03040075 C;TY OF CUPER'I'INO A,
BUILDING DIVISION
PERMIT `CONTRACTOR INFORMATION'"
ayIdnV'bWKLEAF PL JUST WATER HEATERS INC PERMTTNo'03040075
ggfffW'JOSEPH M AND LINDA S TRIJ 1,764 NATIONAL AVE PERvflY"HA/'pC14/2003
(510) 293-9901
TONE: SANITARY NO. CONTROL N0.
ARCHITECTrENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
X00 LICENSED CONTRACTOR'S DECLARATION lob Description
iF I Mrcby affirm that I am licensed under previsions of Chapmr 9(commencing p
t<`u�' with Semion]gM17 of Divisian3of sere Business and Profcssinns Code,end myiicensc is
iq= infull form and effect. REPLACE WATER HEATER FINALE®
License Clear, Lic.p
c�o Dan Contractor (5 0 GALLON GAS)
ARCHITECTS DECLARATION
I I understand my pleas shell be used as public mcnrds APR 2 1 20 03
ot, Licensed Professional p�
g3 OWNER BUILDER DECLARATION BUILDING
I I hereby.('firm that 11, ascent from the Contractors License Law for the
O O which ng remora.(Section 7(Y31,3.Business and Professions Cade:Any city or county
3$� which myuires a permit m construct,alter,improve,demolish.or repair any awnum '
-Zi
Mor to in issuance,also mquirex the applicant for such permit to File a signed statement
YY< that he isliccmcdpursuant tnthe previsions nfthe ContractoisLicense Law(Chapter 9 Sq. Ft. Floor Area Valuation
ZFO (commencing with Section 70W of Division 3 of the B admits and Professions Conc)or
0 5$ that he is exempt therefrom and the bass for the alleged exemption.Any vinhati,on of $744
Section 7031.5 by any applicant for a permit subjects the applicant to.civil rally of .APNNumber Occupancy Type
netmon than five hundred call...(Mr. P Y YP
❑I,as owner of the m,n,or my mtployem with wage as their role compensation, 32618OS6 . 00
will do the work and the structure is not intended or offered for sale(Sm.7W Beat.
and Professians Cade:The Contractor's License Law docs not apply m an owner of Required Inspections
property who build,or improws th.......d who dasmch work himself.,through his 502 - FINAL PLUMBING ENERGY
own employees,provided that such improvements.re not intended ar.rr,.d for sale.It. SO6 — GAS TEST
however,the building or improvement is sold within oto year of completion.LIC mwM,'
builder will hive the burden of proving that he did not build or improve for purpose of 507 FINAL PLUMBING
sale.).
El I,as owner of the Property,am exclusively contracting with licensed eonlncrofa to
consuun the project(Sec.7W,Business and Professions Code:)The Contractors Li.
came Law dos not apply m an owner of property who Wilds or improves thereon,and,
who contacts for such projects with a matraemr(q licensed Fursion,to the Cmuraaor, ,
License Law,
❑I sonexempt under Sec. B&P C for this..on
Owner Data
WORKER'S COMPENSATION DCCLARATION
I hcrchy a(rre under pm.hy of perjury one of to following declaration,:
I hoe and will maintain.Cenifemc Of Consent to self-insure for Worker's Compcm
tion,re provided for by Section 3700 of the Labor Code,for the performance of Ne
work for which this permit is issued.
❑I have and will maintain Workers Compensation Imurvta,u inquired by Section
3700 of the Labor Code,for the performance of Ik were fo which this permit is issued.
My Work.,.Compensation Insurance nnicr and Policy number are:
Car Policy No.: 4
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This smaun need wt he completed if the permit is formic hundmo dullies($1a)
,it Mas.)
1 Certify that in the pkrfmmana of the wart for which this permit is issued.I shell not
employ any person in any manner an at to haeme subject o the Workari Compensation
Laws of Ci lifomia.Date
Applicant
NOTICE TO APPLICANT:It.after meting this Certificate of Exemption,you should _
become subject m the Warkcr s Compensation Provisions'mf the Laho Code,you must
�Q forthwith comply with such Mo•isinn.or Mrmit shall he demerit revoked.
r N CONSTRUCTION LENDING AGENCY
I hereby M.that there is a construction lending agency I'n..he performance of
Y. Y the work for which this permit Is issued(See.3097,Civ,C.)
S10
Leader's
� z Leader's Add.
Q 1 ttnee that I pane read Nis application and ser then and
abmw information mixing is
L U bonder I agree to comply with all city and county ordinances of and sum laws r Upon
m
7('J building mnsuuctproand forhermyOtwhorivrrepreumativesofthi,citymenterupnn thd
LT7 ahovc (We) nad agree
(iniarmify anpurposes
(We)agme to cove,indemnify and keep harmless the City of against against
Z in
equece of the granting
expemc,mit. may inanyway accmc against cold City
APPLICANT CcUNDERSTANDStAtND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
gignemrcof ApplicaHV ARacmr Dam
HAZARDOUS MATERIALScup.m.SCLOSURE Type of Roof
Will the applicant ser forum building ampapt oma or handle Health anmaterial
ai defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 35532(a)? All roofs shall be inspected prior to an roofing material being
C]Y"
❑Nu P P Y g g installed.
Will the applicant nr(marc building ocmpant use equipment or dcvicn which If a roof is installed without first obtaining an inspection,I agree to remove
Ii haxmdnux air mnmmimann m defined by the Bay Area Air Quality Management all new materials for inspection.
trier!
t]Ycs ❑No
I have mad the haka door materials requirements under Chapmr 6.95 o(the Califir
nia Health 6 SafetyCeek,Sections 25505.35533 am1255W.1 undersand Nairthe Wilding
docs not currently haw a teem,that it is my responsibility in nodty the oaupanl of the
requirements which must be met pelf to issuance of a Certificate of Occupancy.
Signature of Applicant Date
Owner or authorized agent Date All roof coverings to be Class "B"or better
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 10029 Oakleaf Place Date: 4-14-03
Owner's Name:---Weiss,Joe
Phone No.(408)253-6878
APN#: 326-18-056 Project Valuation: 5 744.00
Building Permit Info: Bldg--------- Elect-------- Plumb------X----- Mech-----------
Job Description
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 #: 5474-6390-0026-5679f �/ u
Name on Card: ,Just Water Heaters Inc. G�t , l� 1
Expiration Date: 9/05 p
Visa MasterCard
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