03110037 • CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
OUILDING ADDRESS: JUST WATER HEATERS INC PERMIT N003110037
OW NER'S NAME: 1764 NATIONAL AVE PERMIT ISSUE DATE
ANE Y 11/07/2003
°NL: (510) 293-9901 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+oo LICENSED CONTRACTOR'S DECLARATION
4ea F I hereby affirm Nat I am licensed under provisions Of Chapter 9(commencing Job Description
ito with SCc11on7000)rf Division 3 of NC BLemeesand Professions Code,and my license is
)tqo inmuforce ssddrreC' REPLACE WATER HEATER
x i License Clue is
o
DateCrntmdmr (4 0 GALLON GAS)
LIQ
ARCHITECTS DECLARATION
C c U I understand my plans shall be used az public records
H Licensed Professional
g OWNER-BUILDER DECLARATION
a S 1 hereby.(Tens that 1 am exempt from the Contractor's Licensed Law for the
<❑O following reason. ermdun ID3str Business andove. a moll Code Any city or county
m which require a permit m mwrvn,alcor.improve.Jcmolish,Or repair any swuum 0
u Zv` prior to its issuance.alsorequiree the applicant forsuch permil to file a signed statement
psp that he is licensed Poinglart 10 the Provisions of the Contractor's Litgnsta Law(Chapter 9 Sq. Ft. Floor Area Valuaf $900
2� (commencing with Section 7000)of Division 3 of the B usimas and Professions Cooled)or
U�R that he is exempt thomfrvm and one basis for the alleged exemption.Any violation or
Section]031.5 by any applicant for a permit subjects the applicant in a civil penally of 3A651MMer00 Occupancy Type
not more Nan five hundred dollars(5500).
❑ I.as owner of the property,or my employees with wages as their Lode compensation.
will do Of work,and the..Co..is not intended or offered for sale(Sec.7044.Business
and Professions Core:The Contractor's License law does not apply to an owner of Required Inspections
property who builds or improves Hereon,and who doessuch work himself or through his
Own employee,provided that such improvements are not intended proffered for sale.It,
however,Ne building or improvement is sold within one year of completion.the owner-
builder will have the burden of proving Nat he did not Wild or improve for purpose of
sale.).
1,as owner of the property,em exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code)The Contractor's Lt.
cense Law does not apply to an owner of property who Wilds or improves thenars,and.
who comrmin for such projects with a smntracmr(s)licensed pursuant to the Contractor's
License Ltlw.
❑l amcemptunder See. ,B&kPCforthismasrn
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby offing under penalty of perjury one of the following declarations:
1 have and will maintain a cenifiem or Consent m self-insure for WorkersComNn-
Wife,as provided for by Section 370(1 of on Labor Code.for the performance of the
work for which Nis permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for Be performance of de work for which Its permit is issued,
My Workers Compensation Inxrv¢c carries and Policy number aa:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sellirn need not breomplead if the permit is ror roc hundred dollars(1100)
or less.)
I Cerny that in the performance or the work for which this permit is issded,I shall not
employ any proton in any manner an ax an Femme subject to the Workers'Comperuation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:Ir,after making this Ccnificate of Exemption,you should
become subject to the Worker's Compcnsatime previsions of the Labor Code,you must
z rrr to Comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
-+ l hereby affirm but them is a donsuuctinn lending agency l of the performance of
5 the work fur which his permit Is issued(Sec.3097,Civ.C.) —�
i Q Lcndcr' Name
= z Lender's Address
1 e
J Q 1 certify Net 1 have read this application and dace that the above information is
C:)U bonding 1 agree to comply with all city and county ordinances and stain laws relating e
Q U .miding-ammim til ro and bembyacuminp noses. tivu of Nis city to cma upon he
ahovcme rudgma pmpcny for inspection purposes.
H y (We)agree to save,indemnify and keep harmleas the City Of Cupertino against
N inconsequne of s.the
uang Capcsxswhich may in any way awmc against City
V z in consequence o(nhe granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
arenawre of ApphCanvermMxIM Data Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant Of future building occupant sere or handle ha mous material
udef sed by the Cupenino Municipal Code.Chapter 9.12.and the Health and Safety
ode.Section 255J2(a)?.
❑Yea ON. All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or future building Occupant used If a roof is installed without first obtaining an inspection,I agree to remove
pp s P Area
or Mara which g p
ItharaNnus air conmminanuasdc0ned by the Bay Arca Air Quality Management all new materials for inspection.
7d,.
trm"
❑Yes 0 N
I have mad Ne Wrardousmaarials m4uimmcnu under Chaph rei95 of Nc Califo>
Health&Safety Code,Sections;25505,25573 and 25534,1 undersand thuif t e Wilding
not cuncndy have a tenant,Not it is my respons ibility m nbly the ceCupml of Ne
uirtmcnu which must W met prior a issuance ofa Ccnifea¢of Q:mpancy. Signature of ApplicantDate
wner or authorized agent Dam - All roof coverings to be Class "B" or better
i
03 11 � o3
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 10370 North Blaney Ave. Date: 11-7-03
Owner's Name:---Ying,Jane
Phone No.(408)996-2052
APN#: 316-30-090 Project Valuation: $ 900.00
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@justwaterh eaters.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: 4/1/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679
Name on Card: Just Water Heaters Inc. /
Expiration Date: 9/05
Visa MasterCard
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