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
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