03110099 CITY OF CUPERTINO '"�° " s.' t :ox
BUILDING DIVISION PERMIT CONTRA CTOWINTORMATION
Ru1LDINGADDRESS: JUST WATER HEATERS INC PERMIT N003110099
OWNER'S NAME: PERMIT ISSUE DATE
'NICOL LAURA E 1764 NATIONAL AVE 11/20/2003
NE: SANITARY NO, CONTROL NO.
(510) 293-9901
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
100 LICENSED CONTRACTOR'S DECLARATION ��!'T��® O
V 1 hereby af0am
rm that I licensed under provisions or Chapter 9(commencing lob Descrlptlonr
with Section 701 )or Division 3 of the Business and Professions Code,and my license is infull room and effect, REPLACE WATER HEATER
,✓�Z Dam class Cuni (50 GALLON GAS) DEC 3 2003
f Dam TS DE or.
ARCHITECTS use DECLARATION
< I pnderstanJ my plans¢hall um oseJ es public¢cords n
s0
Licensed BUILDING
OWNER-BUILDER DECLARATION
<7 1 hereby of firm that 1 am exempt from the Contractor's Literati Law for the
COO following reason.(Section 7031.5,Business and Pmfcssinm Code:Any city ar county
$ which requires a permit to construct.alter,improve,demolish,or repair any structure
prio,1.its issuoncc.also requires the applicant for such pemiuo Ele a signed statement
EE < that he is licensed punuanunthe Provisions ofthe CommetorsLicenxLaw(Chapter 9 Sq. Ft. Floor Area Valuatic$17 0 0 -
t�p (commeneingwith Section 70X)of Division 3 ofthe Businwand Professions Core)ur
$
that be Is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7831.5 by any aledicmtfor a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than Bw hundred dollars MOB. 34214022 . 00
I.as owner of the Property,m my empl.ydu with wages As their sole campenutinn,
will do the work.and to.¢net..is at intended or offered formic(Sec.7044,Business
and Pofesions Code:The Contractors License Law does not apply to sa owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements us not intended oraRcmd fmmle.IL
however.the building or improvement is sold within ON yeas of completion.Ne owner.
Wilder will have the burden of proving duet he did not Wild ar Impmve fur purpose of
sale I
❑1,as owner of the property,am exclusively contracting with licensed contractors to
cowmct the project(Sec.7(x6,Business;and Profession Cade:)The Conuacmrs Li•
cense law does not apply m an owner of property who Wilds or improves menton,and,
who concocts rot such projects with a contracmr(s)licensed pursuant to the Contractors
License Law.
❑l am exempt under Sec. B k P C(a,this mason
J.Pwrcr Data
WORKER'S COMPENSATION DECLARATION
1 hereby afrirm under penalty of perjury aro of tee following declarations:
1 have and will method.a Cendmi or consent a self-insure for Workers Comped.
cation.m provided for by Section 3700 of the Labor Code,for the Performance of the
work for which mis permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
370E of the labor Code,for me performance of the work for which this permit is issued.
My Workers Compensation Ineamncti carrier and Policy number am:
Cartier: Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed I(the permit Is friend hundred dollars($IQ))
.r less.)
I eenify mm in the performance of the work(or which this permit u issued,l shall not
employ any person in any manner an as to become subject o the Worker'Compcusation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this cenificam or Exemption,you should
become object do the Worker's Compenation provisions of the Labor Code,you most
=`,L, forthwith comply with such provisions or this permit shall bo dimmed revoked.
z O CONSTRUCTION LENDING AGENCY
1 herehy afros that mere its Construction lending agency for the Performance of
^L the work for which this pandit u issued(Sec.3897.Civ.C.) 0
vv
CLi Q lender's Name
Z IenJerE Add.Cz)
U O 1 certify that 1 haw read his application and¢tate that the above Information is
Ty P comet.1 agree to comply with all city and county ordinances and such,laws relating to -
�U building construction.and hereby minnow representatives of mis city to crime upon the
r W shove-memimed Property far inspection i mpascs
(We)agree to save,indemnify and keep humlem the City of Cupertino against
N liabilities,judgments,casts and expenses which may In tiny way accrue against mid City
U Z in consequence of to groat ng of this permit.
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
Re-roofs
HAZARDOUS
Signature of ApplinData,HA2ARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future building occupant erre or handle ha aNaasdSafety internal
as da, a by the Cupertino2(11)? Municipal Coal Chapter 9.12,red the Health and Se(ety
a r-1 ea2ssu(a)7 All roofs shall be inspected prior to any roofing material being installed.
r-1 Yea ONO
Will the applicant at future building Occupant rem equipment or devices which 'If a roof is installed without first obtaining an inspection,I agree to remove
sit he Mous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Diurict?
❑yes ❑Nu
1 have mad the ha,aNnusmemrials requirements unJct Chepmr fi95.rthe Califon
nia Heald.a,Safety Cale,Secu s255(15,25533and25534.1undersandmotifmc building
Jars not cumn0y how a octant,that Il is my responsibility m nouty the cupont N me
mquimmcnn which must be me,prior m issuoncc of a Ceni(icam of Occupancy. Signature of Applicant Date
Owner or authorized agent Dam All roof coverings to be Class"B" or better
I
City of Cupertino Building Permit Application
E-Mail
JobsiteAddress: 10136 Lebannon Dr. Date: 11-19-03
Owner's Name:---MCNicols Laura
Phone No.(408)620-8904
APN#: 342-14-022 Project Valuation: 5 700.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----- Mech-----------
Job Description
Replace 50 gallon water heater
Contractor Information
Company: Just Water Heaters Inc. Phone: (510)293-2012
Contact Name: Dulce Fax: (510)293-2022
Address: 1 764 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/l/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679
Name on Card: dust Water Heaters Inc. z3 8 /
Expiration Date: 9/05
Visa ❑ MasterCard
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