04040125 CITY OF CUPERTIN0 rs n
BUILDING DIVISION PERMIT CONTRACTOR`INFORMATION. -,
n
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT Ngl4040125
OWNER'S NAME: PERMIT 155UE DATE
CARRIE SCOTT 1764 NATIONAL, 04 /20/2004
ONE: SANITARY NO. CONTROL NO.
(510) 293-9901
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG [CECT PLUMB MECH
°Oo
LICENSED I amCONTRACTORcolor
V C 1 hereby affirm that 1 am of she
under provisions or Chapter Code. 9(commencingis lob Description,
b w;NSee llromn]gM)ecDivision]of NC Busincu and Professions Code.and myliccnsc is
n a inrmlmmeanderremt REPLACE WATER HEATER pct p,,
jqz License Class Le.a a
o Dale convactrr (5 0 GAL)
$`,f` ARCHITECTS DECLARATION v''G// p�
ay d'a 1 understand my plans shall k used as public records 2Z 2004
1EQ
t o Licensed PmfdMi...I tea
a5 OWNER-BUILDER DECLARATIONontreapwKUILD{ e�
y 1 kahy affirm mat 1 am cacmpl from the CnnvamlCo e:Any layer Law fon Ik u�vJ t�JJ a l9,
e0 o following rcasnn.(Section?(mourect, Im,. and ve.ii.vions Codc:Any d county GU
which rcyuires a pemrit nt eonxlmn,alar,improve.demolish,m repair any xwaua
° „
_ prior to its issuance.also requires the applicant(orsuch permit to file aligned statement
E zEe that he is licensed pursuant it)the pmvislons of the Contractors License Law(Chapat9 Sq. Ft. Floor Area Valua�T050
Al- (Commencing With Section 7")of Division 3ofdo,Business and Professions Code)or
i that he is attempt therefrom and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not more man five hundred dollars($500).
P Y YP
❑ 1,Asownerofinepmperty,ormyemployeeswithwagesAstheirsoleConfirmation, 35606026 . 00
will do me work,and the arrucmrc is not intended or offered for sale(Sec.7W,Business
and Forrestal...Code:The Com actor's License Law does nor apply Io an uvea.,of Required Inspections
properly who builds or impmvcs maroon,and whodoes sucewmk himulf or mmugM1 his
own employees,provided that such improvements arc not intended or offered for sale.If.
however.the building or improvement is sold within one year of completion.the owner
builder will have me burden of proving that k did not build or improrc for puryose of
sale.).
❑1,as owner of me property,am exclusively contracting with licensed convectors to
eo estmet the project(Sec.7W4,Business and Professions Code!)The Contractor's Li
come law docs not apply to an owner of property who Wilds or improves memon.and
who Contracts for such projects with o Comranm(s)licensed pursuant to me Conuactor'a
License Law.
❑I ameaemptunder See. ,B&PCfmddam&om
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hcrcby affirm under penalty of perjury one of the following declida imes:
L I have and will maintain a Certificate of Consent toself-inmmfor WorkdsCompen-
sation,as provided for by Section 37W of me labor Codc,for me performance of the
work for which this permit is issued.
❑I hast and will maintain Worker's Compensation Insurance,as required by Section
37W of me Labor Codc,for due performance of me work for which this permit is issued
My Worker's Compensation Insured,carrier and Policy num her am:
Cartier: Policy Nu.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thutt[elkin need not W completed limit permit is for one hundred dollars($I"h
n less.)
1..try Out in the performance of me work for which this Permit is issued,l shall net
employ any person in any ro n icr.m as m kco..subject to the WorkersCmersam dion
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Ceni ficam of Exemption,you should
become subject m the Worker'.Compensation provisions of tk labor,Cour,you must
.Jz forthwi lh comply with such provisions or this Form i l shall k deemed revoked.
zCONSTRUCTION LENDING AGENCY
F I hereby affirm that mere is a construction lending agency for the performance of
2' me work for which this permit is issued(Seo.3097.Civ.C.)
W J z lender's Nene z Lcndcr' Address
V Q 1 1 eerily e the 1 have read this y an coon and since that me above information is
0 F corrcn.l agree tel comply wile all my end county ordinances and stmt laws r upon t e
U building cotioncd on,.nd hereby aumonim«pseumalircs of this oily to corer upon Ilio
above.menndgmJ nturoll,s.cost ren inspection pathoses.
H G (We)agree to save,indemnify and keep harmless the Cary of Cuponino against
Z in
egjnce Of the graving And ca serieswhichI,, may in any way ammo against said Ci LY
V z in consequence of me granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by: Date
SOURCE REGULATIONS. s4ta�(7�
Re-roofs
HAZARDOUS
Stgnamrc of AppbaDna
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the appncaOm(Mune build ingoccupantsemor handle hasalm .material
as degneat by Ilio Cu"Ohm Municipal Cork.Chapter 9.12,and the Health and Safety
arc,Sc lien 25532(.)7
t]YCs ❑No All roofs shall be inspected prior to any roofing material being installed.
wm the applicant or furore building Occupant use equipment If a roof is installed without first obtaining an inspection,I agree to remove
np s p q pment or devices which g
lit hazardous air contaminants as dcfncd by the Bay Area Air Quality Management all new materials for inspection.
drot
❑Yes 0N
I have read the emardom materials requirements under Cnapmr6.95 of tk Califon
7does,nolsommlyhom
Hmil &SdciyCab, cdmss255o5,25533vd25539.1undersundmalitmL building
.anan4 Natititmymspemibililywnotifyrkoocupanlofme
gM2mC11 Li WM1iC11 mM51 k met pore I11issuance IIT a GCn11BCdIC of Q[YpNCy.
Signature of Applicant Date
Owner Lir authorized agent Dale All roof coverings to be Class "B"or better
Community Development
a!10-r
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
Fax(408) 777-3333
SUPEkTINO
Buildin De artment
JOB ADDRESS: PERMIT #
22093 BaxleyCt. v S
OWNER'S NAME: Scott, Carrie PHONE # 408-252-4284
GENERAL CONTRACTOR: Just Water Heaters FAX # 510-783-6360
I am not using any subcontractors: 0-0� 4/19/04
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing Just Water Heaters 591329
Roofing
Septic Tank
Sheet Metal
Sheet Rock
(Tile
4/19/04
Owner/Contractor Signature Date
10/28/03
V-)
City of Cupertino Building Permit Application l
E-Mail
jobsite Address: 22093 Baxley Ct. Date: 4-19-04
Owner's Name:---Scott,Carrie
Phone No.(408)252-4284
APN#: 356-06-026 Project Valuation: $ 1,050.00
Building Permit Info: Bldg----------- Elect--------_- Plumb------X_____ Mech________
Job Description
Replace 50 gal 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: 4/1/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679 �3S�
Name on Card: just Water Heaters Inc. 7
Expiration Date: 9/05
Visa MasterCard X
Comments