03110022 CITY OF CUPEWUNO •"' •:��TRAC �
BUILDING DIVISION PERMIT i CONTOR INFORMATION .
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT'003110022
()NGRESq 2L
OWNI:R'SNAME: 1764 NATIONAL AVE PERMIT ISSUE DATE
NANCY HURTIENNE 11/05/2003
NE (510) 293-9901 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
10 0 LICENSED CONIRACTOR'S DECLARATION C= O O O
£ 5m 1 hereby aruthat I am licensed under provisions of chapter v(Commencing Job Description
6W with Section7")of Division 3 Probe Business and Professions Coes.and my license is
C..unin roll terse ane)(rete REPLACE WATER HEATER
I giPj License ClanLic.Is �pp
$ Dam Contractor (4 0 GALLON GAS) t
ARCIII'IT:CTS DECLARATION
E 6 l ondcratanJ my plans shall be uscJ as public rcmrJs JAV
cod
Licensed Pmressional 42004
g OWNER-BUILDER DECLARATION
Contractor's
ON
<S I heresy.('firm That I Om eamnpt from the femio.Co License Law for the
O o following reason.Permit
t Ln L0.Business ane improve.
de imts Calc:Any coy nr county Alf
<m which myuires also p CnPas the aalter.pplicant
improve,demob",fi mpxn my structure /v
Ply
prior its issuance,cmdpursuant to the thprovisions o for such permiuo filiec a,Law atammcm
2Ienromache is ingwJpursuatet70th)(itDvsion3oheCosusinesandcnaclzw(Charter re)or Sq.FL Floor Area Va1Da[.$3b3$5
Z I—° tsommeoe xe pt tocmion 7land the
Division for me al eg emexempt on.An vi lotion or
that he u exempt therefrom and Jm basis for the alleged exemption.Any violation of e'en
Section 7031.5 by any applicant for a permit subjects the applicant to acivil penalty of Fsl3�lg�}7�3Or0 0 Occupancy Type
not more man Bvc hundred dollars($9(Ky. P Y YP
O 1,ai owner ofree proparty,or my employees with wages as their sole compensation,
will du the work,and file structure is not intended or offered for sale(Sec.Wei Business
and Profusions Coes:To,Conmanori License Law does not apply as an owner of Required Inspections
property who builds m improves thereon,and who docs such work himself or through his
own employcu,provieee Nat such improvementsarcnot inks nded oroRered for sole.IL
however,the buildingor improvement is mid within one year ofcompletion,the owner
builder will have the burden of proving that he did not build m improve fur pomosc of
sale.).
0 1.as Owner of the peopeny,am exclusively contracting with licensed convectors to
cmuwa the pmjcm(Sec.?Oda,Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves th)mon,and
who contracts for such pmjcm with a conmactor(s)licensed pursuant o th)Contractor's
License Law.
0 1 sen exempt under Sm. .B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby aRem under penalty of perjury one or eC following declarations:
1 have and will maintain a Cer ifcme of Consent to self-insure for Worker's Compel-
wion,as provided for by Secliun 37M of the labor Code.for the arfaro moc of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,as requited by Section
3700 of be labor Code,for the paha mane of the work for which this permit is issmd.
My Worker s Com pcnaman Insurance Cartier and Policy number art:
Carrier: Policy No.: _
CERTIFICATE OF EX EM MON FROM WORKERS'
COMPENSATION INSURANCE
(Ibisaction need not becompincd ifthe permit is(atone hundreddollars(g UB
or less.)
1 ccnify that in the serfnemance of the work for which this permit is issued.1 shall not
employ any person in any mannerm as to become subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,alter making this Ccnifcam of Exemption,you should
become subject to the Worker's Compensation provisions of the Libor Code,you most
z formwi th comply with such provisions or this Permit shall b)deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a Construction Iendi ng agency Iorthe performance of
x me work fur which this permit is issued(Sec.3091 Co,C.)
!T] Q lender's Name
ltnJcr' ress
Add
0 1
J� 1 ccnify mat 1 have(cad this application and sten that the above ws tmmiun is
ly U surfed I agree to comply with all city and county ordinances Of this arum lent relining to
V building conswnionand hereby authori PC purposes, of this city to enter Upon obs
r 4 about-(W tionrepropene for inspection keepher
(We)agree to save,indemnify and keep harmless thisew City of against id Ci
FN in
equnce of thecostsand cf pens¢mit. may in any wayattac against sale City
Jz APLICANTcof UNDERhe STANDS
Of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signamm of APPIioDam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ser forum building mcupapt em,1Pr and the
Health and
u defined by me Cupertino Municipal Cade Chapter 9.11,and the Hcahh and Safety
Cwc.S❑aYioena 25532a)? ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hmardous air Contaminants as dcflP.d by the Bay Arca Air Quality Management all new materials for inspection.
smict?
OYes ONu
I have maJ the RtraNPus materials reyuiremenR under Chapter b95 of the Cali for.
iia Health&Saf ly Calc,Socuou 25505.25533 and 25534.1 untcrsmnd that if the hadding
dues not Currently have a Clair,that it is my responsibility n notify tbe occupant of are
requirements which must be met prim nissuance vaocmhcaCorOccupancy. Signature of Applicant Dale
Owner or authorircd agent Data All roof coverings to be Class "B" or better
i
03 � � � ���
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 10144 Congress PI. Date: 11-04-03
Owner's Name:---Nancy Hurtiemne
Phone No.(408)255-4118
APN#: 326-53-035 Project Valuation: 5 1,385.00
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: 4/1/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679
Name on Card: just Water Heaters Inc.
Expiration Date: 9/05
Visa MasterCard ® y
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