03110102 crrY of curESION PERMIT W-ONTRACWTOR+INFORMATION
BUILDING DIVISION t y •:?a ky,,.�__ t�
BUILD]NO A OGRESS: JUST WATER HEATERS INC PERMITN903 110 102
811 MINETTE DR.
OWNER'S NAME: PERMIT ISSUE DATE
=HIA BLANK 1764 NATIONAL AVE 11/20/2003
NE: SANITARY NO. CONTROL NO.
(510) 293-9901
ARCHITEC(ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
+00 LICENSED CONTRACTOR'S DECLARATION lob Description
e 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing p
e with Section 70farof Division 3ofthe taxi ncasano Professions Code,and my license is
;ire infull force and effect, REPLACE WATER HEATER p�
y res Z License Cloa Ll.as
F; Oate Contractor (50 GALLON GAS) ■vA! �®
eeY�Y'J` ARCHITECTS DECLARATION q
CW''i 1understandmyplimi ll he need as Fargo card, DEC , 2003
td3
a.l;; Licensed Professional
3 OWNER-BUILDER DECLARATION p�
f 1 hereby affirm phot I am exempt from the Contractors License Law for the y��')r pB'��
O O following reason.(Section WIT I.$.Business and Professions Code:Any city or county - Y w
g which requires a permit tit construct,alter,improve,demolish,or repair any structure
-iy prior In its issuance,alsu requires thmaFplicant forauch permit m film aligned stateroom
that he is licensed pursuant mthe provisions of the Contractor's Licenu law(Ch.arr 9 Sq.Ft. Floor Area Valuati($1586
z l-m (commencing with Section 7(1 of Division 3 of the Business and Profession$Cods)or
9 that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not more Nan It.hundred dollars(5500). 37532055 . 00
0 I,as ownef of tha prepeny,or my crd,d,mca with wage as their ante eompennetmo,
will do Be work,and the stromum is not intended or offered for sale(Sec.?044,Business Required Inspections
and Professions Code:The Choral License Law Joos net apply to an owner of q p
progeny who builds or improves thereon,and who doe such work himself or through his
own employees.provided that such improvements are not intended or offered for sale.If. _
however,the building or improvement is sold within one year of completion,the cameo-
builder will have the burden of proving that he did not build or Improve for purpose of
sal'.).
0 I,a no,of Jte progeny,am exclusively contracting with licensed conductor to
comvuct the project(Sec.7044,Business and probations Code:)The Convectors U.
come law don not apply to an owner of property who builds or improves thereon,and
who contracts run such p xjeets with a convectodt)licensed pursuant to the Commerce&
License La,
0 I son exempt under Sec. B sk P C for this reason
Ownef m
Da
WORKER'S COMPENSATION DECLARATION
I hereby effirm under pamany of perjury arc of that following dalaratiom:
I have and will maintain a Ceniricate of Consent nu rel&insure ro Wmkere Compon'
cation,u provided for by Section 37M of the labor Coale.for the perfomumre of the
work for which Nis permit is ounce.
0 1 have and will maintain Worker's Compensation Insurance
,as required by Section
37M of NC Labor Code,for dc P rImmancc of the work for which this permit is issued,
My Wnrkeri Compensation Insurance carrier and Policy number art:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is ror000 hundmdwllam(5100)
or las.)
1 cenify Net in the performance of the work for which this permit b found,I shall not
employ any person in any manner m u to hccomm subject o the Worked ComFensalion
Laws of California.Date
.Applicant
NOTICE TO APPLICANT:If,after making this CeniRcate of Exemption,you should
become subject m the Worker's Compensation provisions of the Lebo Code,you must
z forthwith comply with such provisions or this perm it hall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
1 herchy a1Bfm that there its connotation lending agency far the performance of C/t}IL
1' the work fur which this permit I$issued(Sed.TOO.Civ.C.) �-
111 Q I<ndw's Name
a.
z I<ndeft Addreu
U Q 1 cenify Net I have read this application and tam that the show information is
U, fr correct.1 agree to comply with all city and county remittances and Stam laws relating to
0U building consWetion,and hereby authorim repreaemativa ser this city to enter upon the
W abovomentioned property for impaction purposes.
11 (We)agree to save,indemnify end keep example.the City of Cupenino against
rat liabilities,judgments,costs and expenses which may in any way&come against mid City
U in consequence of Ne treating or this Permit.
'•' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAlEAR
Signature of Applicactor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant or future Muni bullinge.Occupant
ptelorcof hanand the
Health and
az ecfinw by the C2(en? n Municipal Lade.Chapter 9.12,mJ the Health and Safety
wee,see Ycs 2ss3xa>y All roofs shall be inspected prior to any roofing material being installed.
❑Yrs Otho
will the applicant or 0uum holding decanter use equipment m devices which 'If a roof is installed without first obtaining an inspection,I agree to remove
It hafamou air contaminants as dcftnod by the Bey Arca Air Quality Management all new materials for inspection.
win?
❑Yes ❑Nt '
I have mad the hounlous materials mquircmcnu under Chapter 6.95 or the Califon
Health A Safety Cwe,Sceuum 25505,25533 and 25534.1 undersand thmiftha Biding
ria 7c
dm not currently haw a moral,Nat it is my nommad Wily to notify the uprnt of the
requirement which must Is,mel prior w iawance of a Certificate or Occupancy. Signature of Applicant Date
Owner oranthofivedagent Date All roof coverings to be Class"B" or better
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 10811 Minette DR. Date: 11-18-03
Owner's Name:---Blank Cynthia
Phone No.(408)257-2753
APN#: 375-32-055 Project Valuation: $ 586.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----- Mech-----------
Job Descri tion
Replace 50 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 1
Name on Card: just Water Heaters Inc. L/
Expiration Date: 9/05
Visa MasterCard X
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