03050145 (2) CITY OF CUPERTINO *.rrt � k' "
BUILDING DIVISION pE]uVjIZ i COIyTRAGTURATNF'®RMA�IQN:=
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT N003050145
-A PARSE T)R
OWNER'S NAME: 1764 NATIONAL AVE. : , "B"To n9/2003
PIVEY RUTH H TRUSTEE
NE, (510) 293-9901 SANTTARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
woZ, LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby an.that 1 am IiaMed under provirions of Chapur 9(mmmsneing p
withS 6on7")of Divialon3oftite r�--arb BugProfession Codo,andmylicenseis
n3 bmnto.lneeffaL REPLACE WATER HEATER
,,EZLicense ClassLie.N
Dam Contractor (4 0 GALLON GAS) FINALED
ARCHITECT'S DECLARATION
�y Iundcruendmyplana shall be used as public me.,& JUN 2003
56
�o Licensed Pmfessumill
OWNER—BUILDER DECLARATION
I I hereby affirm that I em exempt from the Como mous License law for the
E A 00 following reamn.(Section 7031.5,Business and Professiot.Code:Any city or county BUILDING
which requires a permus it consuua,allot structureimprove,demulish,or repair any structure
shy poor In its issuance,also requires the applicant for such permit in Me a signediuumun
that be is licensed puts umun the provisions of the Contractor's Uanse Law(Chapter 9 Sq.Ft. Floor Area Valuation
y $ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $600
'� .. Out he u exempt therefrom and the basis for the alleged exemption.Any violation of
Section 703f.5 by any applicant for a permit mbjems the applicant to a civil penalty of APN Number Occupancy Type
nm more thse Bit,hundred dollars($500).
01,u owner of the property,or my employers with wages a their sets eompet.nlon, 35926017 . 00
will do the work,and the structure is not intended or offered for rale(See.7044,Business RE.(I,,,r�I�,qD�
and Professions Code:The Contractor's Li,.Law does not apply be an owner of 502 - FINAL -FDft i NU c 4MRGY
property who buildsur Improv Neeson,and whodms suchwwkhimsel(orthmugh his
own employes,pmvided that such improvements are not inundm oroffered Russia,If. 506 — GAS TEST
however,the building or improvement is sold within one year of comptedan.the sunter-
Wilderwill ban one Wooden of proving thin hedid not build inImprovefor purysseof 507 - FINAL PLUMBING
sale.).
0 I.as owner of the property am exclusively contracting wish licensed contracrea to
construct the project(Sec.7044,Business and Profession Code:)The ConuacmYa LL
cents Law does not apply on an owner of properly who Wilds or improv themon,and
who contracts for such projects with a conVYtors)licensed pursuant to IW Crematories
License Law.
O lamesemptuneer Sec. ,B&PCfmthisreusn
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the fallowing decimations:
1 haw and will maintain a Canificausf Consent to selyimure for Worker's Compere
1• upon,as provided for by Section 3700 of the Iabm Code.for the perfonnanm of the
woh for which this permit is issued.
0 I have and will maintain Workers Compensation Insuranm,as required by Section
3700 of the LAW,Code.for the Performance of the work for which this permit is issued.
My Worker's Compensation Insurance tinier and Polity number are:
Cartier. Policy No.: _
CERTIFICATE OF FXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(Ihb section recd not W completed if tad permit Is foranchunemd dolhos Ol00)
or leas.)
I certify that in the performance of the work for which this pored,is issued.I shall not
employ any person in any manner in as in become subject to the Workers'Compenmdem
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subjecty it Wortpo monsorateis permit"I
Nelabor Code,you mull
.J O fmNwisheoecx on be soeho's Co mor that Pprovisionsoc and
mad revoked.
?rA CONSTRUCTION LENDING AGENCY
[r I WsebyaRrm that Neu iso commztion lending agency our the perkins cof
the work for which this permit is issued(Sm. Co.C.)
Q Lender's Name
z Lender's Add.
U O I cenify that I haw read this application and state that the move ofonnNon is
It,E-' cooecL 1 agree to comply with all city and county mountain;and sou laws notions of
0U building comwetion.and hereby authsdn representatives of this city to tour upon the
{27 aWw-mentioned Property for inspemlan Purposea
(We)agree in save,indemnify and keep harmless the City of Cupmina!gait.(
„y rrAA Ilabllitin,judgmene,cosu and expenses which may in any way accrue again mid City
U r-+ APPLICANTANin D thisof the Staining of permit.
WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
SignSignatureof ApplicaDate
HAZARDOUOU S MATg mic rpa DISCLOSURE Type of Roof
Willy the Cicant orertino future Municipal
Code.Chaptnoaar handle Health and
as defined by the Cupertino Municipal Cade.Chapter 9.@,roti the HeaIN and Safety
ode,Set 25533(¢)? All roofs shall be inspected prior to any roofing material being installed.
❑Yue I-]No
Will the applicant or future Wilding occupant use equipment or devimS which If a roof is installed without first obtaining an inspection,I agree to remove
It harardnm air mro m nmol as defined by Nc Bq Area Air Quality Manag¢num all new materials for inspection.
District?
0Yrs 0N
I have read the th ardnus reuriels requiremsnta under Chapter 6.95ofths Cxlifnn
me HmIth&Safety Codc,ScNoes 25315,25533 and 25534,1 un l aund thin ifft Wilding
Docs not currently haw a tenon.that it is my responslhility in entry dte occupant of the
roquimmenu which mug be met prior W issuance of a Ccnifcau of Occupancy.
Signature Of Applicant Date
DwnerorauNna,<daSent Date All roof coverings to be Class"B"or better
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 7467 De La Farge Dr. Date: 5- 29-03
Owner's Name:---Spivey, Ruth
Phone No.(408)253-2746
APN#: 359-26-017 Project Valuation: $ 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# 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 p�
Name on Card: Just Water Heaters Inc. 42, �9Q
Expiration Date: 9/05 `8
Visa MasterCard ® (�
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