04020010 (2) t CITY OF CUPEWPNO -
BUILDING DIVISION PERMIT nCOiVTRAGT-OR INF;QRMATION �
nu I LDING A DURESS: JUST WATER HEATERS INC PER ""04020010
l
0 W NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NU. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�Oo LICENSED CONTRACTOR'S DECLARATION L� O O O
w Fp I hereby effort that 1 am licensed under provisions or Chapter 9(camm[ncing Job Description
Zto whit Section 70m))of Division 3 of he Business and Professions Code,and my license is
<m In falleandenee` REPLACE WATER HEATER
p da Z Liccnx rmatClClazs Lk,a �p
a 1!J Date CummcCL (4 0 GALLON ) FI®' A LEO
dy ARCHITECTS DECLARATION
S- 1 undcrslanJ my plans shall be usN as Public mcnNs
LLe.
Licensed Professional
FEB 1 8 2004
iys OWNER-BUILDER DECLARATION
E<0 1 hcmhy affrm Nm 1 nm cxcmpl from the Conon Co License Low for the
KO o following meson. (anis in 1031.5.Business and sae,demob h.Or Any city or county
m which reyuimx a promo re construe,alcor,improve,forsu demobit t Or repair any strvnum
ytY tpoor hat he itsissuance.c,ahunquims(he
ovisio s(iffine mchpermitm Moser Lawdmammcm
FDRlhalheiscamcithStcanunmeulDivinnsnrNceommaorrundPnsclrw(Chapter 9 Sq. FL Floor Area Vauatiol871
that he 4 ing exuarph aorefonllandh banks Inaafthe tho.1Buxincur,d P,ares,vihuion err
i res$
that he u exempt tMmtrom and Ile banks for the alleged cssmption.Any violation of
Section 1031.5 by any applicant for a permit subjecu the 2PphCrnsto a civil penalty of APN Number
not moa than fn hundreddpBars($50B. Occupancy TYPe
❑Lis,owner o(the pre,pony,or mycroo,ca with wages as theirsokbomPersation, 37534021 . 00
will do the work,and the awemm is not intended proffered for sale Ike.7044,Business
and Professions Code:The Contractor's Liconse law does not apply to an owner of Required Inspections
pmpeny who builds or improves thereon,and who doessuch work himself or Nmugh his
own employers,provided N0 such improvemenu are not intended or offered for sale.It.
however Ne building or improvement is sold within one year of completion.our owner-
builder will how the burden or moving Nal he did not Wild or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively convecting wit licensed contractors to
comNact the project(See 7044.Business and Professions Code:)The Contractor's Li. .
cane Law Ears not apply to an owner of prop[ny,who Wilds or improves do mon,and
who concocts for such pmjecu with a contraclor(s)licensed pursuant o be Contracmfs .
License Law.
❑I am caempt color See .B&P C for Nis reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
t Ihereby aM.orae,penalty of perjury one of One following declarations:
I haw and will maintain a Certificate of Consent o selr-insum for Worker'sCompcn-
Sarion,az provided for by Section 37M of Ne Lo W,Code,for One x rformamc of the
work for which this Permit is issued.
1 ban and will maintain Worker's Compensation Insurance,u required by Section
DOB of the Labor Code.for use performance of the work for which this permit is issued.
My Worker's Compewtion Inaunnm camp and Policy number am:
Camey. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section acrd not W compieed irthe permit is!more hundwa dollars(51tls)
or kss.)
I certify coal in the per mmawe of her work for which Nis permit is issued,1 shall nut
employ any person in any manor anti to become subject to tbe Workers Compensation
Laws of California.Date
Applicant -'
NOTICE TO APPLICANT:IL aper making his Ccnifcue or Esemptlon,you should
become subject to the worker's Campcwtion provisions of the Labor Code,you must
., z foMwiN comply with such pravuimu or Nis lcomm, hall be deemed invoked.
z O CONSTRUCT]ON LENDING AGENCY
'e~+ I hereby alarm that there is,construction lending agency l'or the performance of
fly the work for which his permit is issued(See 3A),Civ.C.)
U] Q Under's Name
Lcndcr' ess
Addr
U 1 (.� V
V Q 1 certify Nat I haw rind all
tai application and dshateins Net pat suite[ "mtaoan is
IJ bonen,)agree to comply with all city and county ordinances of and sum Inws¢lasing e
pU buildingconstruction.ion.end betebosreco , tr,mrocnuliry of this city to enmrupnn coo
a ahovc(we)agree
toronyLaw find mni fy an keep s.
(we)amen to saw,indemnify and keep hay in an w City of Cupcnst against
LZI U z in corse tree tae Of ts.the gran i and capenxa mit. may in any way accmc against said City
APPLICANT
of the granting of this Permit.
^� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
Re-roofs
Signature of ApmlicaDelta
HAZARDOUS
J� HAZARDODO US MATERIALS DISCLOSURE Type of Roof
(/ Willy the C,somamat Of(mune building Occupant haul r ore 9.12.handle hrruth us and safety
moal
st.
by the Cupcnino MunicipalCode.Chapter 9.12,and coo Health and Safety
Cak.Semon 25532(,,)1 All roofs shall be inspected prior to an roofing material being
❑Yea 0 N p P Y g g installed.
Will thea applicant or future building Occupant use e If a roof is installed without first obtaining an inspection,I agree to remove
pp 6 p o Air Qu or devices which g
it hen,dous air contaminants u dcfncJ by be bay Area Air Quality Management all new materials for inspection.
istrinl
[D Yes 0 N
I how Lead the havardnus materials mquimmcnu under Chapter 6.95 of the Calif., _
nix Health&Safely Code,Statham 255(15.25533 and 25534,1 understand Nu it de Wilding
docs not cuncnily haw a tenant Nal it is my rea,mibilu,m noel,the dncupanl quite
rtgwmmenu which must he met roar to iuumee or a ccooficaue of Occupancy. Signature of Applicant
Date
Owner or.umaritud a goal Dote All roof coverings to be Class"B" or better
U
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 10732 Culbertson Dr. Date: 1-15-04
Owner's Name:---Matson,Wayneine
Phone No.(408)255-6088
APN#: 375-34-021 Project Valuation: $ 871.00
Building Permit Info: Bldg----------- Elect_ Plumb------X----- Mech-----------
Job Description
Replace 40 gallon 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@j u stwaterheaters.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 X b (�
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