03060043 CITY OF CUPERTINO =
BUILDING DIVISIONPERMIT C,QNTRA OR�AN1?.ORMATI
auILDINGADDRESS: JUbT WATER HEATERS INC PERMITNO03060043
11080 WILKINSON AV
WNER'S NAME: 1764 NATIONAL AVE. PERhfIT Iss9ii 5/2003
ERTSHAUSER HENRY F JR AND MA
NE: (biu) 293-9901 SANITARY NO. CONTROL NO.
ARCHITEC IENGINBER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
_op
LICENSED CONTRACTORS DECLARATION Job Description
�J 1 bercby a(Ihm that I who licensed under pevlalon of Chapter 9(commencing
With Section 701.)of Division 3 of the Business and Professions Code.end my license u
^ „ in(ullforteand.flem. REPLACE WATER HEATER p�gpe p�
qz License Class Lic.g—Contractor (40 GALLON GAS) FHYDIIF'�4& ED1
III Dem ARCHITECTS DECLARATION
1 understand my plena shell w used u public records JUN 1 1 20 03
0
Licensed Professional
OWNER-BUILDER DECLARATION
I hcrcoy affirm that 11, exempt from the CCo License Lew for IM BUILDING
Em O fallowing mown.(Section 7 coin Business and Predications c10 Code:Any city or r county
$ which requires a permit re continue.alhn improve,demolish, file
ea signanyed nmdum
dorm its tensed alsounions
uitmphos Ikons for such permit lu0lessigndmupunr9
melbeis licensed purwan io Ne provisions of the Conuwtor's Licmuc 4w(CMp¢r9 Sq.Ft. Floor Area Valuation
$ (commencing with Section 7000)of Division 3ofNeBusiness and Prof.smnaCode)On $770
that M at exempt Nemfmm and du:huts for the alleged.emption,Any violation of
Sodom 7011.5 by bar da¢nliccantforssW).h subjects lM appOnm m a Civil penauy of ppppNN N���my���er Occupancy Type
35618Q72 . 00 .
0 1,a mm of die pmperty,m my employm with wgu u their sots compenudon,
will do the xhtk,and destructors is not intendedwoffcred fmule(Sec.7044,Business p�,,,,,,,,��.r
and Professions Code:The Contractors License Law does not apply m an Owner of 502 — FINAL Y'Y]B71vt7 1 c RGY
properly who builds.improve lhereon,andwhO doeas.h.,it himulfartluough his 506 — GAS TEST
own employee,provided thatsuch improvements en not Intended oroRered for said.IC
however,the Wilding Or improvement is sold within oro you of comPledon.the owner- 507 — FINAL PLUMBING
builder will Mve the When of proving that M did tet Wild or improve fur purpose Of
sale.),
0 1,as Owner Of Ile pmpeny,am exclWvcly contracting with licensed cenuacton w
construct the project(Sec.7044.Boniness and Propnslon Cede:)The Condacter'a U.
ce.e Law don not apply to an oww of property who Wilds or improves thereon,and
Who ctinwets for such projects with a contriumb(i)licensed puranm in the Contnctors
Lkense law.
0 l am exempt under Seo. ,B&PC for this rrsmn
1307.wou Dote
WORKER'S COMPENSATION DECLARATION
1 hereby aRren under penalty of perjury On offt following 600=60":
1 have end will maintain a Certifimmaf Conant m sel6inmre for Wokers Compete
1
rlon,u provided for by Section 3700 of the labor Code,for the performance of the
work for wlllell this permit is Issued.
1 have and will maintain Workers CompeuaHmn Insurance.u requied by Section
0of Ne LeWr Code,far die periormmtt Of the work for which this permit is Issued.
y Workers Compenstion Insurance carrier and Policy number Lie:
rtier. Policy No.:
CERTIFICATE OF EXEMPf10N FROM WORKERS'
COMPENSATION INSURANCE
('fhb tendon wed notbccompleted If the permit Is portion hundred dollars($10)
for[Cast
1 certify that in the performance of the work for which this Permit is issued,l shell not
employ any person in any answer an as to become subject o tbe WOrkcrr Compensation
Laws Of California.Dem
Applicant
NOTICE TO APPLICANT:If.after making Nb CeniOcam of Exemption,you should
become subject to the WOheM1 Compensation pmvistions of the Labor Code,you must
0 O forthwith comply with such provisions Or this permit hall M deemed hooked.
y CONSTRUCTION LENDING AGENCY
'[r Thr
hereby
Which thi that Oche les construction[ending the performance of
a,7 IM work which this permit b issued(Sec.71197,Ci,C.)
ILl Q Lenders Name
zLendelr Addreas .
() I certify mal 1 Tuve read chis application and mm that the salve Information is
H correct,I aghe to comply with all city and county Ordinances and slam laws rotating to
O V building conruc,ion,and hehby authorim repmaenuliw Of this city to cric"pon the
W shove-mentioned properly for inspection purposes.
(We)agree to save,indemnify and keep homeless the City of Cupertino against
V) liabilities,judgments,costs and experura which may in any soy acrnw again,Wit City
V7 in consequence of time granting of this permit.
Fl APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signulue of Applicant/ConDam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will theapplicantLir futurebuildingode.Chaptsohor handle Health
sd Sandal
u do.Sed io the 32(.)? Municipal Code.Chapter 9.11,and the Health and Safety
nae,section us3z(ar All roofs shall be inspected prior to any roofing material being installed.
❑Yes ON.
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
colt hvamou air mnmminams u defined by the Bey Arca Air Quality Management all new materials for inspection.
District?
0Y. ON.
I have read me haramousmucdah tequincoam s under Chapter6.95 of the Califon
ria Health&SafelyCode,Scmoms 505,25533 and255J4,t understood thin ifthe Wilding
dues not currently haws a tenant,mut 11 b my responsibility m andly the mmupant Of me
nquitements which must be me,prior m isavance of a CrniBeam of Occupancy. Signature Of Applicant Date
Owne,nr aathadrnd. ant Dam All roof coverings to be Class"B"or better
r
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 11080 Wilkinson Ave. Date: 6-5-03
Owner's Name:---Ebertshauser, Henry
Phone No.(408)996-9695
APN#: 356-18-072 Project Valuation: $ 770.00
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# 591329 Exp. Date: 3/31/04
Worker's Comp#:1626288-03 Carrier: State Compensation Insurance Fund Exp. Date: 4/l/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679 6
Name on Card: just Water Heaters Inc. Z Z�
Expiration Date: 9/05
�G
Visa MasterCard
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