03040087 CCCY OF CUPEwrINO r �rwt .2".•b.+34~ s� "`` " ?+.. `��..
BUILDING DIVISION PERMIT €CQN,TRACTORgINFO,RM ATI .;.,
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eUlY'RE lRODA DR JUST WATER HEATERS INC PERMITNQ.03040087
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lVb C IlELLEN M TRUSTEE 1764 NATIONAL AVE PBRM"`N7i6/2003
NE: -(510) 293-9901 SANITARY NO. CONTROL N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
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LICENSED CONnRd under
DECLARATION
I V I hereby affirm IMI I am lithe Bu under and
prows of Chapter 9(commencing Job Description
m with Seaion)IXU)of Division3of NC Business and Rpfessium Calls.and mylicc.c is
a< in full force and effect
; ? ucen.eClaa Lie.. REPLACE WATER HEATER FINALaE®
=�o Dow Contractor (4 0. GALLON GAS)
ARCHITECTS DECLARATION
I understand my plana shall he used as public records
3�u APR 2 2 2003
o� Licensed Professional
•u, OWNER-BUILDER DECLARATION
i F I hereby affirm that I em exempt fru.the Contrsssu's License Law for the BUILDING
O O follow ing reason.(Section](131.5,Business and P ofession Code:Any city or county
42�a which requires a permit to emoMmet,abut,improve,demolish,or repair any struma u
uZi prior.its issuance,also requires the applicant for such Permit o file a signed statement
SS< that lie is licensed pursuant in the provisions ofthe Contractor's LiccrowLaw(Chapter 9 Sq. Ft. Floor Area Valuation
[t-D (commencing with Section 70(y)of Division 3 of the Business and Professions Cods)or
`C that hais emmpI thelefmm snit the basis far Ne alleged exemption.Any violation of 90
Section?031.3 by any applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not mo.than five handled delta.(S50o). P Y YP
01.as owner or 0.propel.or my employees with wages As their sole compensation, 36933050 . 00
will do the wont,and Ne suunum is not intended or offered for sale(Sec.7094,Business
and Professions Code:The Contnnor's License law dors not apply to an owner of Required Inspections
property who builds or improves thereon,and who drays such work himselfor through his 502 — FINAL PLUMBING ENERGY
own employees,provided that such improvements are not intended proffered for Axis.If. SO6 — GAS TEST
however.me building or improvement is sold within one year of completion,Ne owner.
builder will have the burden of proving that he did not build or improve for purpose of 507 — FINAL PLUMBING
sale.).
❑h as owner of the property,am exclusively contracting with licensed conlracma to
. convect the project(Sec.7044,Business and Professions CodkI The Counselor's U. .
cense Law does not apply to an owner of property who Wilds or improves theaon,and,
who contracts for such projects will a contractor(s)licensed pursuant to the Contractors
License Law. .
❑I am exempt under Sec. ,B&PC for this resaon
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby tlaw under Penalty of perjury one of the following declarations:
I have and will maintain•Certificate of Cnnsent to sel6insum for Worker's Compen-
anion,as provided for by Section 3]00 of the Labor Code.for the Performance Of the
work for which this permit is issued.
❑I ban and will maintain Walker's Compensation Insurance,as required by Section
l]00
office Ls Wr Code,for the performance of on,work far which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Cartier. Polity No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompetediftbe permit is for one hundred dollars(SIM)
or ks$.)
I certify mat in the performance Of the work for which this permit is issued.1 shall nut
employ any person in any manner an as an become subjectin tbe Workn'Compensation
Uwe of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Com p.wtion provisions Of she Lion rCode,you must
D forthwith comply with such provisions or this peon it mall W deemed myokcd.
ti O - CONSTRUCTION LENDING AGENCY
1 bemby aRrm Nu Nem is•comwninn lending agency Ino low Iw,formal.of
L' the wish fur which this permit Is issued(Sant 3(19].Civ.C.) /1
Y Lender's Name
Add. .-f,N�/✓Yl L/
7 z Lcndcr's Address ,
J Q 1 cenify,that 1 have read this application and slow Nat the alien information is
1,Hcorrect.I agree.comply with all city and county ordinances and state laws relating to
�U building construction,and hereby aulhorne reprommadws of this city to enter upon the
4 a1mve-mentioned property for Ins arcupn purposes.
r (We)agree to save,indemnify and keep harmless the City of Cupertino against
y
liabilities.Judgments.cora and expenses which may in any way seems against said City
..I z in cmtmgmnce of the granting of this perm it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Signemrc of ApplicaDatc Re-roofs.
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Willy t applicant or foam building e.Chaputo.12.handle Health And
as defined io the Cupertino Municipal Cade.Chapter 9.12.end the Health and Safety
IndmsCale,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Yes ON.
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 hamrdous air contaminants as defined by the Bay Area Air Quality Management
mrict? all new materials for inspection.
❑Yea ❑NO
I have mad the hamaJ us materials requirements under Chapter 695 ofNe Califor.
Heal"Safety Cale,Savory 25505,25533 and 25534.1 mukrsanl mu if me kilding
not currently have a tenant,that it is my re po.ibility to notify tho Occupant of Ne
wrementswhich mum kmet poor in issuance ofaCemlicawofOccupancy. Signature of Applicant Date
Owner or authoriucd agent Date All roof coverings to be Class "B" or better
r e � pC�Lc� DO
City of Cupertino Building Permit Application*
E-Mail
Jobsite Address: 10681 La Roda Drive Date: 4-16-03
Owner's Name:--Martin, Ellen
Phone No.408) 252-6078
APN#: 369-33-050 Project Valuation: S 890.00
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: permlts@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
Name on Card: ,Just Water Heaters Inc.
Expiration Date: 9/05
Visa MasterCard
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