03070061 r: CITY OF CUPEWrINO
BUILDING DlvlsloN. PTRMIT ECOlvTRA.CTORINT'OItMATION ,:.
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT N00307006I
0223 MARY ANTR
OWNER'S NAME: 1764 NATIONAL AVE PERMrr L�uE VATE
NE. (510) 293-9901 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o o LICENSED CONTRACTORS DECLARATION
U C I thereby from that I on Retraced under provisions of Chapter 9(amorameot, .lob Descriptiioan`if tl ate.
a�m with Svction]IXXI)of DivlOon]of the Busivn end Pmfcssinv Cudc.end mylic.nsc is V Cm 7D
al in full fmceand effect.
;g? License Class LM.« REPLACE WATER HEATER
Dam ConTS DELL (40, GALLON GAS) AUG 5 2003
ppW3
ARCHITECTS W ie DECLARATION
C I undcraunJ my plain shall M tied as public comms
JdU
5or� Licensed profes,innel BUILDING
Oat 1..BUILDER DECLARATION
4 I hereby Maso .SLC that 11. exempt from the Contnmoo :Any C Low fur the
w D following moms(amrit t ]1151.5,Business and improve,
de nv Code:Any city or Loamy
<m which its isuapermiue cnnsw0.pike int for audemolish,fie a sig anyatmctum
pat heor toir ictored ,also requirestoheh.applisof for Cmttrarmit to file Law ned(Chapter
gg < IhatheencinnxJpontionWahcfmviviovnfthe Contmnessanicenm4wlCode)or Sq. Ft, Floor Area Valuatio,�909
Y $ (cat he Is
(Commencing Secucafr m and of basis
3 of theBusiness
exec prion.Any Vi Code)or
a, Net he b tempt Ncmhom and dm bvis for one alleged exemption.Any violation of
Section 7051.5 by any applicant for a permit subjects the applicant to a civil penalty of 3258ffi2 6*cr00 Occupancy Type
not mom Nen Jr.hundred dollars($500).
❑ I,as owner of the proporny,or my employe"with wages as their sale compensation,
will do Oc work.and the structure is not intended or offered for sale(Sec.7044.Business
and Professions Code:The Contractor.Lt...Law does not apply to an owner of 502 - FINAL PL ui B IN�eCtion GY
pmpeny who build,or improve.Hereon,and who does such work himself.,through his
own employees,provided that such improvements are not intended or offered for ale.If, 506 — GAS TEST
however,Ne building or improvement i,sold within one year of completion,the owner.
builder will have the human of proving that W did not Wild or improve for purpose of 507 — FINAL PLUMBING
sale.). \
(]I.as owner of the progeny,am exclusively contracting with liceved conactort to
onsmer the pmjcct(Sec.7044,Business and Prufcs iom Cade:)The Contractor:Li. '
Leve Law ducat not apply to an owner of property who Wilds or improves Oemon,and .
who contracts for such projects with a eomnctor(q licensed Pont to Ne Contractor's
License La .
❑1.exempt ander Sec. .B&P C for this...a
Owner Dam
WORKERS COMPENSATION DECLARATION
1 hereby&Ran under penalty of perjury one of the following declarations:
I have and will maintain a Ceniricate of Consent o salfdvum for Worker's Courtie
r-
tion,as provided for by Section 3700 of the Labor Cade.for the performance of Ne
for which this permit is issued.
have and will maintain Worker's Compensation Insurance,as required by Section
of Nc Labor Code,for Ne performance of Ne work for which Nis permit is issued.
Worker's Compensation Insurance carrier and Policy number art:
rtier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section need not bec.mPlmcJ If t W permit is fnronc hundred dallan($100)
or[car.)'
1 certify Not in the performance of the..,it for which Ni,permit is issued,I,hall out
employ any person in any manner m as in become abject to the Workers'Compensation
Laws of California.Dam
Applicant -
NOTICE TO APPLICANT:If,after making this Cenifcam of Exemption,you Nnu to
become mhject to the Worker's Com formation provisions of the labor Code,you must
.JO farlhwith comply with rush frevioines m do.permit hall Ise deemed revoked.
z CONSTRUCTION LENDING AGENCY
I hereby Affirm
�-+ Oat iaam Sce.Y 7.Chgagency for the performance of
Uj ti Lto eaderk fur which this permit is issued(Sec.3fN7.Civ.CJ �1
Z)IL7 A Leader',Name
z Lender's Address
V Q 1 minify that 1 ban mad this application and sate Nat the aWw information is
iy F correct.I ogre,to comply wit all city and county on inures and sum laws misting to
DV building convection,and hereby authorize MPrvenktives of this city or enter upon the
Y, W AWK-raemitmed property for inspection purposes.
f. (We)agree to save,indemnify and keep harmless the City of Cupcnina against
r N liabilities,judgmcnts.costs and expense which may in my way mcnic against mid City
V Z in coneequcnce of the grooming of this permit.
ti APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. 91toel
Re-roofs
Signature of ApplicanOCommeLar Desk
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or rumu ,building occupant store or handle mu mous material
as defined by to Cupenin.Municipal.Cod..Chapter 9.12,and the Health end Safety
cad.,section All roofs shall be inspected prior to an roofing material being❑Ye, ❑N. P P Y g g installed.
Will Nor applicant or future building Occupant tax cyuipmcnf.rJcvicet which If a roof is installed without first obtaining an inspection,I agree to remove
,it havamnuac,contaminants ss dcfred by the Bay Ames Air Quality M....Chen, all new materials for inspection.
ntrici?
Oyes ON.
than read Jin hvardnusmawHals mquimmenu under Chapkr6.95 of Ne Caliror
nu Heslth&Safety Coda S.cuma n505.25533 tkwl n5N.l undcnund taw if he Wilding
dors not currently hast a eaumL that it is my responsibility to notify the occupant of th.
myuimments which must W met poor to issuance of a Ccrufmcak of Occupancy. Signature of Applicant Date
Owner r authori>sJ agent Dam
All roof coverings to be Class "B" or better
r.
037 �" � �
City of Cupertino Building Permit Applicatio n
E-Mail
Jobsite Address: 10321 MaryAve. Date: 7-8-03
Owner's Name:---Powers, Dennis
Phone No.(408)252-5564
APN#: 326-52-004 Project Valuation: S 909.00
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-mall: 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/l/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679
Name on Card: just Water Heaters Inc. Z2 1 3
Expiration Date: 9/05 �j0 GI
Visa MasterCard
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