03080068 LDWNCRSNAME:
UPERTINO • '*'
BUILDING DIVISION PERMIT CONTRAGTOR4NFORMATION.
Pd$.M a"r„G3*:v 'x s s "4^°,r➢�" �., a tt'sf�a `.a
ESS: JUST WATER HEATERS INC PERMIT N003080068
176)4 NATIONAL AVE PERMIT ISSUE DATE
G CHAO C
V NE (510) 293-9901 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
±oo LICENSED CONTRACTOR'S DECLARATION O O O O
g u F I Withy affirm that I am canard ander provisions of chapter 9(commencing Job Description
iaa With Section 70M)o(Division 3 ofBc Business and Professions Code,and my license is p��
j0? in mlupme and erre"' REPLACE WATER HEATER �'w®�,,,�®
License Class Lic.0
'g o Dat Contractor (4 0 GALLON GAS)
3 f t ARCHITECTS DECLARATION
I m a I understand my plans shall W used az public records OCT 1.6 2003
)yU
aN Licensed Professional
OWNER-BUILDER DECLARATION caw nn
2<7 1 hereby affirm that I am exempt from Or Contractor's License Law for the BUILD
UT' �p■ING
OO following rcasoa(Section 1121.5.Busmeas and Professinm Calc:Any city m county ry
i w F which requires a permit in construct,alter,improve,demolish,or repair any.aruaum
qty prior in its issuance.also requires the applicant or uch permit to file a signed statement
< that M is licensed pursuant to the previsions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuatio$985
(enmmencifgwith Section RMO)of Division 3ofthe Businessand Promasions Cute)or '
— that he is exempt tbomfrom and the Iona for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 A?N8-Qih6er00 Occupancy Type
not mare man five handed dollars(s50(). P Y YP
❑1,as owner of the property,or my employees with wages as their role compensation,
will do the work,and me strucam is not intended or offered for sale(Sec.7W.Business [� y�gd pgp� (app
and Professions Code:The Contractor's Licemse Law does not apply to an owner of 502 — FINAL P UMB I NCi e EN RGY
property,who builds or improves thereon,and who does such work himself or through his
own employees.provided Bar such improvements are not intended orolfned for sale.It. 506 — GAS TEST
however.the building or impmvcmcm is sold within one year of complmion.the owner
builder will have Be burden or proving Out he dm not build or improve for parposc of 507 — FINAL PLUMBING
sale.)
❑1,as owner of me pmpeny,am exclusively contracting with licensed contractors to
comtruct Be project(See 7044.Business and Professions Code:)The Contractor's Li-
cense law does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant M the Contractor's
License law.
l am exempt under Sec. ,B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby aMo.under penalty of perjury one of the following declarations: ,
1 have and will mainain a Cenif nUe of Consent to self-insure for Worker'sCumpcn-
ution,as provided for by Section 3700 of the labor Code.for the performance of On
work for which this pc.1,is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of the labor Code,for me performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tru section recd not he completed if the permit is Intone hundred dollars(SIM)
nr lcsiJ
I certify Nat in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so az Or become subject u the Workers'Compensation
Laws of California.Dote
Applicant
NOTICE TO APPLICANT:If,aper making ibis Ccni fn¢of Exemption,you should
become subject to the Worker's Compensation previsions of Be fahor Code,you most
�O forthwith comply with such provisions or this Permit shall be deemed invoked.
z N CONSTRUCTION LENDING AGENCY
F+ Thor by whicfirmthnon,i isaeonssite construction agency fnnhe Performance of
L'C me work for which oris that
ims iasucd(true.ion le Civ.C.)
trl Lender's Name x V
_ lender's Address v•�'
U Q 1 cenify that I ham read this application and scale that the above information is
" P: correct.1 agree to comply with all city and county ordinances and suite laws Hating to
pU building eonstrnction.and hereby authorim representatives of this city to enter upon in,
shove-mentioned pmpcny for expenses purposes.
H G (We)agree tp save,indemnify and keep harmless the City of Cupertino against
fq incilitteouninmenu.costs and expenses pswbich they in any way ecerve against said City
U inconsequence of DERSTing ufthis Permit.
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Signature of AppliaDam Re-roofs
HAZARDOUS MATERIALS tsSCLOSURE Type of Roof
Willy t epCaperton Muni ipal bile.Cpaper ore 9,12.and the
h Health
and
Safrarsenal
az defined by the Cupertino Municipal Chile.Chapter 9.11,and the Health and Safny
ode,Section 25532(a)?Yes 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 haaardnus air coram rilms az dcrncd by the Bay Area Air Quality Management all new materials for inspection.
District?
Q Ycs [2 No
I have read the intarO is materials requirements under Chapter 6.95 of Or Califon
ria H rad qb&Safmy Cale.Seedcase 255(15.25533 and 15534.1 undersand mat if the building
docs not cumendy base a tenant Nat it is my respomihittry tr nnd1y the ateupant of the
requirements which Must be MCI poor tniaaaenerofaccmrgafeOfDrcapergy. Signature of Applicant Date
Owner mamhori,ed agent Date All roof coverings to be Class "B"or better
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 870 Ferngrove Dr. Date: 7-28-03
Owner's Name:---Chang, Christine
Phone No.(408)679-0729
APN#: 375-38-036 Project Valuation: S 935.00
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
6 � 6/
Visa MasterCard
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