03090240 CITY OF CCPEW11NO «^*�'s
BUILDING DIVISION PERMIT CONTRACTOR INI URMATION
C C;, T,
PUILDING ADDRESS: PERMIT WATER HEATERS INC PERMIT NO.03090240
OW A MAR DR.
NF.R'S NAME: 1764 NATIONAL AVE PERMITL95UEDATE
NE: SANITARY NO. CONTROL NO,
(510) 293-9901
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�0, LICENSED CONTRACTOR'S DECLARATION O O O O
IuaE I hereby affirm tbut I am licensed under provisions or Chapter 9(com rmocing Job Description
;Zw wish Section 7M))of Division 3 of the Business and Profession Code,and my license is
s in full(One and effect,
License Chace sec.A REPLACE WATER HEATER
it Dam Contractor
ECL (4 0. GALLON GAS) /0
£ ARCHITECTS DECLARATION a7/
iy 1 understand my plans shell W used as public rtenNs V sus
idU (/\7J
"gay Licensed Profcssionel
s OWNER-BUILDER DECLARATION
-� E I hereby alarm that
I am exempt from the Centimeter's License Law for the _
a O following reason.(Section 7131.5,Business and Profession Code:Any city or county
�$ which requires a Permit to convect.film,.Improve,demolish,or repair any Rsuctum
y Friar to its issuance,also requires she applicant for such permit to File a signed statement
�Scep
that he is licensed pursuant In the provision of the Convectors License law(Chapter 9 Sq,Ft. Floor Area ValuatioW 717
tt$ (enmmencing with Section WINE of Division 3 of the Business and Professions Crvtc)or $
3 that he H exempt therefrom and the basis for be ailcged exemption.Any vinlavon of
I Section 7031.5 by any applicant for a Permit subjects be applicant to a civil Penalty of 36Y�i?I�ggt�erOp Occupancy Type
not more Nan five hundred dollars(S500).
0 1,as owner of the property,or my employees wish wages As their sole compensation,
will do the work,and the structure is not intended or offered for ale(Sec.7044,Business
and Profession Code:The Croissant s Lt..Law does at apply n an owner of Required Inspections
property who builds or improves thereon,and who docs such work himselfor through his 502 - FINAL PLUMBING ENERGY
own employ=,provided that such improvements we not intended proffered for ale.If. 506 — GAS TEST
however,the building or improvement is sold within one seas of completion,be owner.
builder will have the burden of proving that M did not Wild or improve for purpose of 507 - FINAL PLUMBING
.[AJ.
0 1,as owner of the properly,am exclusively contracting with licensed eonommrs to
convect be project(Sec.7044,Business and Professions Cade:)The Convector's Li.
cense Law don not apply to an owner of property who builds or improve thereon,and
who contracts for such projects with a rontnnmhi)licensed pursuant in the Committees
License Law. -
0lAnn exempt under Sec. _ B k P C for this mason
Owner - Date
WORKER'S COMPENSATION DECLARATION
I hereby An-'-under Penalty of perjury one of the following declarations: '
Ilaand will main a cei ineme of Consent to self-insure for Worker's Compete
saiion,as provided for by Section 3700 of the Labor Code,for be Performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,As required by Section
37W of NC Iabm Code.for the performance of be work for which this permit is issued.
My Worker's Compensation Insumntt carrier and Policy number am:
Carrier. Policy No.: -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not M complcmd Eche permit is for one hundred dollars($101)
or Ices.)
1 certify,that in the performance of she work for which this Permit is issued.I shall not
employ any person in any manner an As W become subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Cenilica¢of Exemption,you should `
become subject to the Worker's Compensation provisions of the Labor Code,you must
7z forthwith comply with such Provisions or Nis Fastest shall the deemed rcvakcd. l
�a CONSTRUCTION LENDING AGENCY
I heathy affirm that there is a construction lending agency I'nr the performance of
Ys> to work far which this permit is issued(Sec,3097,Civ,C.)
1 Q Under''s Name
= y Under6 Address
I cenify that I have mad this application and sate that be above information is
y coned.I agree to comply with all city ad county ordinances and stale laws relating to
�Ubuilding construction.and hereby loomim representatives of this city to enter upno the
G ahom-mentioned property for infection purposes.
(Was)agree to rove,indemnify and keep harmless the City of Cufenino against
r N liabilities,judgments.costs And expenses which may in any way accrue against mid City
J in e of the granling of
APPLICANT UNDERSTANDS tAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signamre of Applicam/Convecmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant ane or handle haea akin material
As defined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
Code.Section 35573(x)7
Fl Yea ON. All roofs shall be inspected prior to any roofing material being installed,
Will the applicant or future building Occupant no equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haxmdrus air contaminants As defined by the Bay Area Air Quality Management all new materials for inspection.
o'troi?
0Yea 0 N
Its
mad the ha>aNOus materials reyuircmcnks under Chafo:r E95O(thc Califnr
nice Hcol"Safcty Code,Se ma25Ns5,25533md25534.1underswndthatifthe Wilding
dms not cuocn0y ban a tenant,that it is my responsibility m nodfy the Occupant of the
roquirementawhich most IM met prior it)issuance ofaccthrmmofOccupancy, Signature of Applicant Date
Owner or authorivnd agent Date All roof coverings to be Class"B" or better
� 3
City of Cupertino Bu ilding Permit Application
E-Mail
jobsite Address: 19787 La Mar Dr. Date: 9-29-03
Owner's Name:---Agoston, Max
Phone No.(408)253-2343
APN#: 369-10-026 Project Valuation: $ 717.00
Building Permit Info: Bldg__--_-- Elect—_—_—_ Plumb------1L_—_ 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
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