03080071 (2) I CITY OF CUPEW11NO 9 ` - ' `
BUH.DING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT N003080071
0290 yTrKqRTTRn DR
OWNER'S NAME: 1764 NATIONAL AVE PERMIT ISSUE DATE
NANCY BARHELMES
NE: (510) 293-9901 SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i00 LICENSED CONTRACTOR'S DECLARATION
! t, 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing lob Description
wits clion 7ONB of Division 3 of the Business and Professions Cala.and my license is
License
REPLACE WATER HEATER FINAL SO
DateClava com
Dam ConwmaL (4 0 GALLON GAS)
As Chall ECTS DECLARATION (� �r
I W< 1 unticrsunJ my plans shall be uuJ az Public mcnrJs SEP - / [003
)yU Y
o Licensed Pnrfcssinnal
g OWNER-BUILDER DECLARATION BUILDING
q
a 4 1 hereby affirm that 1 am exempt from the Contractor's License Law for the BU ILD'NG
O O following reason.(Sedan 7831.5,Business and Professions Code:Any city ar county CPU
5 m which¢quires a pconit to construct.stmt,improve,demolish,or repair any structure
¢i prior to its issuance,also requires the applicant for such permit to file a signed statement
< that he is licensed pursuant to the provisions tit the Cono>cmr'sLicense Law(Chapter 9 Sq. Ft. Floor Area ValuatlO$749
41--0 (commencing with Section 7")of Division J sir the Business and Profeasiom Could)or
Nal he Is caempt Bacteria.end the basis for me alleged exemption.Any viola8on of
Section 7871.5 by any applicants for s Permit objects the applicant to a civil penalty of 3 @9rN4QbMar0 0 Occupancy Type
Out mom Nen five hundred dollars(1500).
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do Be work,and the structure is not intended or offered for sale(Sec.7014.Business g I���hS�e
and Professions Code:The Conuacmfs Limve Law dose not apply to an owner of 502 — FINAL PeL UMB ING c RGY
property who builds or The
thereon,and who doessuch work Mmxlf or through his
own employees,provided mor such improvements are not intended oroRered for side.It. 506 — GAS TEST
however,the building or improvement is sold within one year of completion,Ne owner.
builder wit;have the burden of proving that he did not Wild or improve for purpose of 507 - FINAL PLUMBING
sale.).
❑1,as owner of the property,am reclusively convecting with licensed contractors to
construct am porous spec.7044,Business and Professions Code:)The Convectors Li.
cense Law does not apply to an owner of progeny who Milds or improves th rear,and .
who contracts far such projects with s emmus m ir(a)licensed pursuata m the Cantr¢mfs
License Lew.
❑I am exempt under Sea B A P C for this return 5
Owner Dale
73011WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of Perjury one of the following declarations;
I have and will maintain a Cent fiction of Consent to self-insum for Worker's Compcm
M
on,as provided for by Section 37W of the labor Code,for the performance of the
rk for which ON permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
of me labor Cade,for the perro mace of the work fm which this permit is issued.
Workers Compensation Insurance carrier and Policy number art:
rtier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nd5seainn need nus be completed If the Nimil is forooe hundred dalton(A(N)
.,I.$.)
I unity that in the pi formance or the work for which this permit is issued.I shall not
employ any Person in any manner so as to become subject o the Worked Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to Be Worker's Compensation provisions of the Leben Cade,you must
.JO forthwith amply with such urvialana or this parm t le halt be deemed revoked.
z CONST RUCTION LENDING AGENCY ^
[r.>-v I farcby Which this
mmthcre issued(See.3 lending agency for the performancc of Y' —
C m the work fur which mix permit is issued(Sec.JD9].Ci,C.)
W z Lcndcr's Name
Addm
RI I�nder's Address
Uz
C.3 0 1 certify Nal I hawmply read thirty Lord
coup and sum that the above information is
W building I agree to comply with all city and coumy ordinances and sue laws relating to
0U ithroongconsnucsion,and hembyeumo purposes. Lives of this city menmr upon Be,
W ehovc(We) cd progeny for emnifyi en kap ha.
6.
(We)egme m uses indemnify end kap harmless the City of against
against
h
liabilities,judgmental,costs end expenses which may in anyway accrue against said Cily
U a.cirsequcau of the gaming of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
Re-roofs
Signature of ApplicaHAZARDOU Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future building occupant More or handle husNuus material
az defined by the Cupertino Municipal Lode.Chapter 9.12.and me Health and Safety
adlL�mhc.S❑e2553](x)?y, ON. All roofs shall be inspected prior to any roofing material being Installed.
Will the appl con,or future building current use equipment or de.ieca which If a roof is installed without first.obtaining an inspection, I agree to remove
it ha/4adou3 air conmmtnants as defined by the Bay Area Air Quality Management all new materials for inspection.
7,.Hczlth"SAfCLYC�,�dam2M5,25533wdM534,lun�m=dmuirft
x8ict?
❑Yes ON.
I hc read the hasanlous materials requirement¢under Chapter 6.95 of ter Califor,
fIM building
snotcurrently havealenxnkrytrements which must be met prior to issuance of a Certificate or Ocapancy, Signature of Applicant Datener ser nithmized agent Data All roof coverings to be Class "B" or better
City of Cupertino Building Permit .A lication
E-Mail
Jobsite Address: 10290 Vicksburg Dr. Date: 8-4-03
Owner's Name:---Nancy Barhelmess
Phone No.(408)253-1 565
APN#: 369-14-009 Project Valuation: $ 749.00
Building Permit Info: Bldg----------- Elect----------- Plumb------JC----- 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# 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. Z2X" T
Expiration Date: 9/05
Visa MasterCard ® U
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