05050133 Pc
ITY OF CUPERT[ aBUILDING DIVISION PERMIT 'JCONTRAC�TR�INFORMATION ILDINGADDRESS: JUST WATER HEATERS INC PERMITN005050133
OW NER'S NAME: PERMIT ISSUE DATE
STMENT 1�1 ALP ,425/2005
NE: SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION O O O O
x w p I Wrtby affirm that l am lianscd under provisions of Chapter 9(commencing Job Description
n<z with SCmmO]Q'IB)of Division 3 of Ne Business and Professions Codeand my license is
in full forte and effect. sa Is
License Class Lica REPLACE WATER HEATER Y Y�Y�pp{`[1Yp®gyp
-'o Dam cmnDECL (4 0. GAL GAS)N J' ARCHITECTS DECLARATION
ED
?�u 1 undcrsmnJ my plans shall W used az public records ")
C Lkcnus Pmfcssimnel 2005
9 g OWNER-BUILDER DECLARATION Contr ON ''GG 11
999 I masa .(Sort Not 11. exempt Item Nm fesnlrazmh License City
o for the
00 following massa(Section](131.5.Business and Professions Code:Any city or county
$9! which requires a Tenni(to rnnswn,alter.improve.Jemnlish,or repair any structure Ell 0
Fiiprior to its issuance.also mquims the applicant for such grait to file a signed stammenl'
Thal he is licensed purmansto the provisions of the Commemrl Liccmx Low(Chapter 9 Sq. Ft. Floor Area 244
A,FG (commencing with Section 7")of Division 3 of the Business and Professions Cosc)oI
i $ into Im u escrept Ihert(lom and the basis for the alleged exemption.Any violation of
Section]031.5 by any applicanlfor a permit subjects ant applicanfto a civil penally of APN Number Occupancy Type
not mom than five hundred dollars(5500).
❑1,az mwmr of the property,or my employee,with wagaz As dlcir som eompenaaann. 32643001 . 00
will do the work,and the swcwrt is not immnded or offered for sale(Sec.]Oda,Business
and Professions Code:The Commerce's License Law docs not apply to an owner of Required Inspections
propeny who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements;art not immicded or offered for sale.IL
however,the building or impmvcment is mid within one year of completion.the owner,
builder will have the burden of moving that ht did or Wild Or improve for puryoss of
sale.).
❑1,as owner of Ne property,am exclusively contracting with licensed contractors to
construct the pmjecl(Sec.701a,Business and Professor Code:)The Contractor's Li
cense law docs not apply no in owner of propeny.who Wilds or improwss thereon,and
who contracts for such projects with a contractor(s)licensed pursuant o the Contractors
LKenx Lit .
O l am exempt under Sec. ,B&PC for this mums
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following damostions:
I ham and will maintain a Cemileme of Conant to self-insum for Workers Compete
sation,az provided for by Section 3700 of the V Wr Code.for Ne performance of the
work for which this permit is issued.
Ej I have and will maintain Worker's Compensation Insurance,az required by Section
3700 of NC La Wr Code.for the performance of the work for which this remit is issued.
My Workers Compemalion Insmama Cartier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu seeing heed not becompletad if the permit is formic hundred dollars(SIM)
nr leas.)
1 aoify Nat in to performance of the work for which this permit Or ismed,l shall not
employ any remain in any manner an az to become subject to the Workers'Compensation
Laws of California.Dale
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you sboulJ
become subject to the Worker's Com remotion provisions of the Labor Codc,you must
.JO forthwith comply with such provisioru or this permit shall N decreed revoked. _
Z M
[CW-. CONSTRUCTION LENDING AGENCY CY
affirm that isconstitution agency l'm the mcrfurmana of
A the workforwhich misroil u usuidSea 0D.CO.CJ
r�
ndr'.Name
U
D. Lendeer's AOtlmsx
U 2
[)Q I anify o c I ply read this application and sum Nm the sWvc information is
ly H cubes I agree to comply with all city and county ordinances this sum laws r upon
m
�O building colulnction,any hereby amhorirzrpomxntativcs of this city is cnmrupnn IN
(~ a
(We)agree to cast,indemnify and kith harmless thew City of Cummins against
p) incoitics,anceofinedgments,costs and Ofthisxx which may in any way accrue against said Ciry
V z APPLTCANTCUNDE granting
StAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
signature of ApplicaData
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant moo or handle M1n Ith a d Safety az defined by the Cupertino Municipal Codc,Chapter 9.12,and the Health and Sa(ny
Codc.Scnion 25532(.)? All roofs shall be inspected prior to an roofing material beim
❑lim
C]No P P Y S g 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
it hanNnue air cmummimn@ az defined by the Bay Ama Air Quality Managcmcnl all new materials for inspection.
islliet?
❑Yes �No
1 have mail the ba a dsmx materials requiu:mems undo Chamarti.95 of the Califon
nia Health&Safety Code.Samomu 25505.25533 and 2553x.1 understand thatifthe Nilding
Vas not co
have s mnanl,that it is my rtspomibility to nntily the occupant n(the Signature of Applicant Date
Owner Lir authorizes age I Dam All roof coverings to be Class "B"or better
13 3
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 10631 Castine Ave. Date: 5-24-05
Owner's Name:---Wilkens, Ellis
Phone No.(408)737-3980
APN#: 326-43-001 Project Valuation: S 1,244.00
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)783-6360
Address: 3400 Investment Blvd. E-mail: permitdept@sbcglobal.net
City,State and Zip: Hayward,CA. 94545
State Contractor's License# 591 329 Exp. Date: 3/31/06
Worker's Comp#: 1626288-05 Carrier: State Compensation Insurance Fund Exp. Date: 4/1/06
Credit Card Information
Credit Card #: 5474-6390-0026-5679
Name on Card: just Water Heaters Inc.
Expiration Date: 9/05
Visa ❑ MasterCard
Comments
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
, CITY OF Fax(408) 777-3333 CUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
10631 Castine Ave. US-Ds"v / 3 3
OWNER'S NAME: Wilkens, Ellis PHONE # 408-737-3980
GENERAL CONTRACTOR: Just Water Heaters FAX # 510-783-6360
I am not using any subcontractors: ���� µ 3 � 5/24/05
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 J
OAW- 5/24/05
Owner/Contractor Signature Date
10/28/03