04020123 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �CON.TTRACT�ORA NFORMATION: ;.
BUILDING ADDRESS: JUST. WATER HEATERS INC 1111No04020123
OWNER'S NAME: PERMIT ISSUE DATE
B
ONE: SANITARY O. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O 0 D
�00 LICENSED CONTRACTOR'S DECLARATION Job Description
U F 1 hereby affirm that I•m IIwvN under previsions of Chapter 9(commencing
with Secdan70010)or Division S of the Business and proll.k.Code.end my license is
^omaserer mtt aand meet REPLACE WATER HEATER F�IV,q�E®
j g? License Class Lic.g
z^ Dam Contractor (4 0 GAL GAS)
ARCHITECTS DECLARATION
Ka 1 understand my plans shall he used as Public mcmrds
OWU FEB 4 S 2004
3G� Licensed Professional
3 OWNER-BUILDER DECLARATION
qy1 botchy affirm that 1 am exempt from the Cornerstones License Law for the
o O BUILDING
i rollnwing (Settle.(Sean 1(D 1.5,Business and Pmfmsiuna Cade:Any city or County
22 which requires a Permit to Conswet,alter,improve.demolish.or repair any structure
prior m its issuance.also requires dee applicant for such Permit to rile s signed statement
dust M is licensed purstram to[be provisions of use Contractor's LECOME,Law(Chapter 9 Sq.Ft. Floor Area Valuatij443
�$ (commencing with Section 7")of Division 3 of the Business and Professions Ced.)or
that he u Exempt dumerrom and tie basis for the alleged exemption.Any violation of
section 7031.5 by any applicant for.permit subjects the•PPliml m a civil Penalty of APN Number Occupancy Type
trot more Dun five hundred dollars(55007.
D l,mo nerofthepmpny,mmyemploymswiduwagnu their salt compensation, 36610078 . 00
will der do work.and dm swetart Y Ml insnded or offered for We(Sec.1044,BusinessRe sired Inspections
and Profesdoes Cade:The Contrarofs Licecuw n mo
e Isdol apply m an ow.of q P
property who builds ser improves thereon,and who docs suc h work himsel f or through his
own employees.Provided Net such improvements are not lnterMW reoffered intake.IL
however,the building or improvement is sold within one year of comPleuon,Ne owner-
builder will have the Widen of proving dust he did net build or improve for purpose of
alc.).
0 I,as.,of use property.am ueluavel,conuseting with licensed conCon,.m
construct the project(Sec.1014,Business and profession Code:)The Common's U.
cents Law doss not apply to an owner of property who Wilds or improv thereon,and,
who contracts for ouch pmjem with a comracmr(s)licensed pursuant ro the Com ucloh
Lk-.444.
0 1 am exempt under Sec. .B&P C far this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby snum under penalty of perjury one of the following declarations:
I have and will maintain a Cenifcom of Concnl m.1r.insum for Worke'sCompcn-
1c,
don,u provided for by Salion 3100 of the Labor Cade,per the Performance of the
ork for which this permit is issued.
1 haw and will maintain worker's Compensation Insurance.as mquned by Section
00 of Ne Labm Cade,for the perrmmantt of the work,for which this pe.it is issued.
y Workers Compensation Imurnmee carrier and Policy number am:
artier. Polity No.:
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This section Used notteco n,acmd if tit permit is for one hundred dollars($100)
or Rus)
1 certify that in the performance of due work for which this Permit is issued,I shall not
employ any person in any manner w u no become abject to the Workmf Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.If,after making this CCTIMCAm of E9emPl10a.you should
b.come subject to the Workcrb ComPersation provision of due Ishm Cod",you muss
.,O fuMwidu comply wits such povuines or this Permit shall he dcemed Taunted.
z- CONSTRUCTION LENDING AGENCY
(-. 1 hereby alliin dust Vert u a conmrucdnn lending agency for the perfmmam'e of
y'> Ne work(or which this permit is issued(Sec.3091.Civ.CJ
{8 Lenders Nam.
D. Lender's Address
U 2 1 tansy that 1 have mad this application and sum Nat Ne eWm infom.1iun u
tw cored.I agree m comply with all city and county ordinances and sum laws misting to
Q U Wilding construction,and hereby auNadm mpreanudv of this city m enter upon dm
D] •hove-mcommed property,for InpeNon pulp..
0. (We)agree w,indemnify and keep hleu the City of Cupertino
m taw, umagainst
V) liabilities,judgmenu,coss andexpenso which may in any way accrue against aid City
U Z
in coueque.of the grammmr
g of this pet
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicandContractur Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant mom or handle hwardous material
as defined by the Cupertino Municipal Code.Chapter 9.13,and dm Health and Safety
cwe.Section 25532(a)1 All roofs shall be inspected prior to any roofing material being installed.
Oyes ON.
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or foome Wilding occupant uw equipment or devices which
it h....thus it conmmimins as defined by the Bay Area Air Quality Management all new materials for inspection.
7doj.es
❑Yu ❑Nu
I have mad Ne haallousmateriols requimmens underChapter 6.95 ofthe Califor.
Health 6 SfetyCode.ScEmm 5505,25533 and 25534.1 understand outifduc Wilding
not currently haw a WAVE,that Ir u my msyoesihility m costly due mcupal of the
uimmcnu which momW met Pnono lssuace or a Ceridca¢of OcaPmey. Signature Of Applicant Date
All roof coverings to be Class"B" or better
Owner ser aatharivea ager, Date
I
City of Cupertino Building Permit Application
E-Mail
,�
Jobsite Address: 1486 Jamestown Dr. Date: e� 4
Owner's Name:---Clute Bill
Phone No.(408)257-3090
APN#: 366-10-078 Project Valuation: $ 443.00
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)293-2022
Address: 1764 National Ave. E-mail: permits@justwaterheaters.net
City,State and Zip: Hayward, CA. 94545
State Contractor's License# 591329 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. s3
Expiration Date: 9/05D�'
Visa MasterCard
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