03040039 70
CITY OF CUPERTINO a*��" a^"' """4"� �.,:
BUILDING DIVISION PERMIT ` Pik,
> LMATIUN `'
F M«�fi I.::pc'i r r�^rays,.
PERMITNO.1.;OU'EB �0�12 U`)9 HILL CT NST WATER HEATERS INC 03040039
OWN E ' PBRMITISSUEDATE
�� EN TUYET T 1764 NATIONAL AVE 04/07/2003
E:
(510) 293-9901 SANITARY NO. CONTROLNO.
ARCHIIECTIBNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MICH
+�O o LICENSED CONTRACTOR'S DECLARATION Job Descri tion
jdj
i hereby sfBrm that I un licensed under provision of Chapter 9(commencing p
M Ih Swtion 707U)of Dividon 3 of tiro Bud nen end pmfcWan Cede.and my Iicenw is
In full forte and effect
3 Duns.. tea.{ REPLACE WATER HEATER
Dam Contractor (40 GALLON GAS)
D AR CHIT DECLARATION
1 understand my plan,aNB he TS he well.pa11gC RSardl
7
;u. Lmcnsed Professional
5D OWNER-BUILDER OHthe Cmm ON
clo
1 hereby Maso .(firm that 1 1. ,Bumpy from the Convectors Licence Lew tar the
p o which M uenwn.(Section 7fDL5,Business and Improve,
demolish.
Cade:Any shy or county
$12 which rIts Issuance
•e also
re core&the ellen applicant
fww,dcmalW,m repair any structure
Fg Sc prior in Wluwnce.aisomqulrouMvisionant fm wchpemitmicese LAe(utemem
gg gay�y< that(commencing
com is licensed pulwant to the or Division
NeCBusinml Llscnwlaw(C Coda)
Sq.Ft. Floor Area Valuation
a C$ (ommenc mount thction erefrom
and the
basis far
of the Business and on,My vi Cmmj ar
�6ut 33 Nene 7 campy Nertfmm end tis WPW fm Iba u the exemption,10 Any Wohtion of
Acta 7031.3 ve any red dont fm.pewit wbfccLL the applicant to.civil Penalty Of APN Number Oce y Type
Act mart than Ove hundred dollen(f5001.
❑1,u owner of the property,or my employees with wages u Nair sole Compensation, ';r997nqcz nn
will do tite work.end the svuctum is not intended m caared torsaleuw
(See.7044.BroRequired Inspections
and Prefesdon Cade:The Continuance, n not apply m an owns,of esnee law deq ns p
pwpenywbu buildsur improves dsomen,end who doessuchwmk himwlforthma{h his 502 - FINAL PLUMBING ENERGY
ownemployces,provided thaumh Improvements am notinteaded maifemd for sem,if,
however,the wilding of improwmenus mid within am you oreompledon,theawnm. 506 — GAS TEST
wilder will have dm burden of proving that be did not Wild m Improve for purpose of 507 — FINAL PLUMBING
❑1,As owner of Um property am eaclnively contracting with licensed contractors In
construct he project(Sec.7004,Business and Profession,Cade:)The Cnmictees Li.
came Law does not apply to an owner of property who builds or impruws Nemo,and,
who cenmets fm such projects with s couanor(,)licensed pursuant to the Convenors
License Law.
❑lune accept undo See .BkPCfor Nla recon -
Owner Dam E
WORKERS COMPENSATION DECLARATIONRr
lo
i
I hereby affirm under peulty of perjury ow of the following dechradons: L
he and wllI maintain aCenlOnmaf Consent msel6lnsum for WorkersCumpen-
n,M provldad for by Section 3700 of Ne labor Code,fm the performance of the -
wwrk for which this Permit is issued.
❑I
have bud will maintain Warl¢rs Compensation I. As required by Seen
3700 of Ne law,Code,fm Ne pedamance of the work forwhich this permit is Issued.
My Workers Compensation Inwnrse carrier and Polley number am: .
cam,, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This senionwad notbecompleted ifihe pomltisforonc hundnAdollan({100)
ar less.)
I certify that In the performance of the work for which this pmmil Is Intend,I Nail am
employ any person in any mm Ar an As to became subject to tis Wafters'Compensation
Laws of cailfamis.Dam
Applicant
NOTICE TO APPLICANT:If.after making this CcrtlBnm of Exemption,you should
became wbjen in Ne Wolce s Compewvo provldws of the labor Cads,you mute
3'Z-. forthwith comply with such proWinn An this permit,hall Ise Accrued rebuked.
OCONSTRUCTION LENDING AGENCY
[r Ihemby a(Tim that New is a comtrm0on lending agency far On,performance of
LYi the warkWit ies(m which this pewit LL lune(See 3D9'1,Civ.C.)Lenders Name
z Lantler.Address W✓`� ,
V 1 ceNfy that 1 haw read this oppllcadon and rote thu the xwve Information Is
morn.l agree to comply with all City and=my callowness And sum laws mining to
CVC building construction.and hereby authodre representatives of this city at enter upon Me o
W shove-mentioned prepay fm Inspection puymma
(We)agree to saw,indemnify and keep harmless the City of Cupertino squint
M Ilabilldesjudimcnta toss andexpewa which may In any my mane against sold City
V mo,u queue of Ne grantingaf this proal.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
Re-roofs
Signature of ApplicanuConummr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant or future building oceupantuom or handle hazardous mamdai
As darned by tiro Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Smtion 25532(x)7 All roofs shell be inspected prior to any roofing material being installed.
❑Yes ONO
WIII the applicant or forum building amupam saw equipment m dcvlma which If a roof is installed without first obtaining an inspection,I agree to remove
It haurdous sir Contaminants As dented by the Bay Area Air Quality Management all new materials for inspection,
slricIT
❑Yes ONO
1 haw need the hanrdns matenais requinmew under Chapter 6.95 of the Califnry
nm Nulty alk Safety Cada,Sectiones 25505,25533 and 25534.1 understand NU lithe building
does not currently haw A tenor.that It IS my miponihllity m nodry NC occupant rd the
requirements which amWnot prior mn,uanceof,CeruneamofOccupancy. Signature of Applicant Date
Owner or Amhmirgd agent Dam All roof coverings to be Class "B"or better
"30el00 .31
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 1083 West Hill Ct. Date: 4-7-03
Owner's Name:---Nguyen,Tuan
Phone No.(408)257-3944
APN#: 362-27-035 Project Valuation: S 877.00
Building Permit Info: Bldg_-------— Elect----------- Plumb------1L.... Mech-----------.
fob 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
L
Address: 1764 National Ave. E-mall: permlts®justwaterheaters.net
City, State and Zip: Hayward,CA. 94545
State Contractor's License# 591 329 Exp. Date: 3/31/04
Worker's Comp#: 1626288-02 Carrier: State Compensation Insurance Fund Exp. Date: 4/l/03
Credit Card Information
Credit Card #: 5474-6390-0026-5679 �( 9
Name on Card: just Water Heaters Inc. T/ �S)
Expiration Date: 9/05 �r6 ,
Visa MasterCard X
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