06060148 CITYOFCUPERTINOAMATER
anty,
EUILDING,DIVISION PERMIT Q , . `'Q �'7 UILpING ADDRESS: HEA,UERS INC PERMrt NDO6060148
21601 COLUMBUS AV
OWNER'S NAME: PERMIT ISSUE DATE
WILLIAMSON JOAN 3400 INVESTMENT BLVD 06/16/2006
NE: SANITARY NO. CONTROL NO.
(510) 293-9901
ARCHITECUENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O
Sop LICENSED CONTRACTORS DECLARATION IO Description
1 Macey affirm Nn 1 w licensed under provisions of Cbapw 9(commencing
with Sudan 70DO)orDiv mmSof Ne Boomers and Profession Code,and my Heenan is
in fall fame and efreet. REPLACE 40 GAL GAS WF/Af4rt
jM2 Lkense Claa Lk.g
� Dam Contractor
ARCHITE=DECLARATION
�y 1 understood my plans shall the used As public records J
k u-3 Licensed Prolessional �� f2' '1006
50 OWNER-BUILDER DECLARATION
I Wrchy aRrm
that I am exempt from the Contractor's License Law for the
following mann.(Section 703 L5,Business and Profesalam Crede:Any city or county
u
$ which mquira permit an conwucl alter,Improve.demoON,or repair any suumum BID no rat $1360
-z y prior m its issuance,atm roquimo the applimm for auch permit m fileuigud mtement
Nat he is licenced punuantm the provixionof the Contractor's License Law(Chapur9 Sq,Ft. Floor Area aluation
(commencing with Section 7000)of Division 3 of the Business and Professimu Code)or
3
that he is exempt therefrom and the basis for the alleged exmtptian.my violative of
Secdon 703 1.5 by any applicant for a permit subjects the applicant to a civil penalty of �-MNT-Mrhbervv Occupancy Type
not mom than Bve hundred dollars(=S
❑1.As owner of the Property,or my cmploym wWt wages as Neo mkmmpenation.
will do Newark,and cm stannum 4 not intended uanead for saln(Sec.70 N.Busirtea Required Inspections
and Profealom Cade:The Cornerstones Lit=Law door ant apply as an weer of q P
pmpeny who builds cr Improves dinosaur.and who does such work himself or through his
wnemploycea,provided that each Improvements sm nm intended oroRered(resale If.
hwevv,the building a improvement Is gold within tum your o(compledw.the wmr-
builder ,will have tho burden of proving Nat he did not Wild or Improve for purp ran of
❑1,As owner of Ne pmpeny am exclusively consisting with licensed coaoacanrs an
construct Ne project(Sec.7044.Businea and Professional Cade:)The Contrmtur'a U.
roma Law does not apply to an owner of property who Wilde or improve theman,ad,
who contracts for such projects with a canuactor(s)licensed pargoem to the Converses
License Law.
❑Iamuxcmpitnder Sec .B&PCfnr Nismamn
Owner Date
WOR11121 COMPENSATION DECLARATION
1 Wmby allirm under penity of perjuryoro of Ne follwing dcdmflom:
Ihaw and ids main by Section
37M of ft Labor
ode.for forWortrfaCompen-
workf r provided(pe mi Sxctisn 3]00 a(the labor Cade.(m Ne perfarmutec of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,As required by Section
3700of the Law Code.for Ne perfameanaaf the work for which Nis permit 4 iso-M '
My Warkses Compensation blurs.carrier and Policy number am:
Carrier. Polley No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(TMs section need tmtteccompkmd If tW permlt Is fortune hundred dallan($100)
car IML)
I«oily that In the performance of the work far which this Permit is issued.1 shall oat
employ any person in any maanerso an An become subject to the Warkere Compenadan
Laws of California.Date
Applicant
NOTICE TO APPLICANT.If.aner making this CemiOcam of Exemption,you should
become subject to the Workrh Compensation provision of Ne Labur Code,you must
,J O forthwith comply with each provision or this permit shall bu deemed orem ed.
rCONSTRUCTION LENDING AGENCY
[-s I hereby affirm that there h a connmmion lending agency for the pelmernnuof
f5: > the work fur which tide permit Is Wand(Sec.3097,Civ.C.)
W�~n. Loners Name
a z Handers Addtm
U O I cenlfy that I have reed this applicdon and sum Nat the show Information is
D.P cancer.I agree An comply with all city and caWly ordinances and late lave relating to
O V building construction,and hereby autharim reprexeutiwa of Nis city to enter upon the
W above-mentioned property for inspection pugpsm.
(We)eg.to uve,indemnify and keep hamnlm the City of Cupertino against
..,H liabilities,judgments,casts and expeam,which may in my way acrnm Against aid City
()r in
APPLICANTUof the UNDERSTANDS ANDof WILLWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicuNCanuacmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant m futwe Wilding occupant mac"handle hasallous material
as dNned by the Currenina Municipal Cade.CTapur 9.12 and dte Health and Salary
Coda.Section 255324)7 All roofs shall be inspected prior to any roofing material being installed.
Oyu ❑Na
Will the applicant or future building occupant use muipmcnl m devices;which
If a roof is installed without first obtaining an inspection,I agree to remove
cmlt hazardous air memannimats As defined by the Bay Area Air Quality Management all new materials for inspection.
Dimi.0
❑Yu ON.
I have mad the hverdau materials requirements under Chapter 6.95 of Ne Califon.
-1.Health&SalmyCede,Sectias 25505,25533 and 25534.1 umerauW that Ads,building
dam ant c meetly lust a Amant.that it a my rmpomibility An notify the ouupens of the
requimwnuamiss a be at prior toiauan«ofaccrifmamorOccupancy, Signature of Applicant Date
Owner or Authorized agent Dam All roof coverings to be Class"B"or better
CITY OF CUPERTINO
em 3 of 3 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35618030 . 00
DATE ISSUED. . . . . . . : 06/16/2006
RECEIPT # . . . . . . • • . : 34897
REFERENCE ID # . . . : 06060148
SITE ADDRESS . . . . . : 21601 COLUMBUS AV
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : WILLIAMSON JOAN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
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
*EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
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 252 . 06 MASTERCARD
TOTAL RECEIPT 252 . 06
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
-------- ---------------------------- -------- ----------------------------
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
acayo I Fax(408)777-3333
OCUPERTINO
Building De artment
JOB ADDRESS: PERMIT#
21601 Columbus Ave.
OWNER'S NAME:Williamson,Joan PHONE# 408-255-5360
GENERAL CONTRACTOR:Just Water FAX# 510-783-6360
Heaters
I am not using any subcontractors: �� � '�^`� 06/13/06_
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
06/13/06
10/28/03
• City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 21601 Columbus Ave. Date: 06-13-06
Owner's Name:---Williamson,Joan
Phone No.(408)255-5360
APN#: 356-18-030 Project Valuation: $1,360.00
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:3400 Investment Blvd. E-mail: permitdept®sbcgiobal.net
City,State and Zip: Hayward,CA. 94545
State Contractor's License* 591329 Exp.Date: 3/31/08
Worker's Comp#: C44510091 Carrier:ACE Exp.Date: 411/07
Credit Card Information
Credit Card #: 5474-6390-0047-8660
Name on Card: Just Water Heaters Inc.
Expiration Date: 06/08
Visa MasterCard
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