03100009 (2) CITY OF CUPERI'INO , 11 - '.
BUILDING DIVISION PERMIT CONTRACT(? INF6RMATION
BU ILDING ADDRESS: JUST WATER HEATERS INC PERMIT No.03100009
09r4 NQRTRqP.AT 9C)
OWNER'S NAME: 1764 NATIONAL AVE PERMIT ISSUE DATE
M
NE: (510) 293-9901 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: „ BUILDING PERMIT INFO
BLDG ELECr PLUMB MECH
X00 LICENSED CONTRACTOR'S DECLARATION O O O
u 61 Whey affirm that I am licensed under provisions of chapter 9(commencing Job Description
with Seed..7 M))nf Division3.(the Bre inessand Pmfcssinns Code,and my license is
<q LicenlseClaaa,"deaeet. Lic.A REPLACE WATER HEATER
o Dor Contractor (4 0 GALLON GAS)
1 g ARCHITECTS DECLARATION
to I understand my plans shall he used As public records
;WU
�w Licensed Professional
3 OWNER-BUILDER DECLARATION
<f 1 hereby affirm that 1 am exempt from the Contractor's License Law fur the
m 0 following reason,(Section 7031.5,Business and Pmfcssions Code:Any city er county
which requires A permit to construct,alley,improve,demolish,or repairanystructure
S=�
poor o its issuance,also requites the applicant for such permit to file a signed statement
mm� that he is licensed pursuant to the provisineofthe Contractor License Law(Chapter 9 Sq.Ft. Floor Area Valuatio$7 C,0'
ZF (commencing with Section 71)0)of Division J of the Business and Professions Codc)or
that he is exempt mere(,..and Ne basis for the alleged exemption.Any violation or
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of g�8pq��®be
not more Nan five hundred dollars(5500). f O 0 Occupancy Type
❑1,as owner of the property,or my employees with wages as their sale compensation,
will do the work and the structure is not intended or offered for sale(Sec.1044,Business
and Professions Code:The Conuaclor's License Law does not apply to an owner of Required Inspections
property who builds crimproves thereon,and who does such work himselror through his 502 — FINAL PLUMBING ENERGY
own employees,provided that such improvements are not intended or offered formic.11, SO6 — GAS TEST
however,the building or improvement is sold within one year.(completion,the owner-
builder will have the burden of proving that he did not build on improve for purpose or 507 — FINAL PLUMBING
ASIA.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.704,Business and Professions Coda)The Contractors Li-
cense Law dose not apply to an owner or property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
j ❑ I am exempt under Sec. ,B k P C Or thisteson a
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declarations: MAR 1 8 2000
I have and will meinuin a Certificate of Consunuo vele-insure for WorkersCumien-
Sation,AS provided for by Section 3100 of the labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,As required by Section (' N
3700 of the Labor Code,for Ne performance Of the work for which this permit is issued. '
My Worker's Compensation Insurantt carrier and Policy number are:
Carrier: Policy NA: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
CThis section need not be complemd if the Permit is for one hundred dollies($ip))
or leas.)
1 certify Out in Ne performance of the work for which this permit is a ved,I shall not
employ any person in any manner so as to become subject to the Workers''Compensation
Laws of California.Dat. -
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
70 forthwith comply with such provisions or this permit shall be deemed ranked.
r r
CONSTRUCTION LENDING AGENCY
1hor which
Norman iss issued
lending 7,O. agency for the Perfortnence of
3i me work for which this permit it issued(Sec.3091.Civ.C.)
QLenders Name -
�z Lender's Address
p 1 minify mal 1 have read this applimahm and sole that the above information is
Hcorrect.1 agree to comply with all city and county ordinances and sole laws relating to
DU building construction,and hereby authome represcroadves of this city to enter upon the
is 6Wi abovcies Judgmoncri ents,costs
for inspection purpowhich ms.
ti (We)agree to save,indemnify and keep hrtmiess the City of Cupertino against
h liabilities of
coarsing of this expenses which may in anyway accmc against=to City
J7 A APPLICANT
of UNDERSTANDS
permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Signawrc ofApplicaDem
Re-roofs 07
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or(omni building occupant store or handle himandums
and
C defined io the Cupertino Municipal Code.Chapter 9.12,and the Health and safety
Code,Section 25532(a)?
' pre ❑Nu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or alum building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
strict?
❑Yes ON.
I have mad the haaarthms materials requirements under Chapter 6.95 or the Califor.
MIA Health tit Safety Code,Sections 25505,25533 reand 25534.1 understood that if dM Wilding
does not curremly have a ran.mat it is my responsibility to notify the occupant of dw
requirements which must be met prior to issuance or A Cerefc.,of Occupancy. - Signature Of Applicant Date
Owner or authorized Agent Dato All roof coverings to be Class "B" or better
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 10964 Northseal Sq. Date: 10-1-03
Owner's Name:---Moghtader, Hessan
Phone No.(408)962-0999
APN#: 316-40-031 Project Valuation: $ 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 z 3 3 cf�'
Name on Card: just Water Heaters Inc.
Expiration Date: 9/05
Visa MasterCard X
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