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CI'T'Y OF CUPERTINO
""9�' "t"� "' ' '
BUILDING DIVISION PERMIT
�CONTRACT.OR TNFQRN ATION� "
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Bu1LDINGADDRESS:
JUST WATER HEATERS INC
PERMIT N003080069
7471 BOLLINGER RD
OWNER'S NAME:
1764 NATIONAL AVE
PERMITLSSUEDATE
BROWN JAMES W
003
NE:
(510)293-9901
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
I hereby of on that 1 am licensed under provisions of Chapter 9 (commencing
wish Scotian 7Wsq of DivixlOn 3 of the Business and Professions Cndc, and my license is
inmBCome andarrect.
REPLACE WATER HEATER0�0
License class Lm. Is
Date Conuacmr
(4 0 GALLON GAS) '
ARCHITECTS DECLARATION
I understand my plans shall be used u Public record!
r (v r av 2 5 q .
J f 4' [003
Limmad Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that Tam exempt from Ne Comracmrs License Law for the
BU
BUILDING O
following moon. (Section 7031.5, Business and Professions Code: Any city or county
lL II®^N G
which requires a Permit to construct, alms improve, demobh, or repair any structure
prior to its issuance, also requires the applicant for such permiuo file a signed statement
Sq. Ft. Floor Area
Valuatio,$923
that he is licensed pursuant o the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7(1110) of Division 3 of the Business and Profusions Code) or
that be Ib exempt therefrom and the bub for Ne alleged exemption. Any violation of
3eiO 0
Occupancy Type
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of
nos more than five hundred della. (SSW).
0 1, as owner of the po perty, or my employees with waged as, their bole compensation.
gg�enG�3DTTTee�d �'Ty,��S uno�
will do the work, and the swcme it not intended or offered fertile (Sec. 7W, Businw
and Profeuiont Code: The Contractor's License Law does not apply to an owner of
502 - FINAL FL'ft 1RffG 4ftRGY
property who builds or improves thereon, and who does such work himself or besought his
ownemployces, pmvigoddrilsuehienprovemems aenotmanded reoffered mrsale. B.
506 — GAS TEST
however. the building or improvement is sold within one year of completion, the Owner.
builder will have the bardan of pm.ing thatbe did non wild or impmw for purpose or
507 — FINAL PLUMBING
sada.).
0 1, as Owner of die property, am exclusively contracting wife licensed convectors to
construct the project (Sec. 7044, Business and Pmfcuions Coca:) "Bum Contractors Li.
cense law does not apply to an owner of property who wilds or improves thereon, and
who contracts for such projects with a commctaf(q licensed pursuant to the Commcto's
License Law.
0 1 am exempt under Sec. B & P C for this ...a
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affrrm under penally of perjury one of the fallowing declarations:
the and will ma mid. aCendfiea¢ of Consent m scIf-m.ma for Wmka, sCompm-
as'u providrd for by Section 3700 of the laver Code, for she performance of the
wod for which this permit is Word.
1 haw and will maintain Wmkeff Compensation IrtsulNa. as NqurRd by Section
3700 of the labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number em:
Caner: Polity No.:
'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not wcompleted if the permit Is formic hundred dollars (SIM)
lap.)
1 ccnify that In the performance of the work for which Ibis Permit Is issued, 1 shall not
employ any peon in any manner an p of become subject to the Workers' Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Cenifcate of Eacmption, you should
become subject to Ibe Worker's Compensation provisions of the Laver Code, you muse
forthwith comply with such pfwilinns of this Permit 0911 be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm this there is a construction lending agency for the perfurmeac of
the work fm which this permit is issued (Sec. 3097. Civ. CA
lentic Namc
n tY
—_ (✓ v
Lender's Addre ss
I ccnify that have roti this application and sue Nat the above information$eng is
_'
bonen. I agree l9 comply with 01 city mat county ordinances and sole bwt elating to
o co
V r
or
and hereby euthonp rposesenmliw of this city l0 elder upon the
ahovo- an Purposes.
ithowngcotioned ro
Properly for
indemnify end keep harmless IIIc City of Cupertino against
(We) agree indemnify
(We) ager
,cove,
liabilities. and roe P! may In any Way acCNC against said Glly
mitwhich
of thecosts
gran of this Permit.
this
of the UNDERSTANDS
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
A APPLICANT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
sienarafe OrnppnesData
HAZARDOUS MATERIALS DISCLOSURE
Will thee (Muni building acupanlaraeoran
Cointser
the Health and Safety u defined by the Cupertino Municipal Code, Chapter 9. 12. and the Health antl safety
ode.Sachs nz55..
All roofs shall be ins ected rior to an roofin material bei. installed.
P P Y g g
❑rob ❑Na
If a roof is installed without first obtaining an inspection, I agree to remove
Will 9. applicant or future building oaupanl sex equipment or devices which
It hazardous, air contaminants u dcRned by the Bey Area Air Quality Management
all new materials for inspection.
1(1617
OYrs [I No
I have read the boardnus materials requirements under Chapter 6.95 of the Califon
nim Health& Safely Coate, Sections 255(15, 35533 and 35534.1 understood the if the wilding
docs not currently haw a tenant. Net it is my responsibility in notify the asupant of Ne
requirements which must he met poor to issuance of a Certificate ofOccupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or authorized agent Date
t
t
C
E -Mail
of Cupertino Buildina Permit ADDlication
Jobsite Address: 7471 Bollinger Rd.
Owner's Name: ---Brown, James
Phone No.(408)253-7861
APN#: 359-23-024
Building Permit Info: Bldg ------
Date: 7-28-03
Project Valuation: $ 923.00
Job Description
Replace 40 gallon gas water heater.
Contractor Information
Mech-----_
Company: Just Water Heaters Inc. Phone: (510)293-2012
Contact Name: Dulce Fax: (510)293-2022
Address: 1764 National Ave. E -mall: 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 Compensatlon Insurance Fund Exp. Date: 4/1/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679 c�
Name on Card: Just Water Heaters Inc.d�� /
Expiration Date: 9/05 / G/
Visa ❑ MasterCard ® (�
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