00110072CITY
l BUILIANcfiivISIONNO CONTRACTOR INFORMATION:
- PERMIT
I
BUILDING nQTf1 0 BUBB RD I JUST WATER HEATERS 10072
owrvl:R'sNSs* SINGLEY
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z S H = LICENSED CONTRACTOR'S DECLARATION
O Z — qqqq e areby affirm Drum I nm of the B anger provisions of Chapin 9 ad my II ceing
F '3CW with gen ion 90ro) affect. inn) urine Businesv and Yrofesxions Coyle, ane mylicense
7 is cefull forceand effect.
O � u License Clz's Lic. k
appp..5 iiia Dam - Contractor
F a 0 �n ARCHITECT'S DECLARATION
g 1 understand my plans shall M usul as public recoNs
p O License) Pnsfeasionul
OWNER -BUILDER DECLARATION '
w u, I hereby affirm that I am exempt from the Common's License Law for the
C 3 following reason. (Section 7831.5, Business and Professions Code: Any city or county
i O which maim a permit to Obswct, alter, improve, demolish or repair any structure
Ipy � prior to itsicmunce.al.so requires the applicant for such permit to file a signed statement
lhm be is licensed purssam to the pnwisions of the Contractor's license Law (Chapter 9
(commencing with Section 70y of Dif,ho n 3 at he Business and Prof—ions Code)
or than he in exempt therefrom and the basis for the alleged exemption. Any 0olmion
of Section 7031.5 by any applicant for n permit subjects the applicant to a civil penalty
of not more than fee hundred dull. H50).
❑ 1, as miner of the prcpeny, or my employees with wager as'
s their stile carn,yealka,
will do the work, and the -structure is not intended or offered for sale (Sec. 70 ,
1. Business and Professions Code: The Commctor'x License Law does not apply to an
owner of property Who build, or impnwe, thereon, rind who does such work himself
or through his own employees, provided that suds improvements are not intended or
offered for sale, IL however the building or improvement is sold within one year of
completion, the owner -builder will hrvc the burden of proving that he did tat build nr
impmve for purnosc ar rale.),
O 1, as owner of the property, am exclusively con mang with licensed enntrucmrs m
common the project (Sec. 70,14, Business and Professions Code:) The Contractor s
License Law does not apply as an ..a, of pop r y who builds or impmve, thereon,
and who contracts for such projects with a contmeturts) licensed pursuant to the
Commemn's License Law.
O lam exempt under Sea . B A, P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
d herehy affirte under penalty of perjuryone of the following declarations
1 1 have and will maintain a Ceniticate of Cement to mlGin om for Worker's
Compensmimn, as provided for by Section 3701 of the "We Code, far the
perromunce of the work for which this permit i, issued.
O 1 have and will memonan Worker's Compevmtinn Fmcum..a, as required by Section
37110 of the Lalsur Code, for the performance of me work lin which (his permit Is
issued. My Worker's Cmupenm(ion Insurance currier and Policy number ore:
Cartier: Policy N.,
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This senion neod not he completed if the Permit is for ane hundred dollars
(3100) nr less.) . i
1 certify fact, in the pttformunce of the work for which this permit is issued, I
shall not employ soy parmal in any manner so as to become subject to the Worker'
Compensation Laws of Calil'umia. Date
Applicant
_ NOTICE TO APPLICANT: IL after making this Cerificate of Exemption, you .should
Z hecnme subject to the Worker's Compemauon Won, of he Labor Coca you must
ZQ Q forthwith comply with such provisions or this permit shall a deemed revoked
F E CONSTRUCTION I -ENDING AGENCY
I hereby n0irit that Bare is o comwaion leading agency, for the performance,
Wof the work for which this permit is armed (Sec. 3197, Co. C)
L Q Denier's Name
Q Z Lender's Address
C.7 Q I cenify that 1 have road his appllcmion rind sole bathe above inlbrmmimn is
kr E. correct. I agree to comply with all city and ..my ordinaries and sum law, (elating
Q U Bo Wilding conslmct...... I hereby amhorlae represunativesof this city til enter upon
�] the above-mentioned pmpcny for inspection purposes.
y Os (We)ngree to rove, indemnify and keep llamdess the City of Copycat.against
0 liabilities, judgmems. cm.w and expenses which may in any way accrue against said
C.7 z
City in consequence mf the granting of miss permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of Applican(ICommnur Duro
HA%ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building «cupanl share ar hurdle h o ardour aatudol
As defined by the Cupertino Slunicip tt Cole, Chapter 9.12, and the Health and Safety
Cole, Section 25532fa1!
❑Yes ONO
Will It,, appllam or future building occupant tiro c,prent or devices which
am hnmNous air contaminants as defined by the Bay Amu Air Quality Management
Hria?
❑Yes ONO
I base read the Womah m mmcdAs recitarment.s under Chapter 6.95 of the
California Health Ay Safety Code. Sections 25505, 25533 and 25534, 1 understand that
if the huilding does not curently have a tamed. that it is my resPammitility to nonny the
occupant of the requirement which must a met prior to issuance of a Certificate of
Occupancy.
owner or numudzcd agent - Date
1764 NATIONAL AVE
(51.0)293-9901..
2000
BLDG ELECT PLUMB MECH
Job Description
REPLACE,40 GALLON GAS'WATER,HEATER
Sq. Ft. Floor Area Valuation
$664
APN Number Occupancy Type
3E.21-715042. 00
Issued by:
Re -roofs
Type of Roof
Required Inspections
502 — FINAL PLUMBING ENERGY
506 — 6AS. TEST
507 — F,INAL PLUMBING
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection. Applicant understands and will comply with
all non -point source, regulations.
Signature of Applicant Date
All roof coverings to be Class `B" or better
OFFICE .
e
Ll
City of Cupertino Building Permit
E -Mail
Jobsite Address: 111 50 Bubb Rd.
Owner's Name:---Singley Sam
Phone No.(408)252-6945
APN#: 362 -05 -042 ----------
lication
i00I�,
Project Valuation: $664.68 ----------
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: 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: 3/31/02
Worker's Comp#: 03KR0001018 Carrier: Clarendon Exp. Date: 4/1 /01
Credit Card Information
Credit Card #: 5474-6331-7168-6326
Name on Card: Just Water Heaters Inc.
Expiration Date: 9/02
Visa El MasterCard LIN
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CITY
OF CUPERTINO
• 1 of 1
BUILDING
PERMIT RECEIPT OPERATOR: nancyc
COPY # 3
Sec: Twp: Rng: Sub:
Blk: Lot:36205042.00
DATE ISSUED.......:
11/14/2000
RECEIPT #.........:
14004
REFERENCE ID # ...:
00110072
SITE ADDRESS .....:
11150 BUBB RD
SUBDIVISION .......
CITY .............:
CUPERTINO
IMPACT AREA .......
OWNER ............:
SAM SINGLEY
ADDRESS ..........:
CITY/STATE/ZIP ...:
CUPERTINO CA, CA 95014-4957
RECEIVED FROM ....:
MAIL -IN
CONTRACTOR .......:
GILROY, JOHN LIC # 15128
COMPANY ..........:
JUST WATER HEATERS INC
•
ADDRESS ..........:
1764 NATIONAL AVE
CITY/STATE/ZIP ...:
WAYWARD, CA 94545
TELEPHONE ........:
(510)293-9901
FEE ID
UNIT QUANTITY
AMOUNT PD -TO -DT THIS REE NEW
BAL
-----------------------
BPWHEATER PER
----------
HEATER 1.00
----------------------------------------
9.99 0.00 9.99
0.00
PPERMITFEE FLAT RATE 1.00
35.52 0.00 35.52
0.00
PERMIT
45.51 0.00 45.51
0.00
METHOD OF PAYMENT AMOUNT
NUMBER
----
OTHER
------------
45.51
----- ---
MASTERCARD
TOTAL RECEIPT
45 51
VOICE ID
DESCRIPTION
VOICE ID DESCRIPTION
•__••_ -----------
502 FINAL
=`----------
PLUMBING ENERGY
__ •_______ ------- ___--------------
506 GAS TEST
'___
507 FINAL
PLUMBING
0