03110100 (2) CITY OF CUPERTINO + *' �' $" " " ' "`"' m*
I BUILDING DIVISION PERMIT RICONTRACT R INFORMA'IaIO-
Bu1LDINGADDRESS: JUST WATER HEATERS INC PERMITNRO 3110100
540 N BLANEY AV
OWNER'S NAME: PERMITLSSUEDATE
THERINE NOLAN 1764 NATIONAL AVE 11/20/2003
NE: SANITARY NO. CONTROL NO.
(510) 293-9901
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
jo0 LICENSED CONTRACTOR'S DECLARATION Job Description
e V I hereby affirm Nat 1 am licensed under provisions of Chapter 9(commencing - P
ewith Section 70f1B)of Division 3oflbc Busincss.of Profcuiuw Code,end my license is
ffl infull mmeand effect. REPLACE WATER HEATER.
j Z License Class Lie.a
F Dete T'S DECLARATION (4 0 GALLON ) �nu p LED ARCNTTECfS DECLARATION is 6®
1 understand my plans shall W wed m public records
eor� Licensed DEC 8 20tl3
1 1OWNER-BUILDER DECLARATION
2x I hereby effort Net I am exempt from Ne Cmdracmr's License Law for the
e O following reason.(Section 7031.5,Business and Professions Code:Any city or county
5$ which mquloas a Permit to construct.eller,improve,demolish,to repair any nodulate
Pricer In its owtomoe,also requires the epplie+nt(0,Such permit file a Signed Haumcnt
22 C thatheislicensedPursuant10LWprovisionsnftheContractoriLicenseLaw(ChapterY Sq. F[. Floor Area 991
2� (commencing with Section 7000)of Division 3 of the Business and Professions Com)or
a $ that he Is emmpl therefrom and the basis for the alleged eacmptio.Any violation of
Section 7031.5 by any applicant fon permit ubjects the applicant in e civil Penally of APN Number Occupancy Type
not mart Nen five hundred dollen(5500). 31630105 . 00
O T.as owner of the property,or my employees with wages as their role compensation.
will do the work,and Ne Swnure Is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Convector's License Lew docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who doessuch work himself onhrough his
own employees,provided that such improvements art not Intended oroRered forsale.If,
however.the building or improvement Is sold within am:year of completion,The owner
Will.,wtll have Ne burden of proving that he did Man Wild or Improve for purpose a(
ole.).
O 1,a owner of dm property,am exelwively contracting with licensed canvacmes to
coestmct the project(Sec.7W,Business and Prafcaaions Code:)The Comoac m's Li�
cense law docs not apply an an owner of property who Wilds or improves Hereon,and,
who contracts for such projects wits a eomrsetorls)licensed Pursuant u she Contncmes
License Law.
O l no exempt under Sec. ,B&P C for Nis reason
IC337(
ner Data
WORKER'S COMPENSATION DECLARATION
Ihereby 4 Mt under penalty of perjury one of the following declarations:
I have and will maintain a CenlfrtMe of Consent sel6iasum for Wari er's Camper.
an,as provided fm by Section 37M of the labor Code,for the performance of the
rk for which Nis permit is isswd.
1 hoe and will maintain Worker's Compensation Insurance,as required by Section
0 of the labor Code,for do performance or the work for which Nis permit is Lewd.
Worker'.Comp rsadon❑tsuunce cartier and Polity number art:
rier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(TMs section need not W complcud If the Permit Is Trane hundred dollars($1 W)
MIR..)
I'cenify that In the performance of the work rot which this permit is issued.I shall not
employ any Person In any mannerso as b Wcome subject to the Worked Compensation
Law.or Calif..!A.Data
Applicant
NOTICE TO APPLICANT:If.afar making this Certificate of Exemption,you should
become Subject ro the Worker's Compensation provisions of the labor Code,you resat
=O forthwith comply with such provisions or Nis permilsha1l W doomed mwked.
by CONSTRUCTION LENDINGAGENCY
�-m for which
thereiWod(Soctinnl. genry for Nc performance of
Z Vu week for which Nis permit is iasud(Sec.3097,CO.Civ.C.1
W Q Lender's Name
=2 Lender's Address
J 1 cenify that I have reed this application and sues that the shove infoo wdun is
correct.I agree to comply with all city and county ordinances and.tau laws relating in
C)SU^ Wilding construction.and hereby authorlm minczenutims of this city to caner upon the
Gq abow-mcntioncd property for inspection purpOWL
gym (We)agree to save,indemnify and keep harmlesa Ne City of Cupi nino against
,..trA liabilities,judgmenW eons and eapenms which may In any way aceme against said City
U Z in consequence of Ne gaming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:3 Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaDau
HAZARDOUS
US MATERIALS DISCLOSURE Type of Roof
WIII y the
Cupem w(Mum Wiling occupant nom or handle Health and
iouOL?dented by the Cupertino Municipal Code,Chapter 9.13,and the HceIN and Safety
.Sedan 25532(87 All roofs shall be inspected prior to any roofing material being installed.
OYca ONO
WM 1W.pplicautOr mt.m building wcupant ase egmpmcm or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t hmardnua air contaminants as donned by the Bay Arca Air Quality Management all new materials for inspection.
❑Yea ONo
I have read the Woodmu materials requirements tooter Court 6.95 of the Califon
ma Health&Sa(ctyeode,yYdom 7.5505.2.5533 and 35534.I vadeffland Nn mf He Wilding
does lar currently have a unapt.Nat it u my responsibility to ramify the occupant of du
requirements which mind Wmet prior toissuance ofaOcNOesuofOccupncy. Signature of Applicant Date
Owner or amhorimd agent Date All roof coverings to be Class nBn or better
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 10540 N. Blaney Date: 11-19-03
Owner's Name:---Nolan, Katherine
Phone No.(408)255-2794
APN#: 316-30-105 Project Valuation: S 991.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----- Mech-----------
Job Description
Replace 40 gallon 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# 591329 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 23 Q /
Name on Card: dust Water Heaters Inc. ff
Expiration Date: 9/05 (�
Visa MasterCard X
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