03090135 C Try OF CUPBR'PINO rNa'. x te' and u: t=Sa3 r'
BUILDING DIVISION PERMIT ,fiCONTRAC-TOR.INF0RMATI0N
g BUILDING ADDRESS: JUST WATER HEATERS INC P�"b'ITNDO3O9O135
041 - MARV A17
OWNER'S NAME: 1764 NATIONAL AVE PERMITESURDATE
ONE:
(510) 293-9901 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
loo LICENSED CONTRACTOR'S DECLARATION
1 hereby affmm that 1 am nerved under provisions of Chapter 9(commencing 106 DeSCrIpUO0
with llSection
and of of Division 3.1'the Bmirca end Profevinm GWC.and my license is
infunfclaustdeffeet. FINALED
Licenseclasa ueg REPLACE WATER HEATER
=�,o Dam Comracmr (4 0 GALLON GAS)
e'SSty ARCHITECTS DECLARATION ,g Q Z ']
eC� l understand my plans shall he used as public records NOV 4 0O3
6D
a O y Licensed Professional
N�q 5 OWNER-BUILDER DECLARATION
X X 1 hereby af0rm that 1 am exempt from the Contractor's License Law for the BUILDING
O O following reason.(Submit M31.5,Business and Pockseinns Chile:Any city err county
$ which requires a permit to construct,alter,improve,demolish,or repair any structure
u¢N prior In its issomec,also requires the applicant forsuch permit to file a signed statement
F< that he is licensed pursuant n the provisions of the Contracmri Lkensc Law(Chapter 9 Sq. Ft. Floor Area Via l u ati� G$796 '3$ (commencing wi in Section 70L`0)o(Division 3 of the Business and Professions Code)or Y
Out he is exempt dandrome and the basis far the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of3 238912-05tcr0 0 - QGGI araC Type
not more ton five hundred dollars(8500). --' - " ---- P y --- - -
❑ 1,as owner of the property,m my employees with cages of their sole compensation,
will do the work,and the structure is not intended or offered for Zak(Sec.7014,Business; ��aa����ee
and Professions coda:The Contractors License Law dots not apply to an owner of 502 - FINAL Required
quMB Inspections NpeCtions
property Who builds or impoves descon,and whodoes such work himself orthrough his
own employees,provided that such improvements,are not intended oroRered for sale.IL 5O6 — GAS TEST
however,Ne building or improvement is sold within one year of completion,the owncr-
builder will have the burden of roving that he did not Wild or improve for purpose of 507 - FINAL PLUMBING
❑1,as owner of Ne property,am exclusively contracting wit licensed contramors to
convect the project(Sec.7044,Business and professions Cade:)The Contractor's Li.
cense,law does not apply to an owner of property who builds or improves themon,and
who contracts fur such projects with a confractor(s)licensed pursuant to the Commences
License Law.
❑I am exempt under Seo. B x:P C for this..ad
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pemlry of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent o self-ivuo for Worker's Compere
cation,u provided for by Smion 3700 of the labor Code.for the peAmantt oeof the
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,as required by Section
"I of the labor Coda for On Performance of Ne wad for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number art:
Cartier. Por icy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlesection died not he completed R the Permit is for one hundred dallara(SIM)
less.)
1 cenify Nat in the performance of the work for which this Permit is issued,1 shall not
employ any person in any manner an as W became subject to the Workcrs'Compensation
Lawa of California.Dam
Appli
E
NOTI [)
NOTICE TO APPLICANT.I F.Compensation
this previsions
ofExemption,dyds,should ,�^n
y become subject y the Worker's Compensation provision of tde labor Code,you mtsu
D /_, foahwithcnmplywith such provision or this Permit mall Wdeemed revoked.
ZO CONSTRUCTION LENDING AGENCY
1 hcroby affirm Out there is a convection lending agency for the Performance of
x the work for which this permit is issued(Sec.3(N7,Cry.C.)
31 AUndcr's Name
1 z Lcndcr's Address
7
J 1 anee than have mad thisapplication
anand Sam that me above information mfatiun is
y F building 1 agate m comply with all city and country ntativ s of and Sam laws r upon
to
C.7 movengconsuuctidn,and hcoby authonpuMpresemetives of thiuity mcnmr upon the
a ahovc(Wo) und agree
for inspection
mnify ad keep hs.
(We)agree to case,and expenses
and kith hay in an the City of Cupenst against
h in
citjnce of ccocaand of this esmit. may In anyway accoe against Mid City
Jz APPLI ANT of UNDERSTANDS
this Permit.
� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaData
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hasucamus
and
as donned io the Cupertino Municipal Code,Chapter 9.13,and the Health end Safety
o
de,Section 235J2(e)? All roofs shall be inspected prior to any roofing material being installed.
❑Yea 71 No
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 hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials For inspection.
suie?
❑Yes ON.
I have mail the haxamous materials requirements under Chapter 6.95 of the Califory
Health h Safety Code.Scenic.25505,25573 and 25574.1 undersand mat iftle Wilding
cs not currently him a tenants Nat it a my responsibility m notify the occupant or me
ulmmena which mutt IN,met prior to issuance ofa Certificate of Occupancy. Signature of Applicant Date
Owner or.uthorixed agent Date All roof coverings to be Class "B"or better
' D3
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 10415 Mary Ave. Date: 9-18-03
Owner's Name:---Liu, Yang
Phone No.(408)517-1036
APN#: 326-52-050 Project Valuation: 5 796.00
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: permits@j ustwaterheaters.net
City, State and Zip: Hayward, CA. 94545
State Contractor's License# 591 329 Exp. Date: 3/31/04
Worker's Camp#: 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.
Expiration Date: 9/05
46
Visa MasterCard
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