04020114 CITY OF CUPERTINO -'� � •' ^°%�'- ��` ` '^�
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION.
BUILDING ADDRESS: JUST WATER HEATERS INC _r PERMIT/4020114
OWNER'S NAME: VIEW 91P PERMIT ISSUE DAZE
ONE: SANITARY CONTROL NO.
ARCHITEC;ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0 0 0 0
u0Z, LICENSED CONTRACTOR'S DECLARATION Job Description
us I Mmby•from that I am licensed under provisions of Chapter 9(commencing
i� with Section 7Wn)Of Division Sof NC Business aM Profevions Code.and my license is
n<n in full to=and effect
5'qi LicenicClasaLie.g REPLACE WATER HEATER' ���Q.��
Zp Dam Conuecmr (119 GAL ELECTRIC) r—
ARCHITECTS DECLARATION
U ImuctsundmyMansshallIse died aspublicrtcrod MAR 1 7 2004
ItG t Licensed Pmfea ioml
OWNER-BUILDER DECLARATION
in
I hereby affirm Nal 1 am exempt from Ne Convector's License Law for the BUILDING stas�pp�
O O following moon.(Section 703 I.S.Business and Pmfessiom Code:Any city or County IU IBSaaD Otl
a 6� which requires a peven to construct alter,improve,demolish.Or mpdr any structure
prior in its issuance,also requiris the applicant For such Permit to file a signed statement
�mOur he i,licensed puimenuO the provisions,of the Contractor,hearse law(Chapter 9 Sq.Ft. Floor Area Valuati011r C)7
C4 (commencing with Section 7")of Division 3 of the Business and Professors Code)or
4�
i $ that le is exempt Ilerefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than five hundred dollars($501,
❑1,mmneroflhepmpeny,mmyemploY withwage•sdscirmlecomNnsrnn. 36641007 . 00 .
will do Ne wok,and Ne swaum is not intended or offered forsde(Sm.70x4,Business
and Professions Code:The Contractors License Law does not apply to in owner of Required Inspections
pmPeny who build,or improves Nemon.and who doessuchwmk himself orthrough his
own employees.pmvidcd that such imprevemems sm not intended Or oferW for sale.If,
however.the building or improvement is sold within one year of completion.Ne owner-
builder will have the Widen of proving til he did not build or improve for purpose of
sale.).
I,as Owner of the property,am eacluvively contracting with licensed convectors to
connect the project(Sec.7014.Business and Psefeadom Code:)The Convector's Li-
terve law drat not apply to an owner of property who Wild or impmvo Nemon,and
who Concocts for such projects with acontr mr(e)licensed pursuant to the,Convactoe.
Licence law.
I am exempt under See. ,B A,P C for this mason
Owner Dat
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one Offt following declarations
I law and will maintain a CertIDcate of Convent to self-insure for Worker's Compen-
tion,as provided for by Section 37W of the labor Code,for the performance of the
7M37M
rk for which 0113•permit is issued.
I haw and will maintain Worker's Compensation Instuvrm,as required by Section
of the tato!Codthe e,for perfmr romcc of the work for which this permit is Wood.
y Worker's Compe remon Ivuiaircc artier and Policy number me:
rrier: Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thessees.reed not xi cmmplcmd if ole T mmit isfmone hundred dollen(SIM)
or los.)
I cenify Nat in the performance of to work for which this Permit a issued.1 shell not
employ any Person in any manner an az to become subject o IW Workers'Compensation
Laws of c.lif..m.D.
Applicant
NOTICE TO APPLICANT:If,after making Nis Certificate or Exemption,you should
become subject in Ile Worker;Com,cosm oro previsions of the labor Code,you mine
.JO forthwith comply with such previsions or Nis Permit shall be deemed revoked.
z y CONSTRUCTION LENDING AGENCY
'ea I hereby affirm that there is a constructim lending agency for Ne performance of
(� > the work for which this permit I.issued(Sec.3097.Co.C.) /
GLendefs Name
z Lender's Addreas
V O 1 certify Nat I have read this application..it irate that the above information is
^F Correct.I agree to Comply with all city and county ordin,nces and state lawn relating to
0 U Wilding construction,and hereby mounie representatives or Nis City m enter upon the
W .1new-mentioned pmKny for inspection pmposea
(We)agree to saw,indemnify and kxp harmless the City of Cupertino against
i h liabilities,judgmenv.casts and expenses which may in any way same against said City
V z in consequence of Oc granting of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signature of ApplicaDave
HAZARDOUS MATE RIALS DISCLOSURE Type of Roof
Will y Te Clicam or fume building Code.
Chaos atom of handle halarlou,maCty
u defined ve the Cupertino Municipal Code.CTapmr 9.12,and Ne HcdN and Sdery
rode.Section 3ss3xa)7
❑tier 0 N All roofs shall be inspected prior to any roofing material being installed.
Will 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
t hazardous air contaminants as defined by the,Bay Arca Air Quality Management all new materials for inspection.
7ma
r ict7
❑Yes ON.
req
1 have mazl the hvaAnusmamrials requireirtents under Chap¢r 6.95 of Ne Hm1dh&SdctyCmrode.Sadorts35505.25533 andM534.1 undcmund belittle Wilding
s not cemtely has a nant espthat it is my ronsibility ton notiy the Occupant OrNe e
timmcnts which most W met priortu issuance ofa Ccdrem,art Occupancy. Signature Of Applicant Date
owner 9r,mbodaedegent Date All roof coverings to be Class"B" or better
b q�, l�
City of Cupertino Building Permit Application
E-Mail
2 170-1
Jobsite Address: 22265 Canyon View Cir. Date: -1
Owner's Name:---Shepela Joe
Phone No.(408)446-0790
APN#: 366-41-007 Project Valuation: S 697.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----- Mech-----------
Job Description
Replace 119 gal electric water heater
Contractor Information
Company: Just Water Heaters Inc. Phone: (510)293-2012
eContact 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
Name on Card: Just Water Heaters Inc. �T /
Expiration Date: 9/056 + (�
Visa ❑ MasterCard r
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