03110038 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT aCONTRACTnRINFORMATION.,'I
Bu 1LDING ADDRESS: JUST WATER HEATERS INC PERMIT N003 110 03 8
OW NER'S NAME: 1764 NATIONAL AVE PERMIT ISSUE DATE
GLENN ANDERT 11/07/2003
NE' (510) 293-9901 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELELT PLUMB MECH
C�
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LICENSED CONTRACTOR ralm,SD1iCLAR fChap
C I hercbr arfirm mm 1 am licensed nndPisinns of Chapter v anmmenang Job Description
su
U
'in
Scaion]IXN))af Division 3o NC BusinessanJ Profcssinna Code.and myliccnse is
.�„ Lemlmmeadaerra'. REPLACE WATER HEATER
5�Z Liana Clens Lica
o Dale Contractor (5 0 GALLON GAS)
ARCIIITECPS DECLARATION
f ¢ 1 understand my plans shall W used as public manors aU APR 2 2 2004
)
O Licensed Professional
g OWNER-BUILDER DECLARATION
Y I hereby aBBm that 1 am exempt rmm the Contractor's License Law rot the
❑ BUILDING o following reason.(Section]031.5.Business and Professions Code:Any city or county
<v,E� which requires a peril to construct,alter,improve,demolish,or repair any structure
°:r prior to its issuance,also requires the applicant for such permit to File a signed statement
st-i< Ihmhcisliscnsedpursuanuot r:pmvmnunflhcCuntra:mr'sLicc ria aw(Chaplain Sq. Ft. Floor Area Valuatio$gg5
_FG (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i; that he is exempt therefrom and the basis for she alleged exemption.Any violation of
Section 7031.5 by anyapplicamfora perilsubjccathe applicant to acivil pcnallyof 3'A'BN2,Q6i9er00 Occu ane—Type
not mom than fiw hundred dollars(S500). p Y YP
O I,az owner of the property,or my employees with wages az their sole compensation,
will do the work.and the structure is not intended or offered for sale(Sec.]IN4,Business,
Professions Cock:The Contractor's License law does not apply to an owner or Required Inspections
property who Wilds or improves thereon,and who does such work himself or through his
own employe s,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or improve or purpose of
sale.),
❑ 1,as owner of the property,am exclusively contracting with licensed convectors to
construct the project(Sec.7(144,Business and Penfossiom Code)The Contractor's Li.
cement law docs not apply in an owner of properly who Wilds or improves demon,and.
who contracts;for such projects with a contranorts)licensed pursuant o de Contractor's
License Law.
❑ 1 am exempt under Sec. .B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby offim under penalty of p rjury ma of that following declarations:
1 have and will maintain a Cenifcam of Conserv to self-insure for Worker's Comperr
7037'W'
on,az provided for by Section 37W of the labor Code,for the performance of the
rk for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,az required by Section
of the labor Code.for the performance of the work for which this permit is issued.
Worker's Compensation Insurance carrier and Policy number aamcr, Policy No.:
CERTIFICATE OF]EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(his action mad not W edmplead if tht permit is fordnc hundrod dnllam fl)(U)
,r Icss.)
I certify that in thepsurronvance of the work for which this permit is issued,I shall not
employ any pe corn in any manner so as to become subject o the Workers Cnmpensalinn
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:IL than making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Ia Wr GMs,you most
�z part comply with such provisions or this Fermi ishall Wdeemed rowdies,
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm that dere is a eonsuuction landing agency Ior the performance of
x the work for which this permit is issued(Sam.3097,Co,.C.)
a]Q Lender's Name
y lender's Addt V —
Q I certify dal I bare read this application and stag that the above Infnmation is
F cond agree e
J 1 agree to comply here all city and county ordinances or
and cram laws relining e
U above-mentioned
construction,add for cbyomhonprposes. ativcs of Niscity toenter upon the
ahovc-ms.judg d property far inspection purposes.
(We)agree Ip save,indemnify and keep harmless the City of Cupertino against
FN Iiaconequence fthecoarsing of this Ps
mit. may in any way accrue against mid City
J z A consequence or the granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REGULATIONS.
Re-roofs
HAZARD
Signazurc of ApplicaO m Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handleamamrial
az defined by the Cupertino MunicipalHe
,Cugc,Chapter 9.13,and the Health
hh anand Safely
oe.s❑mYmeoa 35532rn
ON. All roofs shall be inspected prior to any roofing material being installed.
W
mea applicant or future building dao q Amen If a roof is installed without first obtaining an inspection, I agree to remove
Pp s pans emu"cap t or Jcviccs which g
)haraNnus air comaminanen a Ofirod by me Bay Arca Air Quality Management all new materials for inspection.
sum"
❑Yes 0N
I have reed the hazardous materials requirements under Chapter 6.95 of the Cali Or
nia Health&Safety Cwm,Sections 25515.15533 and 35534.1 undersand that if lM Wilding
Utes not currently haw a tenant,dm it u my respomihil ity to notify the Occupant of the
regwrcmcou,which most beme[poor tuissuance oraccrtIDcamofOccupancy, Signature of Applicant Date
Owner oraumddzedagent Data All roof coverings to be Class"B" or better .
38?
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 18487 Edminton Dr. Date: 11-7-03
Owner's Name:---Glenn Andert
Phone No.(408)255-5887
APN#: 375-22-069 Project Valuation: $ 885.00
Building Permit Info: Bldg----------- Elect----------- Plumb---___X----- Mech_
Job Description
Replace 50 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# 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. 1i3 7
Expiration Date: 9/05 / 6
Visa MasterCard ® v
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