03100010 CITY OF CUPERTINO77 "1111 F:•' «I° & �• '
BUILDING DIVISION PERMIT d,CONTRAC I TNFORMATTON.-
auaolivc ADDRESS: JUST WATER HEATERS INC PERMIT No.03100010
SQ 2ETTE A17
OWNER'S NAME: 1764 NATIONAL AVE PERMIT ISSUE DATE
VENNING JULIA T, TRUSTEE
NE: (510) 293-9901 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�00 LICENSED CONTRACTOR'S DECLARATION Job Description
U 1 hereby affirm that 1 am licensed under provisions of Chapmr 9(commencing P
with Section 7(1 of Division 3 of the Business and Professions Code,and my license is
n in(u 11 fame and effect.
to
Z_ enneelass LIC.N REPLACE WATER HEATER /
Dam 7'S DECLARATION
(4 0 GALLON GAS) ^l
ARCHITECTS DECLARATION V/
I understand my plans
shell be used as public records
o /C r' Licensed Professional Q
S OWNER-BUILDER DECLARATION
I0hereby Maso affirm an 1 oro exempt from the Connector's :License Law for the
40 O whichralrare massa Permit
t ]Cott Business and vin,de mill Codc:Any city toshooting county
which requires a permit ac cores the alter,improve,n Permit t file
e a sig any tW meet
prior er its issuance,also nt to the the applicant for such permit m files signed Cerement
that he is licensed pursuant to the provisions of the Conuanoh License low(Chapter Sq.Ft. Floor Area Valuati$l1F1622-
jl- (commencing with Section 7")a]Division 3 of the Business and Professions Care)or
,u, $
that he is exempt therefrom and the Was;for the alleged exemption.Any violation of
Section 7031.5 by any applicant fare pernahmlijecu the appiit.t to a civil penally of 3RHM'DI9aPbeIOO Occupancy Type
not more than Eve hundred dollars($500). o�'E
❑I,ax owner of Bm property,or my employees with waging w their sale compensation,
will do the work and the swetum is not intended ar oifercd far (Sec.7044,Business
and Profession¢Code:The Contactors License Law docs,not apply to an owner of Required Inspections
property who builds or improves themon,and who doessuch work himselfor through his 502 - FINAL PLUMBING ENERGY
own employees,provided that such improvements ere not intended or offered forwle.If. SO6 - GAS TEST
however,Ne building or improvement is sold within one you of completion,the owner-
builder .will have the burden of proving that he did not build or improve for purpo e of 507 - FINAL PLUMBING
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
conawct the project(Sec.]Odd,Business and Professions Code:)The Contritemr'Li.
cense law does not apply to an owner of property who builds or improve thbmon.and
who contracts for such projects with a contractons)licensed pursuant to the Contractor's
Lkeee Law.
❑I am exempt under Sec. ,B k P C for this moon
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby argon under penalty of perjury ane of the following declarations:
I have and will maintain a Certificate of Consent to self insum for Worker's Compere
Ann
as provided for by Section 3700 of Ne Labor Cade,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the labur Cade,for Ne performance of the work far which thia permit is Issued.
My Worker's Compensation Insaantt carrier and Policy number am:
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thk acerian wed not he completed if tbe Permit is prime hundred dollars($100,
or lcso)
I certify Not in the performance of the work for which this Permit is issued.l shall not
employ any person in any mannerso as to become subject to the Workers'Compeasatlan
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making Iiia Ccrtificam of Exemption,you should / /)
become subject re the Worker's Compensation this provisions of the coed r Code,you must
7Z
become
t with eclmf'sCinnsnsatio pprevisions behe LabrCoded.,
y CONSTRUCTION LENDING AGENCY
— I bcmhy affirm Nn Nem is a construction lending agency for the performance of
the work Y. 7 k for which this permit is Issued(Sec.3097,Civ,C.)
3)0 Linda's Name
z Lender's Address
;J Q 1 certify that 1 have read this application and sum that the slave information is
correct.I agree m comply with all city and county ordinances and¢um mw¢relating m
building construction,and hereby authorise represenuriws of this city to corer upon the
Lki above-mcmioned property for impaction purpeaea.
(Wo)agree to save,indemnify and keep harmless the City of Cupertino against
r N liabilities,judgments.costs and expenses which may in any way same against said City
J7 in consequence of the gaoling of this Permit.
�i APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaHAZARData
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the a Curar or(Mune building e.Chapter
Core m handle Health andearest
az dented by the Cupertino Municipal Codc,Chapmr 9.12,and the Health end Safety
ewe,Se Mien 25532(an All roofs shall be inspected prior to an roofing material beim installed.
❑Yea ONM P P � Y g $
Will the applicant or future Molding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It limanOnus air contaminants es deposit by the Bay Arca Air Quality Management all new materials for inspection.
tsuict?
❑Yes ❑No -
1 have mad the havardousmamrlels requirements under Chapmr 6.95 of the Glifor-
niaHcolN&SafcryCw,Ssniona25505,25533and25534.1undcrswd W ifNe building '
docs not currently how a mnan,that it is my responsibility he madly the occupant of Ne
at
which must w met poor m issuance or a CcNfmat,or Occupancy. Signature Of Applicant Date
Owner oraumari,edagent Data All roof coverings to be Class"B"or better
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 869 Bette Ave. Date: 10-1-03
Owner's Name:---Venning,Julia
Phone No.(408)252-8929
APN#: 369-27-047 Project Valuation: S 1,622.00
Building Permit Info: Bldg__--_-- Elect—_---- Plumb-_—X---- Mech--------_-
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# 591329 Exp. Date: 3/31/04
Worker's Comp#: 1626288-03 Carrier:State Compensation Insurance Fund Exp. Date: 4/11/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679 7r33 c�1"
Name on Card: Just Water Heaters Inc. qt� . /� G
Expiration Date: 9/05 b
Visa MasterCard X
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