03110101 CITY OP CUPEWHNO
BUILDING DIVISION PERMIT ONTRACTOR INFORMATION 3
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t BUILDING ADDRESS; JUST WATER HEATERS INC PERMITNq93110101
8 8 FERN TROVE
OWNER'S NAME: PERMIT ISSUE DATE
)SHI MICHIHIRA 1764 NATIONAL AVE 11/20/2003
10,NE: SANITARY NO. CONTROL NO.
(510) 293-9901
ARCHITECGENGINEER: BUILD]NO PERMIT INFO
BLDG ELECT' PLUMB MECH
=1t� 0
+oo LICENSED CONTRACTOR'S DECLARATION
tFF I hereby affirm mar 1 am licensed under previsions or Chapter 9(commencing lob Description
SZty with scaiunlIXN1)of Division 3 Arlin Business and Professions COs..and my license is
in full force and ere.t. REPLACE WATER HEATER am1p0 ��
p✓f? Liccnac Class Lic.p �eI
o Dale Contract., (50 GALLON GAS)
ARCHITECTS DECLARATION
Eau 1 understand my plans shall he used u public¢cords
ao� .uedPref.ssi.nal DEC 1 9 2003
S OWNER-BUILDER DECLARATION
<S I herchy affirm Nal 1 am.xcmpt from th.Cim rasa License Law for Inc
n o following mason.(Section 703 L5,Business antl Pmfessnns Code:Any city Or county BU'(ss(� �tl, ^'p0c;
m which requires a Permit to construct,alter.improve,demolish,or repair any eruaum
poor In its issuance.also requires the applicant forsuch peniuo rile a signed statement
eta that he is licensed pursuant to the provisions Of the Contractor's Lice=Law(Chapter 9 Sq. Ft. Floor Area Val Itatid 933
i t-� (commencing with Section 7")of Division S of the B usineas and Professions Cour)or
Out he is exempt memfrem and the,baso for Ne alleged exemption.Any violation of
Section 1031.5 by any applicant fora permit subjects the applicant to a civil pcnshy of APN Number
not more man five hundred dollars(s50y. Occupancy Type
37536032 . 00
❑Lasownerof the p1 Itruc or i.moimendeswithwages r Meirsole compensation.
will Pr the work,arta the he Cim n not s Lice d O Law do for sale(See toObs.Business
and arty who
Coat:me Conmecsora and
Law docs not apply Lf an owner or Required Inspections
propertywho build, i improve mereoo,andwho me not
or
offered for
his
own employes.provided that such imprevemwithin not ear Of a m Deere.fm¢ale.If,
builder ,the awrise or deno cntiasold athe ioan tWildorimproeion,mrprowo-
ste.).rwill have the burden of proving ren W did not Wild or improve for puryose Of
ulcJ.
❑1,as owner of the property,am exclusively contracting with licensed conrame s to -
construct the project(Sec.load.Beamed and Professions Cock:)The Contractor's Li '
erase Law does not apply to an owner of propcny who Wilds or improves thereon,antl.
who contracts for such projects with a contractor(s)licensed pursoat in the Contractor's
License Law.
ElI Am ecmpt anchor Sec. ,B Ar P C for this..an
Owner Data
WORKER'S COMPENSATION DECLARATION
I Wreby as.under penalty of perjury arc of OR following decorations:
J 1 have and will maintain a C.rtlfiCae of Comm m self-insure for Worker'a Compco-
action,as provided for by Section 370 of on,Labor Code,fm Ne performance of the
work for which this Permit is issue¢.
1 have and will maintain Workers Compensation Insurance,u required by Section
37W of the Labor Coat.for the performance of the work for which this permit is aided.
My Workers Compensation Insurance carrier and Policy manner are:
cmu'. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Phis section nerd not bccomplemd Htie permit u for ane hundred MIIus($100)
or less.)
1 certify Na in the performance of On work for which this permit is issued.l shall nut
employ any person in any manner so ss m become subject to the Workers''Compensation
Laws ofCalifornia.Data
Applicant
NOTICE TO APPLICANT:If,after making this C-nificam of E.acmgion,you mould
WCPme subject m the Worker Com pcnmtion previsions of the Labor Code.you must
z r-Al-omply wire such provision m mil pe.itslnll W roamed revoked.
z CONSTRUCTION LENDING AGENCY
I herby icMitre that mem is s ed 0 7,Civ.
agency I'nr the performance of
1Ll the work for which this permit u iuuech(Sc,(Soar.3(191,Civ.C.)
a7 Q Under Nam.
z Lender's AJtlmss -
J Q I certify that 1 have read this applicaion and state that the above information is
ry H correct.I agree to comply with all city and county on inamas and sure laws relating to
QU building crnstruetion,and hereby authorin reprecnutives of this city to color upon the
atAweBoil-mentioned prep est for expert esslacchan purposes.
F G (We)agree m save.indemnify and keep harmless the City of Cupertino against
N Iiabiliriu,judgments,he growing
ind.apene which may in any way¢error against acid City
C)z in eanseyuenee of he granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9
Dale
SOURCE REGULATIONS.
Signature of Appbcam/Conbaeor Dare Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant tarfuture building uccupamscore orhanff,h ¢nous maroMM
ss acfind by ate CupeAlan Municipal Code.Chaper 9.12,and the Health and Safety
oro,Section 25532(a)l
❑Yea ON. All roofs shall be inspected prior to any roofing material being installed.
Will the a Beam or future Wilding occupant eo a If a roof is installed without first obtainingan inspection,I agree to remove
pP g p a Air Qu or device which p g
7ni.�lm&S�etyC.d�,S=.25505,2533.dB534.1unk
o
it nn air contaminants az defined by the Bay Arca Air Quality Management all new materials for inspection.
❑Yes 0N
1 have mad On haaadnw materials ayuimments under Chapter 6,95 of the Cah or
uM .ifmc Wilting
s nor eumnaly haw a tenant,mar Ir is my ACRAOMlMBty to nod y the accupant of the
uimmenu which must W met prior At issuance of a CCMfi-a9 of Occupancy.
Signature of Applicant Dale
Owner or aurhmindagent D„e All roof coverings to be Class "B”or better
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 898 Ferngrove Dr. Date: 11-18-03
Owner's Name:---Michihira,Toshi
Phone No.(408)257-8938
APN#: 375-38-032 Project Valuation: S 933.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----- Mech___________
Job Description
Replace 50 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: permitsC@justwaterheaters.net
City, State and Zip: Hayward, CA. 94545
State Contractor's License# 591 329 Exp. Date: 3/31/04
Worker's Comp#: 1626288-03 Carrier: State Compensation Insurance Fund Exp. Date: 4/l/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679
Name on Card: dust water Heaters Inc. �f
Expiration Date: 9/05
Visa MasterCard
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