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03090114 (2) f CITY OF CUPERTINO i BUILDING DIVISION PER CONTRACQIZ INT OIIIIIATION BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT"°03090114 Oise? WHIT2 12IR CT t OWNER'SNAME: 1764 NATIONAL AVE PERMIT ISSUE DATE KONG 09/IF/200'1 'NE` (510) 293-9901 SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH +00 LICENSED CONTRACTOR'S DECLARATION CJ O O O Up I hereby af(rm that 1 am licensed under provisions of Chapter 9(commencing Job Description FZW with SCcOon?000)of Division 3 of the Business and Profession.,Code.and my license is <<O„ mon for,seance cleosae Lie.x o0 erre"' : REPLACE WATER HEATER p Contractor DateContractor (40 GALLON ELECTRIC) erJ` ARCHITECT'S DECLARATION 1 understand my plans shall he used as public records JyU eu0 t, Licensed Professional S OWNER-BUILDER DECLARATION COO reaso affirm that 1 am exempt from the Contractor's License Lew for the O� which followingequwmn. crone 7os5,Business and wc,deloli Code:Any city lir county <mtn which itsimusapcnnit requires the ahcn im for such pOrroutt or repair anystructureQ i i ptlonn its ceased pursuant requires thovisio s of for Contractor's rile a ale(Chtement asp that me cccnudpSectio 7 the provisions of the the Business nd Prchlsw(C Code) Sq.F[. Floor Area Valna(10 5'79 21- (at he ewith Section ofDasisnrthh1cindr.sand Professions Code)or Net Section is exempt therefrom and the beer for the alleged exemption.Any lineation of amhan?oban byany undreddollarsSSW)permit subjcdsthe applicant macivil Penalty of 3WDi�iMci-00 _ Oecu ane .T e _ not more than me nnmrea dollars(ss00). - -- - -- - - - - " P Y YP -_- ❑I,as owner of the property,or my employees with wages m their sole compensation, will do the work,and Ne macture is not intended or offered(or sale(See.0094 Business �y and Profusions Code:The Contractors License Law does not apply to an owner of 5 0 2 - FINAL P NB I Nff'GRhRGY property who build,or improves thereon.and who doessuch work himself or through his own employees,provided that such improvements are not intended oroffered hostile,if, 506 — GAS TEST however,Ne building or improvement is sold within one year of completion,the owner- builder will have the burden of moving Nat he did not build or 507 FINAL PLUMBING sale.). LED ❑I,as owner of the property,.Business s and convecting with licensed contractors i pINA construct La the project apply of an fand Professions ds or The Contractor's and law doe,not apply je an with a of property who sed or impro the thereon,end 2004 who contracts such projects with aconvacmr(s)licenutl pursuant to the Convacmr's FEB O License Law. 4 , ❑Ism exempt unser Sec. ,B&PCfor this rcuon Owner Date BUILDING WORKER'S COMPENSATION DECLARATION 1 hereby affirm antler penalty of perjury one of the following declarations: _ I have and will maintain Is Certificate of Consent to self-IMUM for Worker's Compen- setion,as provided for by Section 37W of the Labor Code,for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,m required by Section 3700 of the Labor Code,for the performance of Ne work(or which this permit is issued. My Workers Compensation Insurance carrier and Policy number arc: Cartier: Policy Na.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not becomplctea!fine permit is forms hundred dollars(SIM) lir les,.) /// l✓Y'._1/V 1 cenify Nat in the perfool of the work for which this permit is issued.I shall not employ any person in any manner so az to become Subject o the Workers'Compensation Laws of California.Date Applucam NOTICE NOTICE TO APPLICANT:IL after making this vis!n s of of Exemption,you should become subjecty the Worker's Coons or this provisions of Whar Cnde,you must 7 O forthwith comply with such provisions or tM1ie permit shall be tlecmcd revoked. i ti N CONSTRUCTION LENDING AGENCY 1 hemhy mTrm this,there is a smmunueinn lending agency fur the performance of the work fur which this permit is issued(Sec.3007,Civ,C.) ALender's Name 33. z Lender's Address J Q 1 cenify that 1 have read this application and mile that be above information is L H correct.)agree to comply with all city and county ordinances andsate laws relating to V building consuuuthm nl ction,and herchyeoriupremmivea of this city wcnterupnn the G ahovetim.juuned propertycosts for ande pe expenses purposes. y (We)agree to save,indemnify and keep harmless the City of Cupertino against rn Iiacoseg once Of the coarsing Of this cawhlch may in any wayaccmc against said City A APPLICANT UNDERSTANDS of this pc WILL '7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. Re-roofs Signature of ApplicaHAZARDOUS MATERIALS DISCLOSURE rdantractor Date Type of Roof Will the applicant or future building occupant stere or hostile hevallous material Ca dcfined by the CupeNnt Municipal,Code.Chapter 9.12,and the Health and Safety cane,s«tion zsslz a>? All roofs shall be inspected prior to an roofing material being-1 Yes ❑Na P P Y g g installed. 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 as defined by the Bay Area Air Quality Management all new materials for inspection. isvict? ❑Yes ❑No ' I have mad the hommous materials requirements under Chapter 6.95 of the Califon his Heolthd,Safety Code,Secuoaz 25505,25533 and 25536.1 understand dust if the building does not currently hoc a tenant that it is my resproodulity w noul'y the Occupant of the requirement%which must be met prior to issuance ofaCanlBcateofOccupancy. Signature of Applicant Date Owner or authorized agent Date All roof coverings to be Class "B" or better � 3o b f � City of Cupertino Building Permit Application E-Mail jobsite Address: 10592 White Fir Ct. Date: 9-16-03 Owner's Name:---Kong,Sarah Phone No.(408)873-2097 APN#: 359-05-128 Project Valuation: $ 579.00 Building Permit Info: Bldg___________ Elect___________ Plumb_____X----- Mech___________ Job Description Replace 40 gallon electric 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: permitsQjustwaterheaters.net City, State and Zip: Hayward,CA. 94545 State Contractor's License# 591 329 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 Comments l