03110104 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION .,
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT N®3110104
37 FOOTHILL BLVD
OWNER'S NAME: PERMIT ISSUE DATE
EED QUEEN LAUNDRY 1764 NATIONAL AVE 11/20/2003
JNE: SANITARY NO. CONTROL NO.
(510) 293-9901
ARCHITECUENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+O ij LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing lob Description
.� with Section 70W)of Division 3 or the Business and Professions Code,and my license is
in mu mree and erred REPLACE STORAGE TANK
? License Class Lu.g (300 GALLON)
MMDau Contractor
7W ARCHITECT'S DECLARATION
i
< I understand my plaasahall lx used AS Public records
S
S Licensed Profcssionel '
OWNER-BUILDER DECLARATION
C<{ 1 herchy affirm the I ore exempt from the f Contractors Co License Lew for the
2 o which
mason.(Section](131.5,Business and improve.
dcviom Code:Any city or roomy
320 which requires a Permit re construct,a@r impmw,h Pomil t m repair any ned ummem
_20, prionoits issuancgahant to Be the
ovisio not forthe sucCon Pmon's Liomwle a Law
(cothat mmencing
ening licensedpursuantT O)of Divisiuo of
B tracsurinlanelsw(C roc)or Sq. Ft. Floor Area Val ua$(81750
d s'ct (cat he is xempth Section t and t f Division rm the Business and on.Any vi Cnde)of
that he u exempt tltertfmm and the burs for du alleged Gumption.Any violation of '
Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more Nan Eva hundred dollars(5500).
t E3
Lownerthe propcny,or myemployem withwagm utheirmle comisenutlen, 1 '�
will doo the work,,And Neswaurt is�atimentictl moRcrtd for ole(Sec.]04d,Busirvss -+ ++�
and Professions Cook:Tim Contractor.Liame Law does not apply to an owner of + + Reg131red'Inspestw $
property who builds or improvesthereon,and whodassuch work himulfor Bmugh his '1 I ; j'
howown ever.the milling ri proal aumech nt is wd wit venticar ofcded moedon.rporect for owner.
however Ne bwtiebrimpmprovinis aathe didnot yeti of completion theowncr.
huiltler will hew the burden of proving Nu he did not build or improve fur puryose of
ulc.).
❑1,as owner of the progeny,em exclusively contracting with liecnud contractors to �"-
construct the project(Sec.]044.Business and Pro(cesiom Cade:)The Contractoh Li-
came Law docanot apply to an owner o(propeny who builds or improws Merton,and.
who contracts for such projects with a eonuactar(s)licensed pursuant to the Comoscmfs
License La-
0 14m exempt under Sec. .B&P C for this reaaon
Owner Dau
WORKER'S COMPENSATION DECLARATION
1hertby Anon
fOr under penalty of perjury one ofthe fallowing decimations:
I have end will meinuin a cmuGcau o(Con ent to ulr-insum for Workces Compere
cation,As provided for by Section 3700 of dm LAW,Code,for But performance of the
work for which this permit is issued.
1 haw and will maintain Workoh Compensation Insurance,AS required by Section
37M of to,Labor Code,for Ne performance of the work for which this permit is issued.
My Workers Compensation Inaum os carrier and Poliry number art:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the Permit is for one hundred dollars 15100)
or less.)
I certify that in the performance of the work for which this Permit is issued,I shall not
employ any person in any manner an as An become subject to the Workeri Comlammtion
Laws of C.lr m x Date
Applicant
NOTICE TO APPLICANT:If.after making this Cenificam of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.,O forthwith comply with such provisions or this Permit be deemed revoked.
Z` CONSTRUCTION LENDING AGENCY
I hereby affirm mat these isco en lending agenry Ire the parfPerformanceof
the woo for which this permit is issued(Sec.309],Co.C.)
W�Q Lcndcra Name
=,z lender's Atltlress
U 0 1 cenify Nat I have read this application and sum that the above information is
(~ correct.l agree to comply with all city and county ordinances and sou taws relating to
0U building Caa4lmNoa,and hereby authorise representatives of Nis city to enter Ulan the
U abovcmonuoned property on inspection purpose-
gL (we)agree to sew,indemnify and keep hnmuss the City of Cupertino against
y liabilities,judgments.e.g.And e.K.which may in my was acmr.,amt Said City
V in conequence of the Bertin;of this perm it,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signature of ApplicaDau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or(Muni Wilding occupant Ch.m store m auntie haesrduun material
AS defined by the Cupenlno Municipal Code,Chapter 9.12,and the Health and Safety
ode.S❑ulo. ❑Nu
25732(.)7 All roofs shall be inspected prior to any roofing material being installed.
e
Will the applicant or future building occupant uta equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It ha]drdnua air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
`O'c
❑Yes 0N
I have mad the hanolous materials requirements under Chapter 6,95 of urs Calif n.
ria Health&Safety Calc,Sections 25505,25533 and 25534,1 undentew that if the Welding
does net cuwntly haw a unapt,that it is my responsibility to notify the tixuraro of the
requimmcnts which mug be met pdorht issuance ora cesurceuof Occupancy. Signature of Applicant Date
Owner or acomn,cd agent rete All roof coverings to be Class"B"or better
d31i � l � �
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 10637 Foothill Blvd. Date: 11-18-03
Owner's Name:---Speed Queen Laundry
Phone No.(408)515-7245
APN#: 342-16-087 Project Valuation: 5 2,750.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----- Mech-----------
Job Description
Replace 300 gallon storage tank.
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# 591 329 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 3 /
Name on Card: just Water Heaters Inc. Z
Expiration Date: 9/05G�,' 6/
Visa MasterCard X
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