03040125 (2) ` CITY OF CUPERTINO 0': s*iv .ra�,*-» .'
BUILDING DIVISION PERMIT WONTRACTOR INIa,ORMATI n N
'I N'9%NGMPMMER AV JUST WATER HEATERS INC PEEMITN1b3040125
T9PIMM BERT I AND SYLVIA Y 1764 NATIONAL AVE PEER V t/ GS/2003
ONE: (510) 293-9901 SANITARY NO. CONTROL NO.
ARCHITEC IENOINEER: BUILDING PERMIT INFO
BLDG EIJ:Cr PLUMB MUCH
�OoF LICENSED CONTRACTORECLA
'S DRATION
F O O O MO
I hemby dorm that I m licensed under provisions of Chapter 9(Commencing - Job Description
with Sanofi 7000)Of Division 3 of the Busicom and Fox essioa Code,std my license is
nigIn fell forte and erfect. REPLACE WATER HEATER
j5 License Clam Lle.0 �p
Z Dam.Contractor (4 0 GALLON GAS) IL�II�YJ 6•i'1 9
ARCHITECT'S DECLARATION F
Iundenundmyphntshall be used as public=red,
;c Licensed Pmfeuionel (t
='0 OWNER-BUILDER
exempt
DECLARATION
Contractor's
ON JUN n 9 2003
0 f 1 hereby.(Sure thus 1 1. exempt from the Cntilim.Code:
e:A nac Lew for the
00 following woes.(Scion 7 Construct.
Business and Profile ori Code:Any city m county
$ which regatta•pmmh re cnatmet,Afar,improve,demolish,lire a sig ed atmchte A3 111 119 a d.I rw
prior In to iuuauc.also rrquims the Applicant for such Permit mfile uigncd statement rswn
F
thin he is licensed purm•nt to the provisions of Me Commnors Liceae law(Chapter9 Sq.Ft. Floor Area Valuation
N (commencing with Section 7000)of Division 3 of the Businessmd ProfeWoa Coast)or
�•a Nal he is exempt therefrom and the basis for the alleged exemption.Any violation of $1040
Section 7071.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy e
not mom than fisc hundred dorm(5500). P Y TyP
01,As owner ofthe property,or my employees with wiles As lheirsom Compensation, 36919042 ' 00
will do the rock and the srretwo Isnot lntendedmOBetW fmah(Sec.7044.Business
and spy@ ♦T�$Q� (�pQs�
Professions Code:The Contractor's Llceme Law does not appy he an owner of 5 O 2 — FINAL YL 1 N Ci CSN I'.RGY
property who bui Id•m Imwork proves lemon,and who dauuch hlmsel f m through his
own employes,provided that such improvements m not intended oro0emd ferule.If, 506 — GAS TEST
however,the building or Improvement is sold within one year of completion,the moor.
builder will have the burden of pmving Met he did not Wild or Improv for purpose of 507 - FINAL PLUMBING
ale.).
❑1.es owner of de property.am exclusively contracting with licensed contra was to
construct the pmjem(Sec.7044,Business and Professions Code:)1W Conuseme,Lb
cense law does not apply In an owner of property who Wilds or Improves lemon,and
who contracts for such project,with acontrscm,p)licensed pursuant to Me Contractor's
License Law.
ImnamptunderSx. ,B&PCfnrthhmaon
Owner Dau
WORKERS COMPENSATION DECLARATION
I hereby anhm under penalty of perjury one of Ne following declaa0oa:
1 haw and will Maintain a Cadficate of Conant t9 aclfdnsum for Windows Comp rn.
UM.,u provided for by genian 3700 of the Labor Code,fa the performance of the
W
for which this permit is heard.
❑1 have and will maintain Worker's Compensation Insurance,a required by Section
31
0)of the Labe,Code,for that performmee of Ne work for which this permll Is issued.
My Waimea Compensation Insurance cattle,and Policy number am:
Carrkr, Policy No.: ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need notboeompleted lithe parrit Is forone hundred dollen(SIM)
or leu.)
I ttWry Net In the inpormaeic of the work for which this permit I.issued,I shall not
employ anyparson In my mortician All he become mbjeut to Me Worka Compeaatlon
Laws of California.Daw
Applicant
NOTICE TO APPLICANT:If,•flet making this Ocri fitate of Exemption.you should
become suhjat to the Werke„Compensation pmvhlons of the labor Code,you mat
,J O forthwith comply with soeh provtaimu or III. ermit i•pshall W deemed rooked.
z" CONSTRUCTION LENDING AGENCY
)-t Iwr•by aiflrm Mut them he Coauudinn lending agency for the perfirmumo of
lk the work for which this permit is issued(Sec.3097.Civ.C.)
W Q Lender's Name
=z Lender'sAddmss
L)Q 1 certify that 1 have mad Via Application and sum Nat Ne show Information is /` ✓✓✓ ��—�
(L cmmct.I gree 10 comply with all city and county ordinances and state Ism muting to
C rV" building construction,and bemby•uNmia MPresenullves of Nis city to enter upon Ne
W above-mentioned pmpeny for Inspection purposes
p5.
(WO)agree to save,Indemnify and keep hermleu the City of Cupertino against
Z) lubilides,judgmcnW cosh and expenses which may in Any way same Saint aid City
IS
C.1 7 In comegwnce of the guiding of this Permit.
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINf 'Issued by: Date
SOURCE REGUWTI0N5,
Re-roofs
Signature of Applkm OU OeDateHAZARAZAR HAZARDOUS MATERIALSsoCLOSURa Type of Roof
.Will Me applicant or future Wilding Occupant some roam the
haardOa materialy
As defined by ted Cupertino Municipal Cade.CMPur 9.13,sM the Health and Sdery
9de,Sation 35553(.)7 All roofs shall be inspected prior to an roofing material being❑tees ON.
P P Y g g installed.
WIII 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 haallous aircmtsminanu As defined by the Bay Area Air Quality Management all new materials for inspection.
uvin7
❑Yes ❑Nu
I have mW the huardous materials requirements underCWpur 6.95 of the Califor.
^Is Health&S•fcyCodg Saw.35505,35533 and 35334.1 undersand that ird a Wilding
docs not curren0y have a tenml,that It is my rupeorbNINIY m ondfy Me occupant lir Ne
requirements which muse be met prior in Wu•me of a Conificase of Occupancy. Signature of Applicant Date
Owner m sathofiva l ,at pate All roof coverings to be Class"B"or better
1
City of Cu ertino Building Permit Application
E-Mail
jobsite Address: 877 Miller Ave Date: 4-28-03
Owner's Name:---Iwanaka, Bert
Phone No.(408)257-8584
APN#: 369-19-042 Project Valuation: 3 1040.00
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: permits6)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/l/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679 7
v �/
Name on Card: just Water Heaters Inc. / I
Expiration Date: 9/056�16 �
Visa MasterCard
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