERTINO3�
BUILDING DIVISION PRRMIT 7s„CONTRACTORSINFORMATIQN �
O UFLDING ADDRESS: JUST WATER HEATERS INCJ� PERMIT N003 110 03 9
OWNER'S NAME: 1764 NATIONAL AVE PERMITMUEDATB
E 11/07/2003
NE: (510) 293-9901 SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
30pp LICENSED CONTRACTOR'S DECLARATION O O O
u 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
�m with Section 7(1(10)of Division 3 of NC Businun and Pmfmaium Code.and my license is
fofull mmaand effect.
LicenseREPLACE WATER HEATER
e n Z Class,
J Dale Contract., (5 0 GALLON GAS)
e' ARCHITECTS DECLARATION
uncle Luc.X
e I understand my Plans dull he used Is public Tocords /
yn �j
5p
Licensed Professorial
OWNER BUILDER mDECLARATION
COO 1 hereby affirm I am exempt from the Contractor's License Law for the
COO fallowing meson(Semon 7W 1,5,lustiness and Profession Code:Any city or county
$ which
a Pomp to criminal.Act,I do rm repair my structure
poor mor issuance.also requires the applicmtfor
such permituto Ole aiguJ
statement ]1138
EE < that he is licensed puuuanmothcproviaionsofth,ContrazmrsUc,nselaw(Chapter 9 Sq. F[. Floor Area Valuat$)
(commencing with Section 7000)or Division 3 of the Buunss and Professions Coils)or
$ Net he Is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031,5 by any applicant for a permit subjects the Applicant o a civil penalty of 3 a,81%12Qikl4er00 Occupancy Type
not more than five hundred dollars($500).
❑I,asowna,afth.prepeny,.rmyemploytes withwegesu theirsme mmpenud...
will dothewoek,and the he Core need's icamse aro cluf.nt apply 7o 44,Business Required Inspections
and Professions Code:The Contpctars Lianas Law soca not apply m an owner of q p
am
who builds or improvesch improvement,m and who dassuch work himself edthrough his
own employes,provided mho such ntI. w tart not Intended m offend for sale.If.
buweroA the building or improvement is sold within one year of complmo Ne owned
builder will have the burden of proving olderolderhe did not had or improve for
puryox of
sa1eJ,
❑1.a owner of Ne pmpeny,am exclusively contracting with licensed contractan to
construct the project(Sec.70,M.Business and Professions Cale:)The Contractor's I.I. _
Cents law does not apply to an owner of property who builds or improves Merton,and
who contracts for such projects with a comoscu rB)lianmd pursuant m the Contractor's
License Law.
❑I am exempt under Sea .B&P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Faulty of perjury oro of the following declarations:
I have and will maintain aCmdriirne ofComent to self-insure for Workers Compero
7C3311M
ion,u provided for by Section 3700 of Ne labor Code.for the pedormmce of the
rk for which this Permit is issued.
El I have and will maintain Workers Compensation Insurance,u required by Section
of NC Labor Cod,.for the performance of the work for which this permit is issued.
Workers Compensation Inwmnce carries and Poliry number em:
rtico Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need Out becamPlomd IHhe Permit is for ono hundred dollars(Sip))
nr less.)
1 modify that in the performance of the work for which this Permit is Wood,I mail not
employ any person in any manorw as us became subject o the Workerf CamPeuatlan
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:IL after making this Ctnircn,of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Coda you muni
'0 forthwith comply with such provisions Of retail shall be deemed invoked.
ti�
CONSTRUCTION LENDING AGENCY
I herby aRnm that its conductioning agency fm robe Performance of /.
'Sa
the wash for which this pe train
is issued(Sec..]0097.7.Civ.C.)
aQ LcUnder'a Name l/
Q z ndcr't Address
V Q 1 certify Nat 1 have read this application and tum that the above information la
coned.l agree to comply with all city and county ordinances and stem laws Totaling to
QV building construction,and hereby authofim representatives of this city to cnmr upon dm
Uabove-mendancd property for inspection purposes
(We)agree t.tiro.indcmniry and keep harmless the City of Cupenino against
rto liabilities,judgments,costs and expenses which may in any way mcru,against aid City
in conamurnee of the flooding of
V APPLICANT UNDERSTANDSIhis AND WItLL COMPLY WITH ALL NON-POINT Issued by: Date -
SOURCEREGULATIONS.
Re-roofs
Signnurt of ApplicandCam Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Willy t applicant or forum bulling e,Chapter
nom or handle Health
maximal
as dented by the Cupertino Municipal Code,Chapmr 9.13,ms the HcaIN and Safety
ode,Sccy ]5532(¢)?
es ❑Na
All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future wilding Occupant me equipment or devices winch If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous air contsminants Is strand by the Bay Area Air Quality Managcmcnl all new materials for inspection.
Idom
❑Yes ❑No
IhaveToad the havardus materials requirements under Chapter 6,95 of the Califnr Hcolth&SafmyCem,Sccuou 25505,25533 and 25534.1 understood th aVthe wilding
not anendy hors a Iona..Nat tit is my responsibility m nodl'y the occupant of thcuirements which mustxmetpoortnissuanaafacerdramafGccupancy. Signature of Applicant Date
ner or autharivad ager Dam All roof coverings to be Class nBn Or better
X3 ( 1 a � -3
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 7919 August Ln. Date: 11-7-03
Owner's Name:---Jen Lee
Phone No.(408)446-9620
APN#: 362-12-014 Project Valuation: $ 1,138.00
Building Permit Info: Bldg_-----_— Elect__-__- Plumb------X----- Mech-----------
Job Description
Replace 50 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# 591329 Exp. Date: 3/31/04
Worker's Comp#: 1626288-03 Carrier: State Compensation Insurance Fund Exp. Date: 4/1/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679 7 I
Name on Card: Just Water Heaters Inc.
Expiration Date: 9/05 ��. (�
Visa MasterCard
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