04020131 CITY OF CUPERTINO r4�Trg.y�a � (�y� 5r�}�p" �a°,g '�r
BUILDING DIVISION PERMIT vsCiljJ.lCl1l:l lel Ll\l� jYgv.�.Trl
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT'904020131
OWNER'S NAME: PERMIT ISSUE DATE
E: SANITARY NO. CONTROL NO.
ANCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
0 0 0 0
�oo LICENSED CONTRACTOR'S DECLARATION
srZ T hereby affirm that I am deemed under provivam of Chapter 9(commencing Job Description
n< wild Sam..7").1`Di,W aSof Me Business and Professions Code.and my license is
in full tome and enact.
'q4 Lmansm Class- REPLACE WATER HEATER am'�JB#�9
A\��®
Date Contractor (4 0 GAL GAS)
e ARCHITHCI-S DECLARATION
^v
Y 1 understand my plans shell be used as public mcnNs - ��� � � 20U4
3 c Licensed Professional
8 OWNER-BUILDER DECLARATION
Com ION
1 naso .mete thus 1 1. tempt fate Ne Professors
Co License taw for the BUILDING
OO
following mmoa(Sermon]IDltr Business and Peale ions Ca de:Any city or county
$ which requites a permit re enmwet alter.improve,demolish.t ore a sir any swnum
pd.,m its issuance,p aimrsu requires W the lbe applicant for such pnamiuoic n se Law(statement
1�0 (cohe mmea licensed pursuant 7010)ofprevisions sionfthe ofe Buacmi and Professions
(Chapter 9 Sq.Ft. Floor Area Valuatiof1804
$ (nus he Is(commencingwildgemf m 700 0)M hands
oforn 3 M NC alleged
ass and an.Any vi Cntls)of 4
.. Nal he b exempt Nemfrom and Ne Esso far Nn alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Me applicant to a civil penalty of APN Number Occupancy e
not more Nan five hundred dollars(5500). P y 1YP
❑T,aao mrafthepropeny,mmyemployceswithwagun0 irsotecompenssoon, 35717022 . 00
will do N)wmk.and the structure Is nolinteaded oronered fauele(Sm.7044,Business
and Profusions Code:The Convenor's License Law dean not apply t.an owner of Required Inspections
property who builds or improves Hereon,and who dos such work himsel f or through his
own employers,provided that such improvements am not intended oroBered fanatic.If,
however,Ne Wilding or improvement is sold within am year of complydon.Ne owner-
builder will have Ne leaden of proving that be did not Wild or improve far purpose of
sate.).
❑1,as owner of Ne property,am exclusively contracting wild licensed contractors m
mnswct Ne project(Sec.7044,Business and Foramens Cade:)The Commences Li.
cents law dean not apply to in owner of property who Wilda or Improves demon,and
who contracts for Such projects with a con onctorts)limnssd pursuant m the Converter's
License Law.
❑1 am exempt under Sec. .B&P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury am of Ne following declarations:
7(37M
have and will maintain aCrnificam ofcoment m elf-imum for Worker'sCampen-
n,ss provided fm by Section 3700 of the Labor Code,for the psRorm....f Ne
for which thin permit is issued.
have and will maintain Worker's Compensation Insurance,So mcquimtl by Schon
of Me labor Cods,far dte performance of Ne work for which Nis permit is issued.
oakmb Compensation Insurance artier and Policy annular am:
er: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This Section need net he completed lithe permit isfaranc hundred dollan(g10lB
m less.)
1 artily that in the Performance of the work for which this Permit is intend.l shall not
employ any psman in any mannerso as to became subject to the Wmkrrs'Compensaflan
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Cenifiote of Exemption.you should
become subject m the Worker's Compcmedon previsions of Me Labor Code.you mum
.0 O forthwith comply with such provisions or this penult shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
[ti ti I hereby aRum Met Vert is a construction lending agency for Me performano of
Ci r7 Ne wars for which this permit is issmd(Sec.7097,Cih,C.)
D7 Q L.ndcs Name
gl�z Lender'es Atltlmss
U Q I madly that 1 have mad this application and sum that Me above inforneatiun is
IL Fn coarct.1 agree to comply wild all city and county ordinances and state laws misting to
DU building construction.and hereby authorim representatives of this city m enter upon Ne
� W shove.marild.rd property Carimpenion purposes'W (We)agree to save,indemnify and keep harmless the City of Cupertino against
not h liabilities,judgmente.costs and sxpenses which may in any way acerae against aid City
U Z in consequence of the granting of this permit.
^� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
SignSignatureof ApplicaDataHAZARDOUDOU S MATERIALS DISCLOSURE Type of Roof
Will the applicantor forum buildings.Chaptsmrearand(b Health and
'
So defined io the Cupertino Municipal Code.Chapter 9.13,and dte Hea1N and Sefery
ode.Section 35533(a)1
El Yen ❑No 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
d haaankma air contaminants as dcfmcd by the Bay Area Air on. ly Management all new materials for inspection.
,so
0Yea ❑Nu
I have mad Me havardos materials requirements under Chapter 6.95 of Me Cabled.
ria HralM&SalotyCode,Sections 25505.25533 and 25534.1 und)uund Not if Me Wilding
docs not currmly hex a tenant that it is my responsibility to norm ly Me accupen7 of Me
requirements which must be met prior to issuance of a Certificate of Occupancy. Signature Of Applicant Date
Owner or authorind agent ' Date All roof coverings to be Class"B"Or better
r
City of Cupertino Building Permit Application
E-Mail
/f/
Jobsite Address: 21685 Lomita Ave. Datei2-2=1 172
Owner's Name:---Dyerjames
Phone No.(408)255-0538
APN#: 357-17-022 Project Valuation: 5 804.00
Building Permit Info: Bldg----------- Elect----------- Plumb----—1LMech-----__-___
fob 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: permlts@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. 2—
Expiration
Expiration Date: 9/05
Visa MasterCard X (�
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