04020025 CITY OF CUPERTINO11W,
BUILDING DIVISION PERMIT _,CONTRACTOR INFORMATION g'
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emLDINGADDRESS: JUST WATER HEATERS INC PERMIT NO.
04020025
t
OW NER'S NAME: PERMIT ISSUE DATE
NE: SANITARY OL NO.
O
ARCHITECTIENGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
eo, LICENSED CONTRACTOR'S DECLARATION
in� ith Section,
thereby affirm that I am 1ieen,ad under provisions Of Chapter 9(commencing Job Description
7")of Division Sof the Busincts and Profeafen Code.and my license is
E icansefell orte mtl eRm
i�o uemn<cau Co^ Nr REPLACE WATER HEATER
"yty� ARCHIECTSDECLARATION (40 GALLON/GAS) S
I understand my plans")W used as public records
30t; Licensed Pmfcssional
3OWNER-BUILDER DECLARATION Q(/
1 Wrtby efOrm
that I .exempt from Nc Cmieaaoe,License Lew far the /
00 following mason.(Section 703 I.S.Business and Professions Code:Any city or roti..
K g which mquiru a Permit to construct.alter,improve,demolish,or repair any sanctum
w�'^ prior in its issuance.aim requires the applicant for such permit to rile a signed statement
fzc that he is licensed punuanttodoProvisiomofNeContractor's littnmLaw(Chapon9 Sq.Ft. Floor Area Valuatio�839
¢� (commcraing with Scotian 7000)of Division 3 of the Business and Professions Code)in
i $
that W In exempt therefrom and U¢breis for the alleged c,amption.Any violation of
Section 7031.5 by any applicant for a permit subjects tW applicant in a civil penalty of APN Number Occupancy Type
nm mom that five hundred dollen(5.500).
Ql.uowner of Ne propeny,mmy employes with wegnu their salt rompewdrn, 31633096 . 00
will do thou work.and the structure is not intended proffered forsale(Sec.7060,Business
and Profanaium Cade:The Convectors License law don nut apply N an owner of Required Inspections
properiywho Wildaorimprow tlemon.andwho doesaachwurk h rrselfm Waugh his
own employees,provided that such improvements Me notinama ed oroRered forsale If,
however,the Wilding or improvement is sold within one year of completion.the owner-
builder will save the burden of proving that he did not Wild Or improv for puryose of
ale.).
❑1,as owner of the property.am inclusively convecting with licensed contractors to
Construct the project(Sec.7144,Business and Professions Code:)The Coneracori Li
cave law don not apply w an owner of property who Wilds of impmw thereon.and,
who contracts for such pmjccu with a contramer(s)licensed percent to the Contractors
License Law.
I am exempt under Sec. ,B&P C for this mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby aRsm under penalty of perjury one of Ne following ccelarromos:
I base and will maintain a Cctifnuof Covent in self-insure for Workers Conri
sallrn,u provided for by Section 37W of the IaWr Code,far Ne pcmformanee of ft
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,u required by Section
]]W of the Labor Code.for IW pcoldrou na o1 Ne work for which this permit is issued
My Workers Compensation Wunnce carrier and Policy number am:
Cartier. Policy NU: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This=Chun need not W completed If the permit is formic hundred dollars(SIM)
or Ica.)
1 certify that in the performance of Use work for which this Permit Is issued.I shall not
employ any person in any manner so sa in become subject to the WoftW Compensation
Laws of California.Date
Appli
E
NOTI —
NOTICE TO APo the WoT:If,atom making n r yisio s of of Exemption.Labor
od you should
become object y it Wohcr'e Compensation this provisions of Nc medr Code,you must
,J Z forthwith comply with such previsions or this Permit shall W deemed revoked.
z CONSTRUCTION LENDING AGENCY
.�..fIWreb ,fErm Nat there iso co.,ion lendin Y g agcmy for Nc perfurmanee of
'Seri Lu week rum which Nu permit is issued(Sec.3097.Civ.C.)
U '
W�z
Lundeen Nam.
=,z Under,Adtlmss
U 0 I certify that 1 haat mad this application end sum Wt the Metre information is
ti,P correct.l agree o comply with all city and county ordinances and sum laws relating to
0 U Wilding construction,and hereby authorize reprnentatiw Of this city to enter upon the
rty
purpo
V.1 a boshmentioned is,cat for espouses which s
F y (We)agree o save,indemnify and keep him less the City of Cupertino against
h in
f the craning espouses which mayin anyway accvc .lost to City
U 2 m consegnence of the granting or this D WILL
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
signalurt of Applicanmv Due
Re-roofs
HAZARDOUS MATE RIALS DISCLOSURE Type of Roof
Will Ne applicam or forum Wilding aeeupanlstorc or handle hvardous material
v defocd by Ne Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
code.S lY.2ss3,(a)7 All roofs shall be inspected prior to any roofing material being installed.
t]Tn ❑Nr
Will the applicant or mture Winding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air contaminants an defiled by the Bay Area Air Quality Management all new materials for inspection.
oorm17
n Tcs ❑No
I have mad theta Na
ous materials requirements under Chapter 6.95 of the Califor.
nia Hn Out a tinlut&SafoyCotic.Sections 7 M5.25533 and 25536.1 unMnuM that if de Wilding
dot Contend,has n.Nat it 4 my reePon ihility o notify the occupant of the
roquircm.nn which must be met prior w issuance of a Ccrofmcao of Occupancy. Signature Of Applicant Date
D
1Owner or auth.d.d agent Dau All roof coverings to be Class "B"or better
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 20189 Apple Tree Ln. Date: 1-22-04
Owner's Name:---S. Repetti.
Phone No.(408)255-5365
APN#: 316-33-096 Project Valuation: S 839.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----_ Mech___________
Job Description
Replace 40 gal 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: perm its@j ustwaterh eaters.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. 7 �
Expiration Date: 9/05
Visa El MasterCard
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