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03070001i J tep j IZW ,1=R O z z r fn a> 117 A UO_ �0 U F -t � U i CITY OF CUPERTINO a ..K*roroaa •S'^�� BUILDING DIVISION PERMIT CON RAGT0R INFORMATION is BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT N003070001 OWNER'S NAME: 1764 NATIONAL AVE - PERMIT ISUEDATE LISA MCCORMACK NE' (510) 293-9901 SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MICH LICENSED CONTRACTOR'S DECLARATION Job Description 1 beeby affum that I am licemed under provisions of Chapter 9 (commencing p With Section 7") of Division 3.f the Business and Professions Cada. and my license u in full forte and effect REPLACE WATER HEATER License ClassLk. N Dat crnunemr (4 0 GALLON GAS) ARCHITECTS DECLARATION I understand my plans shall be used as public records Licensed Profcssionol OWNER -BUILDER DECLARATION I hereby Militia that 1 am exempt (rum the Contractor's License Law fur the follOwing mown. (Section 7031.5, Business end Professions Code: Any cit or rou - which requires a permit to construct, alter, improve, Ucmolish, nr repair IDuetu prions its Women, also requires the applicant for such permitm Olcasign taemem that he is liceruod pursuant the provisions of the Conoretori Liccnm to SGTaprer9 Sq. Ft. Floor,' rd-� Valuatio,$760 (commencing with Section 7000) of Division 3 or the Business and ProfnsirgnGode3yyr - that he 6 exempt therefrom and the basis for the alleged asempdon. Any bid H f I 3 ,0 Occupancy Type Section 7031.5 by any applicant far• palls subjects the applicant ro s civ rally Or not mac Nan five hundred dollen (5500). ❑ 1, u owner of the property, m my amployces with wages u their sole co ssXe , pV,�pg�� T}�gp� (�p� CLv'N will de the work. and the stecture is not intended or offered fou sale taim. 704, Busmm and Professions Code: The contractor's Licem, law does not apply to an owner of Foolery, who builds or improv demon. and who doessuch work himself orthrough his 502 — FINAL YliUts'IB 1NCi RGY own employees, provided that such improvements are not intended oroffered formic. If. 506 — GAS TEST however, the building or improvement is mid within one Year of completion, the Owner - builder will have the burden of proving that he did not Wild or improve for purpose of 507 — FINAL PLUMBING .ale I 1, as owner of the prepeny, am exclusively contracting with licensed contractors to comment the pmjecl (Sec. 7044, Business and Professions Code:) Time Contractor's Li. come Law does not pply to an owner of property who builds at improves thereon, and, who contracts for such projects with a contractor(s) licensed pursuant in the Contactors License tow. ❑ I un exempt under Sea. BA, PC for this mama .. Ms Dam Ooem WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of Ute following dalamiom: I Mw and will maintain a Cenificate of Consent to self-insu , for WorkersCoerce- Am ian, u provided for by Section 37M of the Labor Code, for Nm e performance of the work for which this pemtit is issued. ❑ 1 have and will maintain Workers Compensninn Insurance, a required by Section 3700 of the labor Code, for the performance of the work for which Nis Permit is issued. My Worker's Cnmpenaton Insurance Cartier and Policy number art: Cartier. Policy Na: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE rihissadco recd nom hecmnphoed irthe rani is feooe hundred dollar (S100) or Less.) 1 Certify that in the perforenmea of the work for which this permit is issued. I shall not employ any peuun in any manner an as Or become subject o the Workeri Compensation Laws of California. Dae Applicant NOTICE TO APPLICANT: If. after making this CenMcac of Exemption, you should become subject to the Worker's Compeneation provisions of the Labor Code, you ..At rutlhwith comply with Much provisions or this hermit shall he deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that Vert is a construction lending agency for the performance of the Work for which N 097 is permit Is issued ISR. ], Civ. C.1 Leader'. ork Name �� Lenders Address I eerily Nam I luso Ind this and sate lees the chow Information to ' courting I agree ro comply with all airy an0 county oNinamn used sou laws to city and coon building eor Often any herby auNonae repmenutives of Nis city to toter upon Ute pro ertysaw for inspectionindemnify above-mentioned(WeAre to (Wes) agree to taw. indemnify mU tech hay against akeep ha. the City expensesIn An m AgainstA may In anyway attme againstaid City inconsegenceorthefrauand of the geeing of this permit. mit. A APPLICANT APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINT Issued by:s4tarl Date SOURCE REGULATIONS. Re -roofs - Type of Roof Signature of ApplicanVCODO Data HAZARDOUS MATERIALS DISCLOSURE b Harear handle Will theapplicant or (Muni buildings, AM dented Chapter ache Cupertino Municipal CtWc. Chahmr 9.11, mJ the HcaIN and Safety Nesbitt And " ion de. Section z5532(.)T All roofs shall be inspected to any roofing material being installed. ❑Yes ❑Nu prior If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant Or future building Occupant use equipment or dcvias which ll hanardous air contaminants a dc0ncd by the Bay Area Air Quality Managcmcm all new materials for inspection. Wrier? Imquimments ❑Yes [I No 1 have mad the haardnus materials requirements under Chapter 6.95 of the Califon Health 6 SafetyCoda, Salions 15505,25533 and 15534.1 undemund that if this building es not currently haw a tenant, that it is my tex amihilhy to and I the occupant of the which mum he mel prior re issuance or a ccniicam of Occupancy. Signature of Applicant Date All roof coverings to be Class "B" or better Owner or eulhorivsU eget Data .• • 03o7c�`/ Uty or t-upertino tsuiming rermit Application E -Mail Jobslte Address: 6060 Willowgrove Ln Owner's Name: ---McCormack, Lisa Phone No.(408)887-4707 APN#: 375-38-021 Date: 6-30-03 Project Valuation: $ 760.00 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: 1 764 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: 4/1/04 Credit Card Information Credit Card #: 5474-6390-0026-5679 Name on Card: ,Just Water Heaters Inc. Expiration Date: 9/05 Visa ❑ MasterCard Comments zZ3� 7