03110068 (2) s CITY OF CUPERTINO
BUILDING DIVISION P> ma tVCONTRACTOR INFORMATION
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT N003110068
22762 MAJESTIC
WNER'S NAME: 1764 NATIONAL AVE PERMIT ISSUE DATE
PAUL DAVIS 11/13/2003
NE: (510) 293-9901 SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
100 LICENSED CONTRACTOR'S DECLARATION
C 1 hereby from that 1 am licensed under provisions or Chapter 9(commencing Job Description
F with Seniom 7")of Division Sof the Business and Pmfcssinns Codo,and my license is
inmBforceandeffect' REPLACE WATER HEATER
License Claes Lie,a
is
I- Dale it
(4 0 GALLON GAS)
ee qq ARCHm`CTS DECLARATION
I understand my pkno.h.11 he..itas public records �III���
■�' �LF®
)6
O� Licensed Professional
�1 ,] ffiOWNER-BUILDERDECLARATION
2DEC 1 8 2003
v 1 hereby arm that I am exempt from the Contractor's License Law for the
02 following n oson.(Section 7031.5,Business and Professions Cole:Any city or county
5 which requires a Permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement ��
-xZx< that he is liansed pursuant to the provisions of Ne Contractor's License Law(Chapter 9 Sq. Ft.Floor Area 13
(commencing with Section 7")of Division 3 of the B usiness and Professions Code)or
Nat he Is exempt therefrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permil subjects the applicant o a civil penally of
not more than five hundred dollars(s500). r Occupancy Type
❑1,s,owner of the pmperry,in my employees,with wags,as their into cam ischou ht,
will do the work and due.Wcture is not tneoul or offered for sal,(Sec.1W,Business
and Professions Code:The Conuatim's License Law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not Orended or offered for ale.IL
however,the building or improvement is sold within one year of completion,the names,
Wilder will haw the burden of proving test he did not Wild or improve for purpose of
sate.).
❑1,ea owner of the properly,am exclusively contracting wit licensed contractors to
construct the project(Sec,7044,Business and Profusions Code:)The Convector's Lt.
cense law does not apply to an owner of property who Wilds or improve Lemon,and,
who contracts for such projects with a convactor(s)licensed pursuant to the CaoBeelari
License Law.
❑'go exempt under See. .B&P C for tis rtazpn
Iwo,, DoteWORKERS COMPENSATION DECLARATION
I hereby affirm under penallyofperjury one of the following declarations:
1 haw and will mainuin sCentfamofConsentm self insure forWorkersCampcmon,a provided for by Section 374 of the labor Code,for the performance of the
rk for which Nis permit is issued.
1 haw and will midnight Worker's Compensation Insu once,a required by Section
0 ofth,Labor Code,for Ne erformance of to work for which this permit is issued.
Worker's Cnmpersupon Insurance carrier and Policy number art:
rdec Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not Wcomplered lithe permit is rmonc hundred dollars(SIMI)
or less.)
1 certify tat in to performance of the work for which this permit is issued,I shall not
employ any person in any mortician az m become subject to the Workers'Competsation
Laws of California.Date
Applicant
NOTICE TO APPLICAT:If,after making this Ccnifeam or Exemption,you should
become subject to to Worker's Compression provisions of on,Labor Code,you must
70 forthwith comply with such provisions or thio permit shall W deemed revoked.
Z CGNSIRUCTION LENDING AGENCY'
j-+� I WMby angor tot dere is a construction lending agency ter the performance of5: the /� v
D: work for which this permit Is issued(Sec.3(197,Civ.C.)
Lc
![7 Q Lcndcr's Namc ///Ix/✓I,vsv'yam. U s'"�
Z
Larder's,Address d ,
U O 1 certify dal 1 have rad this application end sum that the above iofmmatdust is
U, F.O corecr.l agree to comply with all city and county ordinances and sum laws relating to
0 building construction,and hereby aulhorim representatives of this city to enter upon the
,hovcmcnriuncd properly,for inspection purposes.
gyp (We)agree to now,indemnify and keep homeless;the City of Cupertino against
F'tn liabilities,judgments,costs and expenses which may it any way accme against said City
U7 in consequence of the gmnti ng of this permit.
�-0 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Signature of ApplicaUComto
mor Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will d,a Cupenl or figure bulling e,OiCtileaftChapter
store or handle heeNous material
az dc.Sed by 25 Cupertino Municipal Coda Chapter 9.12,and tate Heald and gaiety
c.gecdohtzss32(a? All roofs shall be inspected prior to an roofing material beim
❑Ye 1-1 No P P � Y g g installed.
Will the applicant or ranee Wilding occupant use equipment or deuce which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous ai r contaminants a de fined by the Bay Area Air Quality Management all new materials for inspection.
iatriel?
Cl Year ❑No
1 have mad tc hanninus materials requirements under Chapter 6.95 of dm Cali inn
ria Health&Safety Code Sections 25505,25533 and 25534.1 undersand dad if de building -
does not currently haw a mnanl,dal h is my respmulbility to and lY IM occupant of de
requirements which mug Wmet P60Ttoissuance ofaCertificate ofOcapeney. Signature of Applicant Date
Owner or au thorizad agent - Getc All roof coverings to be Class"B" or better
City of Cupertino Building Permit Application
E-Mail
jobslte Address: 22762 Majestic Oak Way Date: 11-13-03
Owner's Name:---Davis, Paul
Phone No.(408)373-6489
APN#: 342-32-118 Project Valuation: S 913.00
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/l/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679
Name on Card: Just Water Heaters Inc.
Expiration Date: 9/05
Visa MasterCard
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