04020124 (2) c>TY of cuPERTINo PERMIT `�U1 PRr�I UR TNIi'UWTA'�ION.'
BUILDING DIVISION
BuILDINC ADDRESS: JUST WATER HEATERS INC PEaMITNo04020124
1OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY C NTROL NO.
ARCHITEC IENGINEE'R: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�Op LICENSED CONTRACTOR'S DECLARATION Job Description
'rt I hereby affirm that 1 am Invested P
ed under previsions of Chapter 9(commencing
whh section 7")afDivision 3 of the Business and Professiors Code,and my license is
in full fore=and affect.
5'Idz License Clean Lle.a REPLACE WATER HEATER
F Dale Contractor (5 0 GAL GAS)
q ARCHITECTS DECLARATION
2 I understand my plans shall M used u public rtcard,
6
3
Licensed Prof cssional
^
OWNER-BUILDER DECLARATION
d a E I hereby.(firm Nat 1 1. exempt from the Cssions r't Licence Law for lne
S:O O following recon.(Section Ronstr Business and de ors Cade:Any city at county
$ which requires a a pormid re construct,.seg improve,t fsuch
demolish,or repair ed twment
pilar to its issuance,also requires the unions or for such act.=.ofileasigned statement
othalmiananamparntanmtbcpmvivioo3 ft oftoonusinmsandPrsoLaw
onsCod(Chapter 9 Sq.F[. Floor Area Valuatj�o�1017
$ that he is(commencingwith Section and of Division 3 of NC Busalleged
axe pt on.Any
Ction or of
Nat a Is exempt therefrom and the buss for Nc alleged camption.Any violation a( '
Secdon 7031.5 by any applicant for a permit subjects the applicant to a cord penalty of APN Number Occupancy e
not more Nan film hundred dollen($500). P Y EYP
01,uownerof0epmppny,ormyemploycuwithwagesutheir Mlemmpenution, .366155033 . 00
will do Newok and Ore swctum is notimmnded oraRemd forsale(Sac.]044,Business
and Profrasiors Code:The Contra tor's Liana Taw docs not apply R an owner of Required Inspections
property who buil ds or i mproves Merton,and who does such wark himal f ar through his
own employees,provided!Nal such improvements an not intended cro0ered for sale,If,
however,Ne building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or improve far purpose of �'p.�a
sale.). eY �■rw O
❑1,as Owner of the property,am exclusively correcting with licensed contractors R
construct to project(Sec.7844,Business and Professions Godo)The Communes W.
caMAR 1 1 ?004
use law does not apply to an owner of property who builds or improve Ihemon,and.
who contracts for such projects with a contrutor(s)licensed pursuant to the Contractor's
License Law.
❑Iamennupluader Sa. ,9kPCfarthisreMan
UNIl011yG
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-irsum forWorker's Compere
7107M
lan,u provided for by Section 3]011 of the labor Code,for the performance of the
rk for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,u required by Section
of the lobo,Code,for Ne perfarmanm of the work for which Nis permit is issued.
y Worker's Compensation Inarance Manor and Policy number are:
rrier. Policy No,: _
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(Misactin...deal he completed lithe permit is fortune hundred dollars(5100)
or less.)
I certify Net in the performance of the work for which this permit is issued.I shall net
employ any person In any mmnor so u 0 become subject to the Workeri Compensation
Laws of California.Dan
Applicant
NOTICE TO APPLICANT:If,after making this Compute of Exemption,you should
become subject to the Worker's Composition previsions of the liner Code,you must
.JO forthwith comply with such provisions or this parent Mall Is,deemed revoked.
z55 CONSTRUCTION LENDING AGENCY
[..r 1mreby.0lrm NU than a ncmarectum indiingagency forth=ptoforma.m.1'
ori? the work fur which this permit is Ibincd(Sec.3097,Civ.CJ
W�0 Lender's Name
az Isnders Addreu _
U Q I certify that 1 haw mad this application and sun that the show information is
IL F correct.I agree to comply with all city and county ono nances and state Iowa relating in
DU building consumcdon,and hereby auNorime mprcuntadve,of Nis city to enter upon the
W shrove-mentioned property for inspection purposes.
LL (We)agree in Mw,indemnify and keep harmless the City of Cupanina against
ti rA Imbilides,judgments,casts and expenses which may in my way acme against Mid City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDO
Signature of Applicepale
HA2AR home b MATE RIALS DISCLOSURE Type of Roof
fumm
Will the applicant or building acupant atom or handle hazardous manrir
as defined by do Cupertino Municipal Coda,Chapter 9.13,and the Health and Safety
carie.sac Yana zss33(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
Will the applicant or future 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 an defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes r-1 No
I have mmf do hazardous materials requirements under Chapter 6.95ofthe Califor-
nialicalthA SamlyCoda.Sections 25505,8533 and 35534.I undcrvand Nati(the building
docs nos currently have a Round,that It u my re.ponability to natil'y to acupant of do,
requiromaomwmehmustxmetprcranissuance ofacamncateofOccupancy. Signature of Applicant Date
Owner or authorind agent Dale All roof coverings to be Class nBn or better
City of Cupertino Building Permit Application
E-Mail
0
� �
Jobslte Address: 7575 Poppy Way Date: 12 13=0
Owner's Name:---Ralston Kristin
Phone No.(408)252-4457
APN#: 366-15-033 Project Valuation: S 1,017.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----- Mech-----------
Job Description
Replace 50 gal 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
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