03100109 (2) C
OF CUPEWHNO W :...vera ,' j ^M
nuu.ninc nrvlsloN PERMIT CONTItAC1 OR�INFOTtMTION
pU ILDING ADDRESS: JUST WATER HEATERS INC PERMIT NO 03100109
0944 NGRIT14SEAL SQ
OWNER'S NAME: 1764 NATIONAL AVE PERMIT ISSUE DATE
)NE: SANITARY NO. CONTROL NO.
(510) 293-9901
ARCIIITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB Mr:CH
0 C
00
LICENSED CONTRACTORS DECLARATION hap JobDescri tion
{U C e hereby effect.that 1 am licensed under provisions of Chapter 9(commcneing p
:z1 with Section]d(l0)of Divizionlof the Business end Pr9fcuinns Code.and mylicesue is
in full force and effect.
{gz License Class Lm.x REPLACE WATER HEATER
i se
T'S DECLARATION
(4 0. GALLON GAS) /
ARCHITECTS DECLARATION
'i Iundcrslnnd my plans shall Mmcd as public rtrords, /
?y
A. Licensed Professional Q
) S that I .BUILDERD the ConTION \V�
0 0 1 hereby.(Tian that 11. exempt from the Commam's :Any c Low for the
o O following roman.(Sado,LConstruct,Mun.s and ve,d.aam Codc:Any city or c unty
cture
5$ which myuirmae,also m�iresthealter,nt for improve, Perlia ore a sig by structure
that to hesf.aancc,d..inin the the the sucContractor.
Lised. iw(Cned hmmcm
-omonamiEttnadpantion7m)ofDisinaznOfbeBmcarandPnal,w(Codt)or Sq. F[. Floor Area Valuatio 750'
2 $ (commencing widM1 Section)1100)of Division Jnflbe Business and Profruiom Cole)or
11
that he is exempt therefrom and be bass for be alleged exemption.Any violation of
Section]051.5 by airy applicant for a permit subjects the applicant to a civil penally of 3 j)!}t( Ipl'bCr O O Occupancy Type
not more man Esc hundred dollars($500).
❑1,As owner of be pmpcny,or my employee.with wages as their sole compensation,
will do be work.and be swclum is not intended or offered for Bale(Sec.7614,Business
and Profe glom Cade:The Contractor's Littme Law does not apply b an owner of Required Inspections
pmpeny who builds or improves beacon,and who does...h work himself or through his 502 - FINAL PLUMBING ENERGY
own employees,provided that such improvements are not intended or offered for sale.If. SOG — GAS TEST
however,be building or improvement is sold within One year of Comdata,be owner.
builder will have the burden of proving bat he did not build or improve for puryoa of 507 - FINAL .PLUMBING
Q I,u owner of the properly,am exclusively contracting with licensed rnannou to
construct be project(Sec.7614,Business and P ofmdom Code)The Comracmrs Li•
cense law does not apply to an owner of property who builds or improves fireman,and
who contracts for such projects with a eontnaor(s)licensed pursuant to be Contractor.
License Law.
❑I am exempt under Sec. ,B&P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby All under penally of perjury one of be following declarations:
1 haze and will msimain a CeniEcam of Continuo selfdmum for Workers Cumpem
W inn,as provided for by Section 37M of be Labor Code,for be performance of the
work for which this permit is issued.
❑ 1 haze and will maintain Workers Compensation Insurance,az required by Section
EWp of be Labor Codc,for the performance of the work for which this permit is Wind,
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action need not Wcomple¢d if be permit is for one hundred Collin affli
or It,,.)
I certify but in the parrormance of the work for which this permit is issocd,I mdl not
employ any person in any manner An U to become subject to the Workers Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Codc,you must —
zQ forthwith comply with such provisions or this Permit mdl be deemed revoked. /�
7) CONSfRUCr10N LENDING AGENCY
1 hereby affirm bad there is a covtmction lending agency for be perfurmance of 44 V
:4be work for which this permit is issued(SAO.3197,Civ.C.)
4 A Lender.Name
Y
�z Lender's Address
;)0 1 certry bat I hese read oris application and stats that be above information m atlan to
y H building 1 gree to comply here all tidy and county matnaimm and ane laws a upon t to
V abort-mding eonzwnionand for
rimby action purpose. mtivesofbisCity to coxaupon the
abovc(We)Agree
property fmimnifyan mcpha.
y (Wc)egedd outs indemnifyandtech hay in
de Cityru Cupertino against
Lo)Z in liabilities, eo6lband of difis Permit.
APPLICANT
In Boy Way OCLNe against cold City
J z A PLICANT of UNDERSTANDS
ing of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature ofApPlicaDam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Willy t applicantumiser forum building e,Chapter
store 9.1 or handle Health andudous Sadd
az defined by the Cupertino Municipal Code,Chahar 9.11.and the Health and Safety
Code,Section 25571(.)? All roofs shall be inspected prior to any roofing material being installed.
Ys :No
applis Anorlwunbuilding occupantuse equipment ordevices which If a roof is installed without first obtaining an inspection,I agree to remove
11tdh,.,[='�It air cnnmminats u dcMed by the Bay Ams Air Quality M.nagemend all new materials for inspection.
7
❑Yes ❑Nu ,
1 have mad be ha sidous mmcrialsmquimmcats under Chapter 6.95 of be Califnry
nix Health&Safety Code,Sections 25505,25577 and15554.1 undcrslnnd bed if tic Wilding
dam not ancndy have a roman,but if is my mspomiEilidy an notify dre asupsm of be
requirements which must W met prior it)issuance of a CcrJfream of Occupancy. Signature Of Applicant Date
Owner or aebodaed agent Date All roof coverings to be Class "Bo or better
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 10944 North Seal Sq. Date: 10-14-03
Owner's Name:---Thilking, Paul
Phone No.(408)255-5473
APN#: 316-40-027 Project Valuation: 4 750.00
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# 591329 Exp. Date: 3/31/04
Worker's Comp#: 1626288-03 Carrier: State Compensation Insurance Fund Exp. Date: 4/1/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679
Name on Card: just Water Heaters Inc.
Expiration Date: 9/05
Visa MasterCard X D J
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