00030057 (2)CITY OF CUPERTINO
PERMIT NO.
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:
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-UILDING ADp/RESS
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SANITARY NO.
APPLICATIONSUEMMALDATE
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PERMIT INFO
LICENSED CONTRACTOR'S DECLARATION
l herby affirm tlw l en linenud uMu provisions of Chelan, 9 (comment
Job liescription -
inficllPecrieeWeRrcd'sfon3.f Bu,innnend fpaiom (�, red mylicc
Liansa a Lic.N /3
1r�01t2�' ' /PP/��lll'E/n�/J�-A�90�/O/>9�✓
Dau .WilIf
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ARCHr DEDECLARATION
useTS
s l W used u Public rccods
I urdcrttW my Phase
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Ilc.ud Pao mionnl
'OWNER-Bm .DE0. DECLARATION
I M1mhY .(Sero that 1 namPe from to Cession, ors License law, (. the
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following reason. 13 m
]031 S. Budnnss and Cade: Any city
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Sq. Ft. Floor Area
ValuaIt
X/')
arena t um. derons
which itsisunpermit mcoronet,Jur, imlaon,h peroub,one.repair sigany,tincture
I sane
prior to ieewnce,dmregeirte Ne applinnt f.nwhpemtilmfile uigtrd uukment
Nat he is licensed purwam to the provisions of Ne Comweer's Li.mk Law (Chapter 9
...
��. L
ingwat Codes or
AFN limber
Occupancy Type
he is emodw.Auiann
thatit basisPWfon of
Nnrt(rom and Ne brie for the alkgd examptl.n. Any
Wm and! ouralleged
[� Y YP
io 31.5 b it
Section roan by any applicant pemtit uubiecu Ne applinnt to a civil Pendry of
!d mor Orn five , (a
15500).
Required Inspections
e,hundredo,edollen
wiNwagasu Nei( com.Bob.
❑ Left.,it. PmpenY•mmsue
intended
Neste (See an, Businnu
willde thesrons
drn .apply
.
Corisnotintednseed
Law n owner gh
and Prfeuioru Code: The Contactors License Ido does na apply to
Coe 1.
nY who Wilds. imlaovu t and who dor such l Stough
W own m a. iakdd a oRc(cd for
his o such i intended
even, Provide Net such roam mid
Is W ofthe
owe i, role Within we
owner- however, the Wilding m Ivtp fpre
b ildyear
r -W il0er will have Nc burden of laavin6 Nu he did na Wild m imPmve fn pk-
mi ce i npir.fee
y '
:� 1, u owner of dw peopeny, un exdudvely cwtuting wIN Ecrnsed nnta.o. so
consrftthe, and Code:) The Cwtumr's
ilk p nut (Sec. ]lea, Busowner
fesid.who
crew
�(///
La of Wilds fid
canoe law dna nm apply to w own. of ray who Wilds. imlaovm thmon. end
2
Q/O
who contracts wchprolecu with. c.nbactm(s) licensed punuwm k the Contacmre
mums
Law.
License law.
O
❑lam cacmla red. Sec. � .BkPCfor Nis rtes.
El
Owner Dak
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WORKER'S COMPENSATION. DECILRATION
I harebw iluni seder Campy oeperjory wd of to fdlowieg dinner.:
.
[have and will maintdn aCeniOcak o(Cournt W self -invert for Wohers Compem
sad u provide for by See 3]00 of Na labor Cada for to perforuarea of Ne
'
wo f. which Ni, permit is issued.
I have ad will tourist; Workers Compenuuion bums cc, u withred by Section
l]00 .Oh. L.Wr Code, forthe P rfdimsnce of to work for which this Permit is imuuueed.
MY WotkefyC gNlpyyrgnce carti.W Policy
Cartier. ((LL rf XllY Policy No: —
CERTIFICATE OF EXEMPTION FROM WORKERS'
,.
,COMPENSATION INSURANCE
(Thissmi.n wd rotbe compleudBNepemdt isfnom M1uodted didlm 15100)
or leu.l
wain the the wort for which due perdtisers'Co till
Toy
any my monenan
not employ any Peron in avymannr m u to become,ubjm m de Wohen'Compeo-
'
aa(CdiPomia. Due
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Applicant
NOTICE Exemption, you uhouls,
NOTICE TO APPLICANT: If, Cion making Nie
become subject1.Nt Wo(h compenr of to Labormad Code, you men
vinin, o t
perreft o
'
forthwith comply with such Provisions or this permit shill be di.trcd tuokd.
Pr this mail
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CONSTRUCTION LENDING AGENCY
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1 hereby dErm the Vert is a coutuNon lending agency Me rW P.fmmewx of
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Re work for which this permit u iuued (S.. 3097, Civ, C.)
Lenders Name
Lender. Adds,.
'I owify that I have rd this application and ewe that Na move information Is
' coraL I slime no comply wit all city and county odinwces ed auk laws rladng to
wildi...... won, ed hereby sudmodr leprtee eadves of this city!. care, upon the
.Wvementiwd Property for i..WU.n Purposes.
(We) ewwe an save, indemnify ad Yap hmorden the City of cupenin, against
Inbilider.jdg(ra:nu, cru and c".. whi y in soy wayaumaagamar said City
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I. masa wrb c of the granting of this u.
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APPLICANTUNDEIj TANDSA' WILL COMPLY WITH ALI, NON -POINT
SOURCE: REGULA"1' NS.
Ll5 s 1
Signatwe of Applit Dar
\ MATERIALS DISCLOSURE
Re -roofs -
Will ilk appliunmrfmurt Wilding.cuprc vtxe orhmdle hazardous makdd
e
as defined by the Cupertino Munic I Cade, Conduct 9. IL end site Health ed Satiny-
CdcS.d.n25533d)] %Pa
Type of Roof
❑yes �'N
All roofs shall be inspected prior to any roofing material being.
Will toapplia.nt ar future Wilding occupant .r agwipment or devices which
mit hsvrdou, ah covuminnnuu feed by Ne Bay Ara Av Quality Management
"t'"'
installed. If a roof is installed without first obtaining an inspection
I to m erials for inspection. Applicant
[3Yu o
a rae remove all new
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un. erstands and will e y with all non point source regulations.
I have tad the hrv,�w mdwals Wirtmd
ents Under Cwpke695 of to Cali.
(.nu Health Ar Safety Code, Seniors 35503, M53] and 2553,1.1 undimmed dual if mfr
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Wilding dnes.d currtmly have a cannot. Nut is my responsibility m notify tIe oaupmt
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oftoro,mormmI which musm bens wmiesw.e ofaCert ¢ e
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Mr
'Signature of A fit Date
Owner or mount Tate
All roof coverings to be Class "B" or better
V OFFICE
880 Dubuque Avenue
NetClerk, Inc.: e -solutions for the contracting industry South San Francisco, CA 94080
(888) 88 CLERK
Buildin
NetClerk Inc.
Contact Name: Scott Waterbury
Phone: (650)624-0426
Fax Number: 1-(877)846-5888
Permit A
cation
To: Building & Planning Department
City:
Phone:
Fax Number:
Cupertino
(408)777-3228
(408)777-3333
Permit Handling Instructions
Please Fax Permit to: 1-(877)846-5888Deliver to job site at first inspection
I will pick permit up at the Building Department in 5 days X Please mail to Contractor address below
Other: please email permit to: permits@netclerk.com
Contractor Information
Company: Just Water Heaters Inc. Worker's Comp #: 02KR000IO18
Contractor: Attn: Arnold
Address: 1764 National Ave
City:
Hayward, Ca. 94545-1722
Phone:
510-293-2012
Fax:
510-783-6360
mail:
perm is@justwaterheaters.net
Comments:
Authorization forms:
Crodit Card Authorization Form
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try ctys below,I ktosit cr toee¢dAriW u ,, Lhep em ofpawt
aesadeea orNrtpal:b ciao aedltnM wtaMatloy ftat6epapora oframit
app8eanom.
Cootteebe'eName �6i8�• - Dae
State Contractor's License # 591329 ClassC-36 B
Credit Card Information
Credit Card Number: 5474-6331-7168-6326
Name on Card: Just Water Heaters Inc.
Expiration Date: 09/02
Visa n MasterCard n
"Agent Authorizatlon"- By completing and returning the Information below,
you authorize NetClerk, Inc to act as an agent on your behalf for the purpose
of submitting permit applications:
To Whom It May Concem:
Let this letterauthodze NetClerk Inc and Its employees and
authorized associates to acres an agent onour behalf- signing for any
and all building permits and licenses
rea red by our company.
Signature:
Printed Name. H4 14 Go t C ax -1
Title: _ CIN /(1%Ui5 i✓M
Company. UST'to%4ii✓1 ({fti►aV*U5, PIJCr