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PPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
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BUILDING. MEC MECHANICAL
PING PROB N(: A1HCKSrrB AL
nuu.mrvr. vxodecr mRNnY'IcnnoN
I� FERMII'N(
50001
BUILDING ADDRESS: �{
SANI 1'ARY NO,
APPLICA'l ON SUBMITTAL DATI'.
V/
A E' 1'110 B:
CONTRACT( NAME J jVf)
N/C
CONTROLT,
�WNER'S
C� V/f
❑
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ARCIi1TELT/IiNGINBER: LIC NO; AUURES,S: �N
Jp
CONrAC7E PHONE:
In(,
BUILDING PERMIT INFO
BLDG ELECT [I[ UUMMBB MECH
El El El
�Ny/
tar/Q q ^ ^ O / El Consultant Fees d ny AP%& (Initial)
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm That 1 am IicenKA under provisions of Chapter 9 (commencing
with Secliun]IX)0)af Division 3 alta, Bovine, and Profe,si... Code.andmylicenocis
in full however effect,
QTY ELECTRIC PERMIT 19:1:
PERMIT ISSUANCE
JOR DESCRIPTION
RESIDENTIAL'
❑SIUWL ❑ KITCHEN REMODEL
� 3—
Duro Cnmm
Date Clens Contra
APPLIANCES -RESIDENTIAL
[I ADDITION El PLUMBING RE -PIPE
❑MULThUNI'1' ❑STRUCTURAL
MODIFICATION
❑INT17RIOR ❑CHIMNEY REPAIR
IMPROVEMENT E]SWIMMING POOLS
REMODEIJREPA1R ❑DEMOLITION
❑ OTHER
ARCHITCC7`S
ARCHITECTS DECLARATIONPANEIS
I undersand my plans dI W used ox public records
UPT0200 AMPS
Licensaf Professional 2014000AMPS
OWNER -BUILDER DECLARATIONOVER ["AMPS
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following no on. (Section 7031.5, Baine., and Pnrfe,i tar, Cale: An, city or ,,only SIGNS ELECTRICAL
Indicating
which require, a permit at construct. shoe, intprovc, demolish, of repair any strucare
prior to its osn:me,, also requires the applicant lin such Fortino fife adgncdstmemenl
tam he is licensed por,urnrro the provisions of the Gmummrs License Law(Chapter 9
(emarancingw,In Section RXXO of Division 3 oche Bu,lnassumd Professions Code) or
that he is exempt Ihe,eftvm rad the basin for the alleged gumption. Any violation of
Section 7031.5 by any applicant lir. Penni, subjects the apF1' ,,.cieil penalty of
.to mora Than five hundred dollar, 0350X0.
❑ La, owner of the proPeny or myungnloyces with wages its their sale mntpemaion,
will do the work, and the,truamm is not Intended ondfcred for sole ISa.91W4, I3uxinc,v
moil Pores...... Cuda: The footman., License Law it, nal apply,, an mvncr of
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECT RIC
OUTLETS -SWITCHES - FIXTURES
COMMER 1 '
C:1NIIW BLDG/ADDITION [_1 I3EM01.1'rION
❑'I'I3NAN'f ❑ FOOD SERVICE
IMPROVEMENT
OI ITER
prapary who hood. or iar,00va, ihmcon, nal wan doe,,ucM1 work him,cll'or thrvcgn
his wn cmplayees, provided Inn such Impmvenumr, are ern imm�AcJ tar u1creA for
o
Sale. If, however. the huildmg or ngnoventent i, soil within enc your sal annplmiom the
NEW BEISOFNTIAL ULECTR PI'.
.PI'. FLOOR ARRA
S/SQ. FT.
owner -builder will haveIha burden of proving Thal he did out build or intprovc or f ar-
pnmof sale.),
I] L it, owner ol'The III .at exclusively contracting with licensed ntmmctor, Ia
.......el the project (See 7144, Baninc, and Profcssfan, Cow:)'Ira Contender, hi-
sclawdoesoutupplywanownerof property vsho build, or Improve, thereon.and
TOTAL:
QTY. PLUMBING PERMIT PEI?
who contracts im,ach projects with a controclaI bossed parsaanl m the Contractor',
License Law.
PERMIT ISSUANCE
1 am exempt under Sec. . Ii & P C for thio re.sen
ALTER - DRAIN & VENT - WATER (fs)
VALUA'T'ION
nor Data
WORKERS PIiN3AT10N DECLARATION
BACK FLOW PROTECT. DEVICE
O 6—
nderPCOM
lhereby Ing
andwill mai under Penalty I)( ofCaYon,oftheitexce following dmlke", Cs:
�IM1av, and will maimuinu Ceniacar,n(Consnuo,df-inwmfnr Worker's Camper-
onion, me provided for by Section 3710 of the Labor Cedc, for the performance of Inc
week for which this .is is issued.
DRAINS - FLOOR, BOOP. AREA, CONK
FIXTURES - PER TRAP
✓ (-�
STORIED
TYPE CON5'TRUCf10P
1 have and will maintain Workd Compensation havomme, a, required by Section
l]W nOne labs Ctde. fur the pe ..save of the work for which this Permit is i,uad.
My Werk lion rand Policyn ��
Camiec nw Policy No.:�
CERIIFIC OMPE SATIO INSUROM WORK[RS' /
CNN INSURANCE
GAS -EA.SYSTEM-I WC.40N'LISTS
GAS - EA. SYSTEM -OVER 4 TEA)
GREASF/INDUSTRL WASTE IN'IERCT:PfOB
OCC. GROUT`
APN
3vL 5(S6<
BUILDING DIVISION PEES
(Thioseetion need not he completed Blue permit is Corona hundred dollars(SIM)
or less.)
I certify tam in the performance of the wad forwhich this permit i, iomed.I shall
no, employ any person in any manner sn us m became mbjed ns IM1e WorYsri Comp,n-
GREASETRAP
SEWER - SANITARY -STORM IIA. 200 17.
PLANCIIECK (Bili
ENERGY ItiC
(TRADING FEC
' moan Laws of Califumia Doe WATER HEATER W/VEN`EMLFC R
Applicant t
j NOTICE TO APPLICANT If, afar narking this Cenificam of Exemption, you should
' become subject to the Workers Compemmion previsions of the Labor Code. You m.'I
' forthwith comply with such provisions or this permit Shall Ise deemed revoked.
WATER SYSTEMlT12EATING
WATER SERVICE
SOILS FEE
CONSI'RUCI'[ON LENDING AGENCY
I arena firm that there is a cunswcllan lending agency for the per4snaame of
The wed 6r which did, Fcmti, i' IosncJ Soc. 30I7. Civ. C.)
NEW RESIDENTIAL PLMB. SQ. FT.
?'AID
])are Recap a
AL:
Leder', Name
LcaLeader', Addis,TOTAL:
a ix
BUILDING Plil?
I wni(y That I have read Thi, rpplicntion and ,are that the above Tolentino
s
O correct. agree m or, I (with all city and eoumY nnllorn<cf and xam laws rearing he
� building ...... Imnion, and hereby nnlnnrirarcpr<,connive, of lois uilymenmr upon the
Q TY. MECHANICAL PERMIT FEE
SEISMIC Plil?
171AC'I'RIC II?I?
above neem in 1.1 prnpc"Y for iollisednn Su Po,c,. PERMIT ISSUANCE
(We) agree To srvc, indemn lty and I,ou, hunnle, Ila City of Cepenlno a6ltinn
hahiliticg3Wgntenl,,co,analy-1w.oc, whichmay in any wry.cnacrgnir"'aid City
ALT ER OR ADD TO MECH.
PLUMBING FEE
.name me of fle grtutin, ti thi, TeTait.
APPLICANTUNDFI3S'IANDS ANTI WILL COMPLY WITH A[.I, NON -POINT
AIR HANDLING ON[*[ (TO I10X)CF1,II
MECHANICAL FEE
SOURCE; REGULATIONS.
AIR HANDLING UNIT (OVER 111,00 CFM)
CONSTRUCTION T'A%
Slgarare of Appliern/Commton Data
EXHAUST FOOD(W/DUCT)
HOUSING MI'IIGA[ON IEE.
HAl RDOUS MATERIALS DISCLOSURE
Will the applicant or hom holding ercupunl store or handle hae..does material
as defined by the C.P,oina Municipal Co -la, Chape, 9.12, and the Health and Safety
Coda, Scctinn 25532(.)?
HEATING UNIT CTO 100,1X0 BTU)
HEATING UNIT (OVER 10,000 BTU)
DYcs Fl No
VENTILATION FAN (SINGLE RES ID)
PAID
Doc Receipt
0.511 the applicant or future building occupant use quipmenl or devices which
emit hmardous air contaminants as defnod by the Huy Area Air Quality Management
BOILER - COMP (3HP OR IdBgYr BTU)
TOTAL:
District?
E] Yes No
BOILER -COMP (OVER 1010.0g) BTU)
i
ISSUANCE DATE
I have read the lmurdeaS nulerials mems ant@r ChaPrcr G.YS nC du Cali- AIR CONDITIONER
re.25
foliaHealth Safety Code,3Tinas]Shat,25533ua1nsihib Imonifytl tealiftine
NEW RESIDEM'IALMETH. SQ. Pf.
gdoesn have a Tamm. that n is my rexof a CMit m notify the occapum
o(thc requiremcnu which must be,mt poor m iuuanee of a Cenilicne of ticcupancy.
ofthe re docs not cow which
TOTAL:
ISSUED BY:
Owner or authorized agent Date
OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: christya
Sec: Twp: Rng: Sub: Blk: Lot:34245017.00
INVOICE DATE......: 01/11/2000
REFERENCE'ID # ...: 00010044
SITE ADDRESS .....: 10395 MELISSA CT
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: GLOCKLER HERRMANN S AND HILTRU
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-2620
CONTRACTOR .......:
GILROY, JOHN
LIC # 15128
COMPANY ..........:
NST WATER HEATERS INC
ADDRESS ..........:
1764 NATIONAL AVE
CITY/STATE/ZIP ...:
HAYWARD, CA
94545
TELEPHONE ........:
(510)293-9901
PEE DESCRIPTION
CHK TOTAL FEE PAID -TO
-DATE BALANCE DUE
_______________
BPWHEATER
___ ---------
P
____________
9.99
______-----
0.00 9.99
PPERMITFEE P
35.52
0.00 35.52
-----------
---------
------------
45.51
0.00 45.51
ID--
DESCRIPTION
VOICE
ID DESCRIPTION
106
c -------
SEWER & WATER
202
-------------------
UNDERFLOOR PLUMBING
301
ROUGH PLUMBING
302
TUB & OR SHOWER
502
FINAL PLUMBING ENERGY
506
GAS TEST
507
FINAL PLUMBING
JAN.10.2000 10:11AM NETCLERK INC
CITY OF CUPERTINO
BUILDING PERMIT APPLICATION
10300 Torre Ave. CuperEno, Ca. 95014
WC #IWN' (408) 777-3228
PROJECT ADDRESS: 10395 Men33a Court
PROPERTY OWNER
NO. 893 P.14
BLDG # SUITEIAPT #
CONTRACTOR
OWNERS NAME: Glockler, Harman
NAME Just Water Heaters Inc
MAILING ADDRESS:103B6 Mellen Court
MAILING ADDRESS: 1754 National Ave.
CITYISTATEZIP: Cuperano, CA 93014
C1TY/STATEZP: Hayward CA 946451722
PHONE #: ( 408)448.2280 FAX III. ( )
PHONE #: ( 610h293-2012 PAX #: ( )
E-MAIL ADDRESS:
E-MAIL ADDRESS: PermitsQu3twaterheaters.nel
%D� 3 Al .7- — al 9
BUSINESS LICENSE#: 15128
EXPLAIN WORK TO BE PERFORMED: Water Heater Replacement 40 Gallon Gas
BUILDING: ELECTRICAL:
REAOOF: RA2ARDOUS I= AREA: YES _ NO_
TYPE OF EXISTING ROOF COVERING:
NUMBER OF EXISTING ROOF COVERINGS REMOVED: C
NUMBER OF EXISTING ROOF COVERINGS RIrrAINED: U
PROVIDE I.C.B.O. REPORT NO.
IMPORTANT NOTICES
APPUCANPB CERTIFICATION
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE
ABOVE INFORMATION IS CORRECT. I AGREE THAT IF A PERMIT IS IS-
SUED FOR THE DEMOLITION DESCRIED IS THIS APPLICATION, ALL THE
PROVISIONS OF THE PERMIT AND ALL LAWS AND ORDINANCES
THERTO WILL BE COMPLOD WITH.
HOLD HARMLESS CLAUSE. The pennime(s) by acceptance of the permit,
agree(a) to Indemnify and hold harmless the City of Cupertino from and
against any and all claims, demands and actions for damages resulting from
operations under this panni5 regardless of negligence of the City of Cupertino
against all such claims, da nds or *cions.
In corAormiy, with the proVlens of Section 3800 of the Labor Code of the
State of California. the applicant shall have coverage under (1), or (II) deslg-
natad below or shall Indicate' items (111), or (IV), or (V), whichever to applicable.
If however tram M is checked hem (IV) must be checked as well. Mark the
appropriate method or compliance.
emeft m]ad Waribe prw.40" of chapters owin
Ream 70110) of tvtilf am autln.sa nPmfN Cade,a dmV scerse is I, full and
eaecL
Llesae a 591329 1 class C36 B as: 03131!2000
PAYMENT
AOCOUNTfk
MECHANICAL: PLUMBING• e/
NUMBER OF EXISTING ROOF COVERINGS: 0
PROPOSED ROOF COVERING:
VALUATION: 625.00
NOTICE TO APPLICANT
I hereby affirm under penally of pedury one of the following declarations:
( ) L I have and will maintain ■ cerddceta of eonsent it, Wf4 mune for we*,,- corn -
peril as provided by Sedan 7700 of the tabor Code, for the porformanee
or as work which this permit Is Issued.
(1) u. 1 have and will maintain workers' compensation Insurance, as roquImd S
ton 3700 or the ma
Labor Code, for the perfornce of the work for which thiseo
Cmill Is Issued, sty workera' eempensadon Insurance carrier and policy num-
Cardy' Clarendon
Polley Number 02KR0001018
( ) e The mat M me work done Is $100 er lase.
( ) N I caAlty that In the lArfonnance of the weak forwhich this parrilt In Issued, I
• shell not employ any person In any manner so sa to became aubjec ta work -
am' mmponsation laws of California. I further a4mowle ige Lhat I understand
that in the event that I should become subject to the workeri compensation
provldona of the Later Code of Celkamle and fail to comply forth with
provisions of Section 3800 of the Labor Code, that the perms harain applied for
Ball be deemed revoked.
( 1 V. I candy as the owner (or de meant for the owner) that In me performance of the
wmk for which this permit Is issued, I will employ a contractor who mmpllea
with that workers' mmpeasdon Iowa of Caltpnia and who, prior to the of
menmmant 01 any work, will the a completed copy of this term wIM the Central
Forma 9umou.
AMOUNTS:
Scott Waterbu
DATE Printed Name of Applicant
JAN.10.2000 10:10AM NETCLERK INC N0.693 P.13
990 Dubuque Avenue
NetClerk, Inc.: e -solutions for the contracting industry south San Francisco. CA 94000
(999) 88 CLERK
le
From: NetClerk Inc.
Contact Name: Scott Waterbury
Phone: (650)624-0426
Fax Number-, 1-(877)846-5888
Permit Application
To: Building & Planning Department
City:
Phone:
Fax Number:
Cupertino
(408) 777-3228
(408) 777-3333
Permit Handling Instructions
Please Fax Permit to! 1-(877)846.5888 Deliver to Job site at first inspection
I will pick permit up at the Building Department in 5 days HxPlease mail to Contractor address below
Other: please email permit to: permits&etclerlccom
Contractor Information
Company: Just Water Heaters Inc. Worker's Comp #: 02KR0001018
Contractor: Atm: Arnold
Address: 1764 National Ave.
City: Hayward, Ca 94545-1722
Phone: $10-293-2012
510.783.6360
fl: oermitsCa iustwaterheaws.
Comments:
Authorization forms:
Credit Cana Authorbartlon form
r wsrea i,+c
ret:
amq
tPa;,.�pet,
• af�ader>daa edRMaged.ao adtlt�eyepededaaaa@d
ta.t�maattueu�etadee,tax asympe■o[ae®a
9 '
State Contractor's License # 591329 ClassC-36 B
Credit Card Information
Credit Card Number: 5474-6331-7168-6326
Name on Card:
Expiration Date:
Visa n
Just Water Heaters Inc.
09/02
MasterCard
ApentAudmb+0ea'- By owrytloting andira uming the brign anon betow,
You aathotla NetCWYk hue to act as an agerton your baWfbr thepurpoee
ofsubmioing patent applications:
rb Whom NAtWCb tpemt