03070002 (2) CITY OF CUPER'fINO �. � a'os-,,rr.a-- r � , so,, V
BUILDING DIVISION PERMIT fCON,TRACTO.R INFORMATION ,-,°
BUILDING ADDRESS: JUST WATER HEATERS INC PERMITNO03070002
01 cl�) FpTpwnnT) ng
OWNER'S NAME: 1764 NATIONAL AVE PERMIT ISSUE DATE
LANA HYSINGER
NE: . (510) 293-9901 SANITARY N0, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+o o 'LICENSED CONTRACTOR'S DECLARATION
F 1 hereby arum Nsed al I am licenunder prnvisims nfChapmmm
Chapter 9(commencing Job Description
�iW with Seetion]OIMBuf Division S of the Business and Prufesvions Codomd my license is �tlGAn ,Q A�tL p.�l
.�„ in mumreeamerr`"' REPLACE WATER HEATER ����1YlP"4 Yoe h�
p�?
License Class Li,
Da cpmraemr (4 0 GALLON GAS)
SStj ARCHITECTS DECLARATION JUL 0 9 2003
W u I understand my plans shall W used as public menods
soy Licensed Pmfcssional
BUILDING
OWNER-BUILDER DECLARATION
j<x I hereby affrm that I amx mpt from the Contractors License Law Cot the
00 following a n.(Section 7031.5.Business and Pndessions Code:Any city Or county
5 m which requires a Permit to construct.eller.improve.demolish,or repair any structure
_ZQ prior to its issuance.also mquimnhe applicant(orsuch Permit u rile aligned statement
@ o that he is licensed pursuant Sq. FL Floor Area Valuati(k,�743
ns
a� (commencing with Section?(1 )of Division 3 of the Business and Professions Code)or
it Nat he is exempt the0om and On,basis for the alleged exemption.Any vinlauon of
Section 7031.5 by any applicant for a permit subjects Nc applicant to a civil penalty of 34%TNgQbjlber00 Occupancy Type
not more Nan five hundred dollars(S500).
❑I,as owner of the propcny,or my employees with wages as their sole compensation,
will do the work,and the sbuctme is not intended or offered for sale(Sec.7064.Busi. R�,pp����Ing
opera,who
Code:The Cath[... , rad whoento Law does or applylfan Owgr is 502 - FINAL 911 MBINUc RGY
it rt huboil ode Dues Ncrenn,and who does such work apply1 ora Ow M1h f
Own employ=.provided Nat such improvements are not intended or offered(orale.If. 506 — GAS TEST
however,the building or improvement is sold within one year of completion.the owner.
builder will bare the burden or proving that he did not wild Or improve for purpose or 507 — FINAL PLUMBING
1,as Owner of the properly,am exclusively contracting with licensed commodes to
construct the pmjcct(Sec.701m.Business and Professions Code:)The Contracmri Li
cense Law does not apply to an Owner of proper who wilds or improves Ihemon.and
who mmmuM for such projects wit a conlracror(s)licensed pursuant to the Contractor's
License taw.
I am exempt under Sce. ,B&PC for this ocean
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under perud y of perjury ane of the following declarations:
1 have and will maintain a Cenificam of Consent to self-insure for Worker'sCompen-
1371W
ion.as pe.idcd for by Sc tion 37M of the tabor Code,for the performance of the
rk for which this permit is issued.
1 have and will maintain Workers Compensation Inmrance,a required by Section
of dm Laver Code,for the performance of the work for which this permit is issued.
Worker's Compensation Insurance carrier and Policy number amrrier. Policy NO.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($IN))
of lea)
I ceni(y that in the performance of the work Tor which this Permit is issued.I shall not
employ any puritan in any manner an a to become Subject o the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the worker's Compensation provisions of the tabor Code,you must
.J O rurthwiLb comply with such Provisions or this permit shall be doomed revoked.
Z h CONSTRUCTION LENDING AGENCY
'N I herebywhich
that thereissued(Sec. lending agency for d¢Performance of —
".� Le work(tar which Nis permit is issued(Sec.W.Civ.C.)
W Q tender's Name
jz Lenders Address /
U Q 1--try Nat I have read this application and sum Nat Nc above innorrodion is
IL P: coned.1 agree IO comply with all city and county ordinances and state laws relating Ip
DU building construction,and wrsby authorm mpreaenmises or this city to cnmr upon the
above-mentioned ju
dgments.
c ret for inspection purposes.
CL (We)agree to save,indemnify and keep harmless the City of Cupertino again,
N in
equnce of the grand
expenses which may inany way acerve against mid City
O,'� mconseyucnee of the gmming of this permit.
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT Issued by: Date
SOURCE REGULATIONS,
Stgnawre of AppbcanVComramr am
Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Inc applicant or future building Occupant store or handle hazardous material
a defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
I
le,Section 255321a)?
❑Yrs ONO All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use c If a roof is installed without first obtaining an inspection,I agree to remove
equipment Qu of devices which g
it ler?hajtax air contaminants a Jcfncd by Nc pay Area Air Quality Management all new materials for inspection.
Nrid?
❑Yes ONO
I have mad the hasrdrms materials mquinements under Chapter 6.95 of the Califon
Health&Safety Code,Sccuwts 25515.25533 and 25534.1 undersund ther if the building
el not cumenlly base a tenane that it u my msprosRoHLY m noti ry the occupant of the
uirements which must to mel prior to issuance of a CeNOcam of Occupancy.
Signature of Applicant Dale
Owner urauthcriacdagentD,te All roof coverings to be Class "B"or better
d3 � 7d
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 10192 Fi rwood Dr. Date: 6-30-03
Owner's Name:---Hysinger, Lana
Phone No.(408)446-401 7
APN#: 342-35-021 Project Valuation: S 743.00
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# 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
FExpiration
5474-6390-0026-5679
ust Water Heaters Inc.
9/05 _+ 7
Visa MasterCard
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