03080073 CITY OF CUPERTINO +
BUILDING DIVISION PERMIT CONTR�CTORTNFURMATIQN
BuI LDINGADDRESS: JUST WATER HEATERS INC PERMIT N0.03080073
• OWNER'S NAME: 176)4 NATIONAL AVE PERMIT ISSUE DATE
DAVE FAHEY 2003
NE: (510) 293-9901 SANITARY N0, CONTROL NO.
ARCHITECT'/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
100 LICENSED CONTRACrOR'SDECLARATION JobDescri [ion
I hereby affirm that 1 am licensed under previsions of Chapter 9(commencing p
with Section 70at0 of Division 3 of Ne Business and Professions Code,and my license is
mmnrate mulefmct. REPLACE WATER HEATER
jyZ LimA.Cl.. Lic.g
.eFi Deas Cumnctar (4 0 GALLON GAS)
ARCHITECTS DECLARATION
I u I urbcmand my plan shall M used u public recends AUG 2 •' 2009
6
l
er Licensed Profcuinnal
OWNER-BUILDER DECLARATION ���
i 8 1 hereby affirm that 1 am exempt from the Connectors License Law for the LDUVO
no following reason.(Section 703 1.5,Business and Professions Code:Any city or county V'�A
g which requires a permit to construct.alk,Imptnve,demolish.or repair any structure
prior to its issuance.auurequires beapplicant foruch permit to file asignedmaumem
¢
that he is licensed pursuant to the providers,or the Commons License Law(Chapter 9 Sq.Ft. Floor Area Valuatio�711
2 9 (commencing with Section 7100)of Division 3 of do Business and Professions Coded or
that he Is exempt therefrom and the huts for the alleged exemption.Any vinlation of
y
Section 7031.5 by am applicant for a Permit subjects the applicant m a civil penalty of 3.TAPIR Mallcr O O Occupancy Type
nos mom than five hundred dollars($500).
❑ 1,is owner of the property,or my employees with wages As their sole compensation,
will do the work,and the sVucture is not intended m arrered initiate(Sec.7044,Business g�� d�Isn�
and Profusion Code:The Cmrux toe License law docs not apply m an owner of 502 - FINAL PL'YfESB I NCU c RGY
property who builds or improves diversion,and who does such work himself or through his
own employees.provided that such lmpmwmenu are not intended oroffued for.le.If, 506 — GAS TEST
however.the building or improvement is sold within one year of completion.she owner
bander will ban the burden of proving that he did not wild or improve for purpose of 507 — FINAL PLUMBING
is)
❑I,As owner of the property.am eaclusively convecting with licensed enormous an
construct see project(Sec.70d4,Business and Profession Cade:)The Contractors LF
cense law docs not apply to an owner of property who builds or improves themon,and
who contracts for such projects with a conuaclor(s)licensed pursuant u the Curvature ,
License Law.
❑I Am exempt under Sec. B@PC for this recon
Owner Data '
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
130711
have and will maintain a Canificate of Consent to se161mu a for Worker's Compere
on,.provided for by Section 3700 of be labor Code.for the performance of she
k for which this permit is issued.
hive and will maintain Worker's Compensation Insurance.ss rcquircd by Soction
0 of Ne labor Code,for the performance of the work for which this Permit is issued.
Workers Compensation Insurance carrier and Policy number am:
iee Policy Na.:
CERTIFICATE OF MEM MON FROM WORKERS'
COMPENSATION INSURANCE -
(Thu action recd not be completed if Ilse Permit U for one hundred dollars D100)
or less.)
I certify that in the performencA of the work for which this permit Is issued,I shall not
employ any Person in any manners As m become subject o the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Centficato or Exemption,you shmuW
become subject to the Workers Compensation provisions of the tabor Code,you mut
Oforthwith comply with such provisions or Nis Permit shall W deemed revoked,
ti.yN. CONSvRVCn ONLENDINGAGENCY
I hereby sift that have its Q comSec3lending agency for We Iserfamana of
1i work for which this permit is issued(Sec..30097,Civ.C.)
Lenders Name
7 Z Lender's AOdrass
J p 1 certify that I haw read Nis application entl sate that da.soon information is
E+ correct.I agree To comply with all city and county ordinances and nam Tawe relating to
7 U building convection.and hcmby suthrriu representatives of this city to Amur upon the
G
w
avo-msntioned propertyrp
for inspection puoses.
(We)agme to Mi,indemnify and keep humle.the City of Cupertino against
Iimlli8ea.judgmcou.CNIA and Asturias which may in anyway aceme,against said City
U z Aconsequence of the granting of I
LICANT UNDERSTANDS WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicanVCrnData
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the eppenl or future building occupant none handle allous maudal
ss Cu
defined by Bre Cupertino Municipal Code,Chapter 9.11,. He
and Use Health and Safety
ale.Section 15331(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yas C3 No
Will the applicant or roue building occupantom equipmanl or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hatArdous air concrnimru.defined by the Bay Arta Air Quality Management all new materials for inspection.
trict7
❑Yes ❑Nu
I have mW the harArdlms materials requirements under Chapter6.95 of dte Califon
ria H.1th&Safmy Codc,Scctiuu 355(15,15533 and25534.1 undcrrand that if du wilding
does not currently haw a arrant,that it u my responsibility m Willy the courses of Use
requirements which must W met prior In issuance or a Ccnfficate of Occupancy. ,Signature Of Applicant Date
Owner or.mhonxed agent Data All roof coverings to be Class"B" or better
c>
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 10903 Canyon Vista Dr. Date: 8-12-03
Owner's Name:-= Fahey, Dave
Phone No.(408)255-2666
APN#: 356-28-007 Project Valuation: S 711.00
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: 1 764 National Ave. E-mail: permitsOjustwaterheaters.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
Name on Card: just Water Heaters Inc.
Expiration Date: 9/05 6k 61
Visa MasterCard X
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