06030150 CITY OF CUPERTINO ' Iwo
BUILDING DIVISION PERMIT ��CONTRACI'�C1R,INTUI�IA`CIN.
BUILDING ADDRESS: Quz,1 viPERMITNO.
10327 COLD HARBOR AV
OWNER'S NAME: PERMIIISSUBDATE
In BAKER CHARLES A AND CAROLINE L3400 INVESTMENT BLVD 03/27/2006
ROME: - (510) 293-9901 SANITARY NO. CONTROL NO.
ARCHI'IECT/EJGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+O i] LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm that 1 am licensed under previsions of Chapter 9(commencing
with Satimn]IXMB of DIN,Ion 3 of the BUYtxasnd Profesaio"Code,aM my Iicnase b
i� InmRforoeandeBea. REPLACE 40 GALLON V11VA - HEATER
;i- DaenmGl", Cog LED
se Q� Dam ARCHITECTS DECLARATION
e a I understand my plans shall used Despubl crecoNs
�+ Licensed Professionaloa
5 OWNER-BUILDER DECLARATION JUN 70 YYRR
i I I hereby affirm that i am exempt from the Contractors License taw for the
O 0 following reason.(Section 7031.5,Business and Pmfeasluna Code:Any city or county lin #%Elk $925
5$E which mquims a permit to construct,stmt,impraw,demolish.or repair any In"Wre
i prior to its ismnce,also requires the applienl for such permit to III easignedsrammcm
e that he is licensed pursuant mthe Pnl9lAlnn,ofthe Corm cure,License Law(Chapter 9 Sq.Ft. Floor Area Valuation
(comm acing with Section 7000)of Division 3 of the Business and Professions Code)or
.. that he o exempt Nvefmm and the bub for the alleged exemption.Any violation of
Sectlor,7031.5 by any applicant for a permit,objects the applicant to a civil penalty of umber Occupancy Type
net come Nn five hundred dollars($500).
❑I,as owner of the pmpeny,or my employees with well"as their sob compensation.
will do the work end theswuurt I, or intended or offered for W.(so 7W.Busiws Required Inspections
and Professm.Code:The Costumes Lt..law doss rat apply to n owner of - q p
property who builds or i nmows Nemon,endwho doessuerh work himselforthrough his
own employers.provided that such improvements art nolinuo de d nafferad for We If,
however.the building or improvement Is mid within as you of completion,the owner•
builder will haw the burden of proving that he did not build or improve fn purpose of
um.).
❑1,Is Owner of the property,am exclusively contracting with licensed contractors an
construct the project(Sec.70",Business and Prefestlau Code:)The COntemes U.
«"e taw does nm apply m an owns of proper who builds or improves damn,and,
who coraco for such pmjecm with a contcrar(s)licensed pursuant an the Comnctor's
License law.
❑I am exempt under Ser. .B k P C for this reser
Owner Dam
WORKERS COMPENSATION DECLARATION
I hereby affin under peWty,of perjury one of the fallowing dechat dmu:
❑1 haw and will maintain a Cenlfi"k of Consem to self-i"um fur Workeea Compcn.
sedan,as provided for by Section 3700 of the labor Cade,for the performance of the
wart for which this penis isIssued.
❑I have and will maintain Workers Compensation lunance,as mquimd by Section
3700 of the labor Cade,for the perfonanceaf the work for which this permit is Ismail.
My Workers Compensation Insurance artier and policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fhissatlnn ash nothecomplemd Hthe permit Is parent,hundred do0ara(SIM)
or icer.)
I certify that in the performance of the wart for which this Permit is issad.I shall not
employ any person in any mnnerm as to became subject to the Workeri Compeuation
laws of Califomia.Dam
Applicant ,^I /
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption.you should V
haeme
.J subject m Wohee Compensation iaiau of the Labor Code,you most
O forthwith comply with soh previsions or tis Permit shall he domed revoked.
6
'Z rcol., CONSTRUCTION LENDING AGENCY
P I hereby aRrm that there its nstm
eoction lending agency for the performance of
a the wor
k for which this penis 4 issued(Ser.J077,Civ.CJ a `
LsOulo's Name
] z Zanders Add.
U Q 1 ceNfy that 1 haw mad this application aha sum Out the above information is
i,, (~ conn.I agree to comply with all city and county ordinances and state laws misting to
Q V building convection.and hereby amhoeire representatives of this city to cnmr upon the
iT7 above-mentioned properly for inspection purposes.
L��1 gy (We)agree to saw,indemnify and keep harmless the City of Cupertino against
Q liabilities,judgments.costs and expenses which may In my way aces agal"t Lid Lely
V in consequence of the panting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicamtCommoor i Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant stare arhandlc Intonations material
as defined by the Cupertino Municipal Cade.Chapter 9.11.and time Health and Safety
Cache,Section 255320)?
❑Yu 0 N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
It Mardon air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Y" ❑Nu I
I ban mad the ha,aNas materials requirements under Chapter 6.95 of the Cali foo
nix Heal d:Safety Code,Sections 15505,15533 and 25534.1 understand tot irdw building
dors not currently haw a mnnt,that It b my nexpomibillty to ratify 0m aceupnt of the
nxp1ma entswhichmustWmelpriorwissuancesuraCcAdmamsuroccupancy. Signature of Applicant Date
Owner or amhorissd Agent Dam I All roof coverings to be Class nBn or better
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: kiersaw
COPY # 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36910006.00
DATE ISSUED. . . . . . . : 03/27/2006
RECEIPT #. . . . . . . . . : 33741
REFERENCE ID # . . . : 06030150
SITE ADDRESS . . . . . : 10327 COLD HARBOR AV
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : BAKER CHARLES A AND CAROLINE L
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3329
RECEIVED FROM . . . . : JUST WATER HEATERS
CONTRACTOR . . . . . . . : GILROY, JOHN LIC # 15128
COMPANY . . . . . . . . . . : JUST WATER HEATERS INC
ADDRESS . . . . . . . . . . : 3400 INVESTMENT BLVD
CITY/STATE/ZIP . . . : HAYWARD, CA 94545
TELEPHONE . . . . . . . . : (510)293-9901
OE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW HAL
_____ _____________ __________ __________ __________ __________ __________
BENERGY PERMIT FEE 1.00 34.86 0.00 34.86 0.00
BPWHEATER PER HEATER 1.00 10.79 0. 00 10.79 0.00
PPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
__________ __________ __________ ----------
TOTAL PERMIT 84.02 0.00 84.02 0.00
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ____________ ________________-_
OTHER 84.02 MASTERCARD
TOTAL RECEIPT 84.02
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
ITY OF Telephone(408)777-3228
Fax(408)777-3333
WUPEkj,JN0
Building Department
JOB ADDRESS: PERMIT #
10327 Cold Harbor Ave.
OWNER'S NAME:Charles Baker PHONE #408-252-8942
GENERAL CONTRACTOR:Just Water FAX # 510-783-6360
Heaters
I am not using any subcontractors: 03/21/06_
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
• UeQ ' ^� 03/21/06
10/28/03
oc�o 30► 15D
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 10327 Cold Harbor Ave. Date: 03-21-06
Owner's Name:---Baker Charles
Phone No.(408)252-8942
APN#: 369-10-006 Project Valuation: $925.00
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: permlts®justwaterheaters.net
City,State and Zip: Hayward,CA. 94545
State Contractor's License# 591329 Exp. Date: 3/31/04
Worker's Comp#: 1626288-02 Carrier:State Compensation Insurance Fund Exp.Date: 4/11/03
Credit Card Information
Credit Card #: 5474-6390-0047-8660
Name on Card: just Water Heaters Inc.
Expiration Date: otola&
Visa MasterCard
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