03060141 (2) • CITY OF CUPERTINO
BUILDING DIVISION PERMIT .CONT=RACTOWINFORMATION• t -
OUILDwOADDRFSS: JUST WATER HEATERS INC PERMIT"003060141
0121 PARI21i 121
a OWNER'S NAME: 1764 NATIONAL AVE PERMITIsun DATE
VANARARA
(510) 293-9901 SANITARYNO. CONTROLNO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BGS ELECT PLO MECH
O
.00 LICENSED CONTRAC'TOR'S DECLARATION Jb Descrip IIOn
I I hereby affirm o
that 1 em licensed under provisions of Chapter 9(commencing
with Section 7M))of Division 3.f the Business and Professions Cods,and my license is
in full force and efrccL �p
>q_ LicebseClave Lieif REPLACE WATER HEATER u�
9�, Dau Coanr ECL (40 GALLON GAS) L''as
ARCHITECTS kuse DECLARATION
I understand my plain obeli W used a public records
AUG 14 2003
eo� Licensed Professional
-
OWNER-BUILDER DECLARATION
�<y 1 hcmhy air..that I on exempt from Ne Centre,o's License Lew(or the �J u'�
OE following mason.(Section 7031.5,Business and Professions Codc:Any city or county Dtlkg
I$ which requires a permit it construct,alar.impmw.demolish,or repair any structure g kt
-I j, prior to its issuance,also requires the applicant for such permit to rile a signed statement
p < that he is licensed pursuammthe provisions ofthe CamracmriLicense Law(Charter 9 Sq. Ft. Floor Area Valuatic$964
t(�Fs (Commencing with Section 7000)o(Division 3 of the Business and Profeasinns CNe)ur
., that he is exempt therefrom and the basis for d¢alleged exemption.Any violation of
Section 7031.5 by any applicant far a permit subjects the applicant to a civil pcmlty of 3 IW414`OiMcirO 0 Occupancy Type
not mom than five hundred dollen($500). _ p y yp
❑1,as owner of the property,or my employees with wages as their role compensation,
will do the work.and thessucture Ts not intended or offered fouale(See,7 W,Business Required Ins ectlon
and Professions Code:The Co urames Liam Uw does amt apply m an owner of q
property who Wilds or improves thereon.and whodoesauch work himmLUMBI ifor through his 502 - FINAL PEN RGY
own employees.provided that such improvements am not intended orrffered Errors.It. 506 - GAS TEST
however,Ne building or improvement is sold within one year of completion.Ne owner.
builder will have the burden of proving that be did not build or improve for purpose of 507 - FINAL PLUMBING
1,as most of the property,am exclusively contracting with licensed contractors to
contract the project(Sec.7054,Business and Professions Codc:)The Comracurs Li.
ave law does not apply to an owner of property who Wilds or improve themun.and .
who contracts for such projects with a consactor(s)licensed pursuant to the Contractor's
License Law. '
❑I no exempt under Sec. ,B h PC for moon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby aRlrm under penally of perjury one of Ne following declarations:
I have and will maintain a Certificate of Consent to selfdnsum for Worksra Compen.
1037.1ri
lon,a provided for by Section 3700 of the labor Code.for the performance of the
rk for which this permit is issued.
I have and will maintain Workers Compenation Insurance,a acquired by Section
of the labor Code,for Ne performance of the work fa which Nu permit is issued,y Workers Compensation Insurance carrier and Policy number am:
me,. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('This seamen need not W completed lithe permit is for one hundred dollar($100)
or Ices.)
1 certify that In the performance of the work for which this permit is issued.I shall not
employ any person in any mannerm as to become subject to the Workcn'Compensation
Laws of Califumia.Data
Applicant .
NOTICE TO APPLICANT:If.after making this Certificate of Exemption.you should
Woman subject to lW Wmk&l Compensation previsions of the Labor Code,you must
OfoMwith comply with such provisions or this parm i shall W deemed revoked.
zCONSTRUCTION LENDING AGENCY
P2 I Wmhy.from that there its construction rending agency,far the performance of p
D: > the work for which Nis permit is iuued ISm.3097,Civ,C.) — y_
a� Lenders Name
z Landcri Address
U Q I cattily that 1 have mad this application and stets that the above information is
IL F correct.I agree to comply with all city and county ordinances and stale laws mlating to
0 V building construction.and hereby authoda represcnutives ofthia city to enter upon the
,�• alwve-mentioned progeny forinspection purposes.
F (We)agree m ave.indemnify and kap harallleaa the City of Cupertino against
fn liebilities,judgmenu.cusu and expenses which may in any way accrue against mid City
V Z in consequence of the granting of this permit.
a-• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicmUConData
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will one applicant or future budding occupant Chapter
tstore or lad the
Health
sd Safety az defined by the Cupertino Municipal Cudc,Chepler 9.11 end the HaRh end Safety
Iiad.Code,Section 25532(all All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
Will the applicant or future Wadingamupantuse equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It harardno oil contamimanu a darned by the Bay Arca Air Quality Mm..ano t all new materials for inspection.
.
❑Yes ❑NnI have sad the haammndous materials betri mt tok,Chapter 6.95 of the Califor.
Health g:Safety Code.Smuov 25505.25533 and 25534.1 tarok stand that if the Wilding
not currently ham a ameba,Nu.et it is my vesponsi hit ity fy doe cupent of de
uirements which must W met pour m issuance of a Ccmificac of Occupancy. Signature of Applicant Date
Owner or authorized ns em Date - All roof coverings to be Class "B" or better
C)
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 101 31 Parish PI. Date: 6-23-03
Owner's Name:---Yanahara, Gary
Phone No.(408)255-0216
APN#: 316-44-025 Project Valuation: 5 964.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----- viech-----------
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: 4/11/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679 2 2 3
Name on Card: just Water Heaters Inc.
Expiration Date: 9/05 ,J¢ /�-, 6/
Visa MasterCard ® �s
Comments