03040135 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �CoNTRe�CTUR INFORMATIONx "�
i 'l4glff0SfiTOKES AV JUST WATER HEATERS INC PERMIT NO 03040135
TM`?MG 1764 NATIONAL AVEERMTTs�e��0/2003
NE: (510) 293-9901 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
yO6 LICENSED CONTRACTOR'S DECLARATION JobDescrition
w i hereby affirm Nal I con licensed under provisions of Chapter 9(commencing p
i9 with Sxtkn7")af Divi.m.3 or We Buineu and Prnfeuims,cMA.md my liana is
"�,% infunfoneanderfem. REPLACE WATER HEATER ���� ��
op a Umose clan. Lic.g
qqq Dam comourour (4 0 GALLON GAS)
ARCHITECT'S DECLARATION t 2�0�
I understand my plans shall, a used public records MAY 1
DyU
c Licensed Professional
OWNER-BUILDER DECLARATION
I 1 herchy affirm that I am exempt room the Contractors License Law far the BUILDING
0 o following moon.(Section 7031.5.Business and Professions Code:Any city at county
$ which requires a Permit to cnnuruc4 alar.improve.demN W,of repair any structure
prior to its issuaae,cels,requires the applicant for such permil to files signed stsmmem
�r< that he is licensed pursuant to the provisions lithe Contractors Lee=law(Chapta9 Sq.Ft.Floor Area Valuation
��Q (cmaormcin{with Sation 7000)of Division 3 ofthe Business and Promations Cuda)or
e that he is exempt therefrom and We basis for the Alleged exemption.Any violation of 3
Section 7031.5 by any applicant for a permit subjects thc applicant to a civil Penalty of APN Number Occupancy Type
net mate than I..hundred doll.(x500). 3 2 6 4 7 0 2 4 . 0 0
❑T,an owner of the pmpeny,or my employee,with wages u Weir mle compensation,
will do We work.and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
And Profusions Code:T,Contractor's License n law donot apply m an owner of 502 - FINAL PL_UMB I NU ENERGY
properly who basIlds orimprove,Woman,and who macssuchwork himself ter through his
awn employees,provided Wtsush impmvemenu are nm intended or offered formic.If, 506 — GAS TEST
however.We Wilding or improvement is wild within ane year of completion,the owner-
builder will have the buNen of proving Wal he did not Wild or improve for purpose of 507 - FINAL PLUMBING
sake.).
❑I,as..,of the Property.am exclusively mommating with licensed conuactors in
construct We project(Sec.7044,Business and protrusions Code:)The Commences Li.
cense law dost not apply m in owner of property who Wilds or improves Norton,and
who contracts for such projects with a commcmr(s)licensed pursuant m the Contractors
Lkena Law.
❑I am exempt under Sec. B&P C for this mason
Owner Date
Aft WORKER'S COMPENSATION DECLARATION
1 hereby elfam under penalty of perjury can of We following declarations: -
1 have
and will minuin a Certificate of Conant to self-insure for Workers Confirm.
cation,As provided fon by Section 3700 of Lha labor Cook,fon me Performance of the
work for which this permit is issued
❑1 have and will maintain Workers Compensation Insurance,a required by Semon
37W of We Labor Code.for the performance of the wart for which this Permit is issued.
My Workers Compensation Lnmunce carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissectloo need not,completed If the permit is format hundred dollars SIM)
or less)
1 certify that in the performance of the work for which this permit is issued.I shall nm
employ any person in any mannerm As to become subject to We Workers Compensation
Laws of C Wm.iA Dam
Applicant
NOTICE TO APPLICANT:If.after making this Cer00ca a of Emmldion,you Would
,come subject m the Worker's Compensation provisions of thus L Ire,Code,you most
.JO forthwith comply with such provisions or this permit shall,clamed mvoked..
zV) CONSTRUCTION LENDING AGENCY
'[w I hereby i0rm that Were is a conswction lending agency for the perfurmme of
C? the work for which this permit Is issued(See.7097,Civ.Cd
W Q lendch Name
=z landeh Address �
U 0 1 certify that I haw read this application and sum Wu We above information is
�y F coral I ague m comply with all city and county ordinances and auk laws relating to
QU building construction.and hereby authorise roprrxnutivet of this city to enter upon the
tg7 above-mentioned Pmpeny for iapecton Purposes.
Ff^a (We)agree to save,indemnify and keep harmless the City of Cupcnino against
to liabilities,judgments,cam and estimate;which may in any way mcme against Sid Of,
U Z in consequence of the{ranting of this permh.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
Re-roofs
Signature ofApplicadUConumetor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant ter future buildC g k,Chanumm of handle licaltoa mamrii
as defined by the Cupertino Municipal Code.Chapter 9.13.and the Health and Sicty
Cmk,Section 25532407 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑Nu
Win the appfteant or future building Occupant sea egmipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it Wurdnus air contaminants a dc0ncd by the Bay Area Ail Quality Management all new materials for inspection.
District?
El Yea ONO
1 have mad the haardous materials requirements under Chapter 6.95 of the Califor•
nia Health A,Safety Cade,SaIron 25505,35533 md25534.I understand thallfthc Wilding
does not cumindy haw a mnam,that it is my responsibility to Amory theoccupant of thc
regwrements which mum,met Our mlaummmofaCertificate ofoccupancy. Signature of Applicant Date
Owner or authorimd agent Date All roof coverings to be Class"B"or better
1
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 10460 Stokes Ave. Date: 4-30-03
Owner's Name:---Yung,Yuk
Phone No.(408)996-0168
APN#: 326-47-024 Project Valuation: S 133.00
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: permlts®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
CreditCard #: 5474-6390-0026-5679 2� 735
Name on Card: just Water Heaters Inc. /7 /
Expiration Date: 9/05 b I
Visa ❑ MasterCard X
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