03080072 CITY OF CUPEWFINO
BUILDING DIVISION PERMIT CONTRAGTQRINFORMATION
BUILDING ADDRESS: JUST WATER HEATERS INC PERMITNO03080072
OWNER'S NAME: 1764 NATIONAL AVE PERMIT ISSUE DATE
ASH ROBIN T AND CHERYL G 08 /15/2003
ONE: (510) 293-9901 SANITARY NO. CONTROL NO.
Im
CHITECT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
10Lm that I LICENSED CONTRACTORS vi,im, ATION
rChap
I berchy affect that I em Of the
nd under provision.of Chapter 9(commencing lob Description
i¢ h Section70)(B(feet. 3ofthe Business and Profession Code.and my license Is
s ull force anJ cf(en. RIVALED;� nse ClMs Lim.N REPLACE WATER HEATER r'�A ® E®
ctotrxcwr (50 GALLON GAS) ami.
ARCHITECT'S DECLARATION
I understand my plans shall the used as public records Q[gT _ry a.Loo�
),u SEP (
sQ� Licensed Pmfcssi...I -.
$ 5 OWNER-BUILDER DECLARATION
7<Y I hcrehy.(Sero that I am exempt from the Connector's License Lew for the �'�'��
$ following massa.(Senium]onstr t.alter, and Professions Code:Any city ter county
which its issuance.
s u a Permit re quires t e,alien improve,h Perlia nr repair any structustatement
-mi 'hat hepoor incensed pursuntto thstbeisionnt for suchparmiuofile aicense ned aw(Chlcmcot
< that he is Sq. Ft. Floor Area ValuatiO$844-
u�S (commencing wi th Scaion7")of Division 3 of the Business and Professions Coofor
— Nat he is exempt do ref ion and the basis for the alleged exemption.Any violation of
Section 7011.5 by any applicant(or a permit objects the applicant to acivil penalty of 3�s'{N0,1f 1cx 0 0 Occupancy Type
not mare man rove hundred do]]..(goo). P Y YP
❑I,u owner of the propeny,or my employees with wages As their sole compensation,
will do the work and 0..wctum is not intended or offered for sale(Sec.]044,Business R dhS�e ttO�S
and Professions Cade:The Contractor.License Law dace not apply to en owner o! 502 FINAL PPL�B I NG c N t':RGY
prepeny who builds or improves themon,and who does such work himself or through his
own employees,provided that such improvements are not intended of offered for sale,If, S06 — GAS TEST
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving ton M did not Wild or improve for purpose of 507 - F I NAL PLUMBING
ole.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to --
condmact the project(Sec.7044,Business and Professions Code:)The Convector's Ll- .
cense law docs not apply to an owner of property who]milds or improves thereon,and
who contracts for such pmjecm with a contractor(s)licensed pursuanun the Certainties
License law.
❑I em exempt under See. B A P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby aRrm under penalty of perjury one of tbe following declarations:
I have and will maintain a Certificate of Conant to wif-insure for Worker's Compen.
satian,ss provided for by Section 17IX1 of the labor Code,for me performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
5700 of the labor Coda,for the Fortiori of me work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF FXEM"ION FROM WORKERS'
COMPENSATION INSURANCE
oltis section need not hecompated Blue:permit I.for one hundred dollars(91(1)
r less.)
1 certify Nm in the performanee of me work for which this Permit is issued,1 shell not
employ any person in any manner an As to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccnificae of Exemption,you should '
Became Suhjcm to the Worker's Compensation previsions of the lahnr Code.you must-
�0 fomwi th comply with such provisions or this term it shall be deemed revoked.
z CONSTRUCT]ON LENDING AGENCY
]hereby affirm that mite is aed(Se.constructionW7 lending agency lot Performance of
1' the dura for which cols permit i.issued(Sec.J(yJ],Civ.CJ kid.
YQ Lender's Name
D z I<nder'Mddrru
J Q 1 certify that 1 have read this application and state that the steam information is
U. correct.l agree to comply with all city and county ordinances and slam laws relating to
�O building convection.and hemby authorize representatives of this city to enter upon the
Na above-mentioned property for impaction Pmpaus.
(We)agree to sam,indemnify and keep harmless dte City of Cupertino against
ti rn liabilities.judgments,costs and expenea which may in any way scenic against said City
J7 in consequence of the granting of this Permit.
tam- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REGULATIONS,
Re-roofs
HAZARDOUS
Signamrt of ApplicaData
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF
Willy the Cupertino
Municiputure al ode,Chapter 9A2.
handle Health us and Safety al
as defined by the Cupertino Municipal Code,Chapter 9.11,rod the Health and Sa(ny
Code,Section25571(a)?
❑Ym ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant ase equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove -
dt haaardous air contaminants as depred by the Bay Area Air Quality Management all new materials for inspection.
uict7
❑Yes ❑Nu '
I have read the hmaNam mamrialsmquimmcnu under Chapmr6,95 of the Califnr.
nis Healthk Salcty Code,Secuun 2550S,15511 and]5554.1 understand that if the building
does not currently ham a tenant,that it is my responsibility to nodty the ueaupmt of ma
requircmcnu which most M met show issuanceofs CcNfcam of Occupancy. Signature Of Applicant Date
Owner or as hoid,ed agent Date All roof coverings to be Class"B" or better
3e� � �Z
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 21 810 Rlfredi Ct. Date: 8-4-03
Owner's Name:---Robin Ash
Phone No.(408)464-3107
APN#: 357-16-121 Project Valuation: $ 844.00 .
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: Oulce 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: 4/1/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679 Z2� cL
Name on Card: just Water Heaters Inc.
Expiration Date: 9/056
Visa MasterCard
Comments
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