03080092 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRA CTOWPOORMATIO,N -.
BUILDING ADORM: JUST WATER HEATERS INC PERMIT"'03080092
OWNER'S NAME: 1764 NATIONAL AVE PERMIT ISSUE DATE
NE: (510) 293-9901 SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEOCH'
i00 LICENSED CONTRACTOR'S DECLARATION
I;WE I hereby affirm that 1 am licensed under previsions of Chapter 9(commencing Job Description
< with Section 701)(Baf Division 3ortheBusinoasoM Pmlisixom Codc.and my license is
infullerr"`' REPLACE WATER HEATER FINAL.EO
> in full fares Clea Llc.N
Dao Contractor (4 0 GALLON GAS)
ARCHITECTS DECLARATION
£ u Iunderstandmyples,shallWusedupuhlicrecords AUG 2 6 2003
o Licensed Professional
3 OWNER-BUILDER DECLARATION
'vf e S 1 hereby affirm that I am exempt from the Contractors License Law for the BUILDING W
❑O following mason.(Section 7831.5,Business and Prefessiuns Code:Any city or county
3- which mquims a Permit to construct.aper,improve,demolish,or repair any structure
her pnonnitscensed de,tlsarequires Provisions
sOf far ouchm1wo'micese Lawdnammem
(Commencing
licencedpussuaet lathe pmvivisionf theeB usinar's License Law Code)or Sq.FI. Floor Area - ValUatdQn059
[�O (commas xempth5[nian70W)of Dasisfrthe or alleged
exempt and Pi.Any n&Ction u, 4'I'
��$ that he is exempt Nertfmm and the buts for the alleged caemption.Any violation of �va.o�i�Ns��.,,h
Section 7831.5 by any applicant for a permit subjects the applicant to a civil finally of 3 2V4T3f 1nkr0 0 Occupancy Type
not mom than Eve hundred dollars($508).
❑I,u owner of the propdeny,or my employees with wages u their sole compensation.
will do the we&.and the structure is not inmnded or offered for sale(Sec.7044,Business p
and Pmfcssions Code:The ConlnctoM1 License Law does not apply to an owner of 5 02 — FINAL pL utreBdINUeCENERGY
progeny who build&arimpmves thereon,and who doessuch work hinderer through his U
own employees.provided that such improvements are not intended or offered for aide.If, 506 — GASTEST
however,the building or improvement is sold within one year of completion.the owner.
budder will have the burden of proving Nat he did not Wild or improve far p.m.of 507 — FINAL PLUMBING
sale J.
t]1,as owner of the property,am exclusively contracting with licensed contractors to
comtmm the project(Sec.7044,Business and Preroasions Code:)The Contrscmri U.
come Law does not apply to an owner of property who Wilds or improves Ihemon,and,
who contracts far such projects wi lh a conlractorls)licensed pursuant to the Contractor's
License law. _
❑1 an exempt under Sec. .B As P C far this recon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following declupions:
1 here and will maintain a Ccnifmoe of Continun-
o self-insure for WorkersCompe
sat00 ian,u provided for by Section 37W of the Labor Code,for Ne performance or the
work for which this remit is issued.
1 have and will maintain Workers Compensation Insurance,u required by Secti1on
37of the labor Cade,for to performance or the work for which this pchrol is issued.
My Worker's Cnmreaation Insurance artier and Policy number am:
Cartier: Policy No.: _
CERTIFICATE OF EKEM MON FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need nal W completed if the Permit Is rnroac hundred dollasa($lip)
or less.)
I worry that in the peffirmoace of the work for which this permit is iuucd.I shall not
employ any remain in any meander set as to become subject to IW Wmken'Compeussion
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cenificale of Exem prim,you should
became subject to the Worker's Compensation provisions of the Labor Cade,you must
,Z forthwith comply with such Provisions or this Permit shall be deemed minicar,
Z O CONSTRUCTION LENDING AGENCY
[--r I hereby affirm that there is a conseuctinn lending agenry fm the performance of
G' the work fur which this permit Is issued(Sec.3W7,Civ.C.)
If3 Q Lender's Name
Lender's Address
U 0 1 certify Nat 1 have road this application and sure Nat Ne above information is / -
P conccL 1 agreeto comply with all city and county colossuses and sum laws mooing la
pU building construction.and hereby station,representatives of this city to enter upon the
[21 above-meminned property for Inspection purposes.
gy (We)agree to save,indemnify and keep handless the City of Cupentna against
y liabilitles.judgmenq rests end expenses whicM1 may in any way a[crve againn said City
U Z ineonseyucnceefthegmntingohhis Mrmit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApfilicaDam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ror mfuture building e,Chapter
❑aim or handle Health
anmasetial
ss defined Section
the Cupertino Municipal Code.Chapter 9.12,and the Hoalth and Afcty
Idoes
tk, CY.25532(&)? All roofs shall be inspected prior to an roofing material being Installed.
❑res ❑Na P P Y g g
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Tit haaafdnus air contaminants u defined by the Bay Area Air Quality Managcmdem all new materials for inspection.
wict?
❑Yes [3 No
1 have mail Ne havoous materials requirements under Chapter 6.95 of the CaLmr.
Wilding not evmalo y how a tenant,that it is my responsibility as notify IW wmupant Of the
yuimmcnts which must be met prior to issuance of a Cemfreax of Occupancy. Signature Of Applicant Date
Ownm or suthadsed apsol Date All roof coverings to be Class "B" or better
o a Z
�City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 21336 Rumford Dr. Date: B-18-03
Owner's Name:---Madapurmadh,Vilas
Phone No.(408)51 7-0748
APN#: 326-41-016 Project Valuation: $ 1,059.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----- 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 1[aa�a6
Name on Card: just Water Heaters Inc. f�
Expiration Date: 9/05 �G �• G
Visa MasterCard
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