03090225 (2) CFCY OF CUPERTINO '• i' %h -'--"� �` al' '
BUILDING DIVISION PERMIT gQ NTT2ACT(1R INFORMATION
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BUI LDING ADDRESS: JUST WATER HEATERS INC PERMIT N0.03090225
2049 Mr rTRT,T.APJ IRT7l
OWNER'S NAME: 1764 NATIONAL AVE PERMIT ISSUE DAM
MOSS
NE: (510) 293-9901 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
I00 LICENSED CONTRACTOR'SDECLARATIONO I W mby alOrm mal l am licensed under previsions of Chaplar 9 frnmmcncing Job Description
on
Semiun 7gkq of Division)of the Ousinun end Prafcuinns Codc.end my liccnu is
4 mmnmmasserra'' REPLACE WATER HEATER
p 2 Liccnu Clwa Lir.M
k Dam comm CL (4 0. GALLON GAS) /
Z ARCHITECTS DECLARATION Q
i W I understand my plans shall W used an public records
s Q
'0
Licensed Professional
( Oat I am BUILDER DECLAR
ATION
)0 0 I hereby reaso affirm that 11. exempt from the Cssions Co Liccnu Law ret lW
:0 O following reason.(Smtiun 71DL5,Business and improve,
demolish,
h,or Any oily or county
$ which rets issi n Permit litre vires the
pita nt forso,h Permit t of repair any structure
prions incensed pursuant to
lhovisiosof for Cork Perinoicense ned Law(Chapter
a be mentccnud pursuant to the provisions of the Contractor'susinesnd Prof Law(Chootr9 Sq. Ft.Floor Area V31USI10@606'
exp (commis xem it therefrom
and M trusts
rMe al aged Business and on.Any
Cook)or
Y
� mal W is exempt therefrom and the baso for doe alleged exemption.Any violation of
Section 7031.5 by any applicant for a peril subjects me applicant to a civil penally of 3 9f9IN2bRIlller 0 0 Occupancy Type
not mare than Five hundred calla.(IM.
❑I,as owner of the prepcny,or my employees with wages as their sole compensation.
will do the work and doe structure is not intended or offered for sale(Sec.7044,Business
and Pmfessions Code:The Contractor's Liccnu Law does not apply t an owner.of Required Inspections
pmpenywhs builds or improves thereon,and whodoessuchwurk himmlforthmughhis 502 - FINAL PLUMBING ENERGY
ewnemployess,provided malsuch improvements aunot ioundedo(offered forsale.If, 506 — GAS TEST
however,me building or impmwment!amid within ane you of completion,me owner-
builder will have the burden of proving that he did not Wild or improve for purpose of 507 - FINAL PLUMBING
sale.).
❑ I,as owner,of me property,am exclusively contracting with licensed convenors to
construct the project(Sec.7044,Business and Pmfessions Code:)The Contractor's U.
ants Law docs not apply in an owner of propcny who Wilds or improves thereon,and
who comment for such projects with o conrclor(s)licensed pursuant to the Contractor's
License Law. '
❑ I am exempt user See. ,B&P C for this..on
Owner Dat
WORKER'S COMPENSATION DECLARATION
1 hereby afEr under penalty of perjury one of me following declarations:
it,1307M
I haw and will maintain a Cenifate of Consent to self-ituue for Worker's Compere
on,as provided for by Section 37W of Me IaWr Codc,for the pcAommrrc of dm
rk for which mit pcmlt is issued.
1 ban and will maintain Workers Compensation Insurance,u required by Section
of me labor CMc,for Ne performance of Ne work for which thin peri(is issued.
Wuskeh Co.Notation Insurance abler and Policy number am:
rtier. Policy No.:
CERTIFICATE OF EKEM PTION FROM WORKERS'
COMPENSATION INSURANCE
(This section orad not W complewd if lW permit Is faro.hundred dollars($1010)
of less.)
I certify that in the performance of the work for which this Permit Is issued,I shell not
employ any person in any manner so as to Wcome subject to the WorkeW Compensation
Laws of Califomie.Data V
Applicant
NOTICE TO APPLICANT:If,after making this CC fifiCAIC of Exemption,you shsUld
Wcome subject to the Workers Compression;Or this Permit
mil of Ne Labor Code,you Cwt /)
��[ foMwith comply wire such provisions or mit permiuhall W deems revoked. ( /
Z O CONSTRUCTION LENDING AGENCY
I hen:hy affirm that mere is a construction lending agency In performance of
Ye > the work for which this pcmil is issued(Sec.3W7,Civ.C.)
f]� Lenders Name
Z Underi Address
0 1 really that 1 have read this application end nut ren the show information is
]. P correct 1 agree to comply with all city and county ordinances and sure laws orating In
D V building construction.and Wmby aulhono,upmmmstivw of this city to cnto upon me
N W ,hove-mentioned property for inspection purposes
r a (We)agree In save,indemnify and keep harmless the City of Cupertino against
fA
liabilities.judgments,costs and expenses which may In any wry Arne against mid City
J `LZ in consequence of to Booming of this pefmil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaDataHAZARDOA2ARDOUS MATERIALS DISCLOSURE Type of Roof
Will me epCuIent or forum building e.Chaps nom o handle Health and
u defined by me Cupeninn Municipal Code.Chapter 9.12,and the Health and Safely
cndp, ea2ss3z(,)7
0 Yes ON. All roofs shall be inspected prior to any roofing material being installed.
'
Will the applicant or future building occupant esu equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous ai r contaminants as de fined by the Bay Arca Air Coal ily Management all new materials for Inspection.
rYl(I[l:r
❑Yw ❑No
I have mad me haasNous materials requirements under Chapter 6.95 of me Califnr-
niceHealth&Sorely Coda,Sections 25505,25533 and 25534.1 undenund that if me Wilding
M.net cu ooll,new a mast mar Is is my ommurbibil ity to mod l'y she cupam or me
mquimments which mostW mel prior to issumce of a Certificate of Occupancy. Signature Of Applicant Date
Gwner(it authorized agent Date All roof coverings to be Class"B"or better
• City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 22049 McClellan Rd. Date: 8-21-03
Owner's Name:---Moss,John
Phone No.(408)255-4687
APN#: 357-13-021 Project Valuation: S 606.00
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: Oulce 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. 233
Expiration Date: 9/05 6g
Visa MasterCard X I
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