03060142 CITY OF CUPERTINOd ,. r ,wm?'k
BUILDING DIVISION PERMIT 4CONTRACTOR INrORMAThON .
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT ND03060142
OWNER'S NAME: 1764 NATIONAL AVE PERA11T ISSUE DATE
NE: (510) 293--9901 SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
= =
u o p LICENSED CONTRACTOR'S DECLARATION Job Des
4w 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing v®
nte1 with Seen..7000).f Division 3o(IW BuMmuramd Professions Code,and my license is
aLi,,nwfull nmand erree'' REPLACE WATER HEATER
= LWanseG1as, Lie.N OCT 2 1 2003
Dow-am.CL (4.0. GALLON GAS)
ARCHITECTS DECLARATION
1 undciapnd my plans shall he used as Public records
;W
C Licensed Pmfcssianal - BUILDING .
OWNER-BUILDER DECLARATION
M I hereby affirm that 1 em exempt from the Contractor's License Law for the
00 following moon.(Section 7131.5,Business and Peffetedmn Code:Any city or county
.�m lar which requires a permit to cnm(uct,site,impmse,demnluh,of affair any nromum
ZS^ prim In its issuonec.alm mquims the applicant farmth permitm fileasignednatemcnl
xx< that he is licensed pursuant othe provisions Of the Contractor's License Law(Chapter 9 Sq. Ft, Floor Area Valuat3O$600
FO nammercing with Section 7")a(Division 3 of the B uainens and Noressions Code)or
i $ that he is exempt thcmfmm and the basis far the alleged exemption.Any statelier of
gecdon7(31.5 by any applicant far a Permit subjects fee applicant o a civil Penalty of 32 J`194`0jh*cr00 Occupancy Type
not mart Nan five hundred della.(SSD().
❑I,u owner of the property,or my cmploycc with wages as their sole campewtion,
will do the work,and the swclum is not intended or offered fonato(Sm.7014,Business
and Professions Code:The Connector's License taw does not apply to an owner of Required Inspections
Property who builds or improves themon,and who does such work himselfarthmugh his 502 FINAL PLUMI3ING ENERGY
awn employees.provided that uch lmprovemenu an not intended oraffemd fortune.If. 506 — GAS TEST
however,the building or impmwmem is mid within ane year of completion,the owner-
builder will haw the burden of proving that he did ret Wild of improw for puryose of 507 - F I NAL PLUMB I NG
tile.).
❑h as owner of me Intercity,am exclusively contracting with licensed carnation to
constant the project(Sec.7044,Business and Professions Code:)The Contractor's Li.
cense Law does not apply to an owner of property who builds or harrows themon,and .
who contracts for such projects with a conumtoos)licensed pursuant W the Contractor's
Lice=law.
❑1 an exempt under Sec .B&P C for Ihia moon -
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affan under penally of perjury ane of the following chelonian
1 haw and will maintain a Conran of Consent to se14Wum for Warkoes Comfort,
aslion,as provided for by Section 37M of the ISWr Code.for the performer of im
work for which this Permit is issued.
❑I Mw and will maintain Workers Compensation Inmnnce,as required by Section
37W of the Lator Code,far the perfarmmce of Ne work for which his permit H issued.
My Worker's Compensation Insurance crier and Policy number mi
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This otMon need not be tionicted if the permit Is Inane hundred dollars(1100)
or less.)
I certify that in the performance of the work for which this Permit is issued.I shall not
employ any Whom in any mmnerm u W become subject to the Workeri Compenpuan
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation previsions of am Labor Code,you must
.JO forthwith comply with such provisions or this petmiul.11 be deemed revoked. /1
ZN CONSTRUCTION is ICONLENOINGAGENCY
Ihet by which rte mnmeniucoasSec.30 lending agency for dm fcrfurmermc of /)/��/dIW/)wAvY`/'. U✓ `.'`
C' me work fur which this permit is issued(Sec.309'!,Civ.C.)
W z Lender's Name
� z Lender's Address
V O 1 certify that 1 haw read this application and slam that he above information is
W F correct,l agree to comply wife all city and county orlinarcn and state laws misting to
pU building construction,and hereby submim refmxntniws of this city to carer upon the
u7 abave-mentumcd property for impecuon purposes.
a (We)agree to on.Indemni fy and keep families the City of Cupertino against
.y to Liabilities,judgments,costs and expenses which may in any way accrue against mid City
I.C) hi,Permit,
APPL Ce
ANTUNDERSTANDS of the analog Or tAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signature of ApPlicDem
HAZARDOO US MATE RIALS DISCLOSURE Type of Roof
Will the applicant
upert or future building Occupant,Chpt slam or handle Haddeus material
as defined by the Cupertino Municipal Code,Chaffer 9.13,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to an roofing material beim installed.
❑Ya, ❑Na P P � Y g g
wit me appnaart of mtare building o capers am equipmentatdevi ea which
'If a roof is installed without first obtaining an inspection,I agree to remove
it Mnit nua air cnnmmnnmls u dcfmcd by the Ray Ana Air Quality Management all new materials for inspection.
atria?
❑Yos ❑Nn
I haw read the Wand,Ws materials requirements under Chapter 6.95 or be Califim- �
itis Health&SafclyCom.Sections 25505.75533 atat 25534.1 undersand feat if lM Wilding
data not curcmly haw a remain,that It u my res,andhility W noufy the WCUPant of the
requirements which mut be met Our W issumce ofa CMOcac or Gccupmcy. Signature of Applicant Date
Owner or amharizcd agent Dam All roof coverings to be Class "Ba or better
3 ,-) c)
City of Cupertino Building Permit Application
E-Mail
jobslte Address: 20531 Shady Oak Ln. Date: 6-23-03
Owner's Name:---Carter, Mikery
Phone No.(408)720-9268
APN#: 323-44-014 Project Valuation: S 600.00
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®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. 2-2,
Expiration Date: 9/05 c 6/
Visa MasterCard ® o
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