03090204 CUPERTINO
BUILDING DIVISION PERMIT 1CONTRACTn RINFORMA,rTION ,
rs, . ,VrB$ r
PUILDINGADDRESS; JUST WATER HEATERS INC PERMIT NO.03090204
y�OWNER'S NAME: 1764 NATIONAL AVE �"h'IT issue DATE
NE' (510) 293-9901 SANITARY NO. CONTROL NO.
7ARC.,HTTECTIENGINEER, BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
I hereby eMrm Thal I em licensed ander provisions fir Chapmr 9(commcntlng Job Description
Section 7")of Division 3 of the Busiess and Professions Code,and my Items.is
l tomeand effect.class Lic.N REPLACE WATER HEATER
C.Oulmor (4 0 GALLON GAS)
ARCHITECTS DECLARATION
1 1 understand my plans shall he used as public records
>yU
Licensed Profcuianal
OWNER-BUILDER DECLARATION
aE I hcrcby M.that I am exempt from the Contractors License Law far the
p O following mason.(Section 703 IS.Business and Professions Cade:Any city ar county
5$ which requires a permit to construct,alcor.Improve,demolish,or mpeir any suucwm
poor its issuance.also requires the applicant for such permit to file a signed statement
<
that he is licensed pursuantto Oc previsions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuati 192
[�O (commencing with Section 7000)of Division 3 of the B dulness and Proiesinu CMe)or '7
$
that he is exempt themfrem and the but,for the alleged exemption.Any=of
Section 7031.5 by a,epplicanlfar a prrmiuubjects the applicant to a civil penalty of DI5I�ItY�C 00 _ Occupancy Type
not mom N3aVpN{
an live hundred dollars(M). - -- --
❑I.as owner of the prepenl,or my emplowes with wages as their sale compensation,
will do the wart,and themucmm isnot intended or offered forsale(Sec.7061,Businw Required Inspections
and Prefesslom Code:The Comrssmrl License Law docs not apply I. owner of
property who builds or improves thereon,and who dmuuch work himself or through his 502 - FINAL PLUMBING ENERGY
own employms,provided that such improvements are not intended or offered for sale,If. 506 — GAS TEST
however,the building or improvement Is sold within one year of completion,the owner.
builder will haw she burden of proving Out W did not Wild or improve for purpose of 507 - FINAL PLUMBING
sale.).
❑1.as owner of On progeny,am exclusively contracting with licensed contractors to
construct the project(Sec,7044,Business and Professions Code:)The Contractor's L6
sense Law docs not apply to an owner of property who Wilds or improv theream.ad,
who contracts for such projects with a contractor(s)licensed pursuant to the Contractera
Lim.Law.
❑I son exempt under Sec. ,B&P C for this recon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby eR, under peulty of perjury mm of Or(allowing declwatherec
hew end will maintsln a Cenif¢ate of Consent to self-insure for Worker's Compere
tion,as provided far by Section 3700 of the labor Code.for be performance of the
work for which this permit is issued
❑1 haw and will maintain Workces Compensation Iuurrece,as rryvired by Section
37W of the labor Cade,for the performance of the work for which this permit is issued.
My Worker's Comp oini on Insurance carrier and Policy number are:
Cartier. Polity No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('TMs ruction need not becompleted Irl W permit its rare=hundred dollrm(SMO)
of leas.)
I modify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner an an In become subject to the Workers'Compcuation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compevation previsions of the Labor Code,you must '
�z Forthwith comply with such provisions or this permit shall he we=ed revoked.
r'� CONSTRUCTION LENDING AGENCY
t hereby affirm Nat them its mm a action lending agency fortbe performance of
34> the work fur which this permit is issued(Sec.3097,Civ.C.)
Y Q
Under',Name
D z Lander:Address --
Q 1 certify that I haw read this application and sum that the anion information us
y ^ correct.I agree to comply with all city and county ordinances and sum laws relating to
SV' building Constitution.and hereby authorim repmsematiws of this city to corer upon the
'hove-mentioned property for inspection Purposes.
C (We)agree to saw,indcmni(y and keep hamilm the City of Cupc"bm against
rat
liabilities,judgments.core accrue gd
and eapmucs which may in any way ns,sod City
;J 7 in consequarec of Ne granting of this permit.
�i APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
Re-roofs
Signature ol'ApplicauntlComostair Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the a Cupent or furore ipal Co e.Chanumre or handle Health
anmaknal
u defined by the Cupertino Municipal Code.Chapter 9.13,and Om Health and Sa(cry
Cr,
"'yo-
cetiaAll roofs shall be inspected prior to any roofing material being installed.
QYes ❑No
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
i h4xardlla3 air contaminants u defined by the Bay Arca Air Quality Management all new materials for inspection.
tricl7
QYou 0 N
I have mad the humdous materials requirements under Chapter 6.95 of the Calier.
ria Health&Safety Code,Smuvu 25505,25533 and 25534.1 understand Nat if the Wiming
doss not currently hew a tenant.Nat it is my responsibility an notify IW acupam of the
mquimmcros which must be met prior to issuance ora Certificate of Occupars, Signature of Applicant Date
Owner tar aulhofi2ed agent Dam All roof coverings to be Class"B" or better
r
: b3 � 7oZoy
City of Cupertino Building Permit Application
E-Mail
lobsite Address: 22430 Cupertino Rd. Date: 9-24-03
Owner's Name:---Gavlio, Lois
Phone No.(408)252-6750
APN#: 326-50-070 Project Valuation: S 1,192.00
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 _ G
Name on Card: Just Water Heaters Inc. Z 3
Expiration Date: 9/05 .�� G/
Visa MasterCard X
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