05080062 CITY OF CUPERTINO3'` 'aw.a.�, 'r-o' fT"i%�:
BUILDING DIVISION PERMITCONaTRACTQR INFO MATIQN
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT NO-05080062
21412 ELM QT
OWNER'S NAME: PERMIT ISSUE DATE
LEE SHODISS 3400 INVESTME 2005
HE SANITARY NO. CONTROL NO.
(510) 293-9901
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�Oo LICENSED CONTRACTOR'S DECLARATION
m I Mrchy affirm met 1 am licensed order provitiom of Chapter 9(commcncing Job Description
with Section 7000)of Division 3 of me Business and Prof ns oro Code.and my license is �'
,�. immnmrc ,ma effect. REPLACE WATER HEATER
�? License Class Lic.N R
e ❑ Dam Cmrtrucrr 50 GAL GAS P v',
££'J` ARCHITECTS DECLARATION
W U 1 understand my plans shall M used u public recordfes'
I.
Liamcd Pmfcssional �3J
au.G 0
3 OWNER-BUILDER DECLARATION ZOOC
ef 1 Mrchy alirm Nal I am exempt from do Contr,ctofs License Law for the ,tom' JJ
O o following mason.(Section 70]1.5,Business and Professions Chale:Any city ar county H`ltS
< which requires a permit to Construct,almo improve,demolish,or repair any structure
prior to its issuance.also mquime the applicantfor such permit to File a signed suement �y
that licensed pursuvnuo dm pmvisiomoflM Cantrxsur's License law(Chapter9 Sq.F[. Floor Area e'b r,1 aU$a,.954
EEC
(Commencing with Section 70w1 of Division 3 of the Business and Professiam Code)or
i $ that M is exempt ahcrtrmm 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 On Bw hundred dollars($500). 36201015 . 00
❑1,u owner of the pmpeny,w my cmpl0yces with wages u Meir sole eompensaaion,
will Prthewon.ands: he Conisnoti Lice=
nta(pec.7044,Business
and Profmsiobu Code:The Co,there ri License haw uch not apply m rt owner is Required Inspections
own
who builds i improvsu marcor.and who does auc tendo himselfed farad his
own f.
however.me
buiprovidedmrris suchimphawmentsartnos intended moRered the own r-
Wilde,,Nebuildingor e.of rocntishaltwithin rote year of completion.the purpose
of
builder will have 0th bunter of proving that he tit not build are improve for purpose of
sale.).
❑1,as owner of the,property,am exclusively contracting with licensed contractors t0
construct the project(Sce.7044.Business and Pretensions Code:)The Contractor's Lt.
come Taw does not apply in an owner Of property who builds or improvm menton,and.
who contracts for such pmjecu with a con racrr(s)littmed pursuant m the Contra,tod
Lieer¢law.
❑lam«ere"mder See. ,B&PCfarthisrason
wrier Data
WORKER'S COMPENSATION DECLARATION
1 hereby Wind under penalty of perjury one of the following declamations:
I have and will maintain.Cenifalm of Consent to self-insure for Wark l'x Compms-
sation.as provided for by Section 3700 of me labor Code,for the performance of the
W.
for which this permit is issued.
❑1 have and will maintain Workers Compensation Imurunce.as axryimd by Section
3700 of the labor Codc,for the perfamourec of the work forwhich this permit is issued.
My Worker's Compensation Insurance caricr and Policy number art:
Cartier: Policy No.: _
CERTIFICATE OF E(EM MON MOM WORKERS'
COMPENSATION INSURANCE
(Thu section need not hecompleted file Permit is lm one hundred dollars($100)
or kss)
I cenifv that in the performance of the work for which this permit H issued.I shall not —�
Laws.mpl.;o Cslif.on in any manner so as r Mcomc xubjcn to tM Workers'Compensation
Laws of California.Dale
Applicant
NOTICETOAPPLICANT:If.after Compensation
this CcrincaO of Eaaw o d you mould
bec.mc suomp r the Workers Compcmation er tit Out of the Lahr Coda you most
z fonhwim comply with sato pr.visiom are this permit mall be teemed revoked.
z O CONSTRUCTION LENDING AGENCY
l hereby affirm that there is a construction lending agency for the performance of
a the work fur which this permit is issued(Sec.3097,Civ.C.)
1 lenders Name
z Lender's Address
U O 1 ttnify 0.11 have read Oia application and sat¢mat doe aMw information is
D. P correct.1 agree to comply with all city and county ordinances and sum laws relating 10
0U building Construction,and hereby aumorim mprcecnutivel of this city to color upon tM
ahovc-mentioned property for imitator,.purposes
Ha (We)agree to save,indemnify and keep harmless the City of Cupmeino against
liabilities.judgments,casts and expenses which may in any way accrue against mid City
U Zin comequeriec of the grunting 0(this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature are ApplicaDataHAZA
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or futurebuilding occupant erre or handle hr�ooa material
u C. by the Cupertino Municipal
cipal Codc.Chapter 9.13,and the Health ad Safety
ode.Section 3ss3z(a)'
❑Yon ON. 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
it havardnus air contaminants u defined by she Bay Area Air Quality Management all new materials for inspection.
7DL.st,iC,l
❑Yes ON.
I have mad the harard oes mistrials requimmonts under Chapter 6.95 of the C ilifar.
Health&SafctyCodc,Seen=35505.2555]xrd 25534.1 tunkrgard dot if lM building
es not currently haw a Oman.that it u my responsibility m notify the occupant.(de
uirements which mug M mos poor m issuance of a CcdOcam of Occupany.. Signature of Applicant Date
mm or atmr,dzed as.nt pato All roof coverings to be Class"B"or better
OS� � �;��
C®
City of Cupertino Building Permit Application
®® E-Mail
yyII o s�
jobsite Address: 21412 Elm Ct. DateP9-O5
Owner's Name:---Shodiss, Lee
Phone No.(408)421-9773
APN#: 362-01-015 Project Valuation: S 2954.00
Building Permit Info: Bidg— Elect Plumb___t__ Mech
Job Description
Replace 50 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 #: 5474-6390-0047-8660 G S>f
Name on Card: Just Water Heaters Inc. 3 0
Expiration Date: 06/08 �(�,
Visa ❑ MasterCard
Comments
r®
Community Development
acu
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS: PERMIT#
21412 Elm Ct. U Ste'�"" G Z
OWNER'S NAME: Shodiss, Lee PHONE # 408-421-9773
GENERAL CONTRACTOR: Just Water Heaters FAX # 510-783-6360
I am not using any subcontractors: �� � �Q R'�f^ � 7/01/05
Signature Date
Please check applicable subcontractors and complete the following information:
yj 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
�40y—+013L- , 7/01/05
Owner/Contractor Signature Date
10/28/03