04020026 CITY OF CUPERTINO 4^s, T - �T
BUILDING DIVISION PERMIT k§-Oa'TIR&b 1108,,'i, "{'- 1;0LA a'
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT NO 04020026
1
OWNER'S NAME: PERMIT ISSUE DATE
ONE:SC SANITARY A2 OL NO.
ARCHITECT/ENGINEER; \ BUILDING PERMIT INFO
BLDO ELECT PLUMB MEOCH
Atop LICENSED CONTRACTOR'S DECLARATION Job Description
U 1 hereby.m.met 1 am licensed under previsions of LTapwr 9(commencing
with Section 7")of Division 3 of the Businessand Professions Code.and my license is
kfull force and,rt`m REPLACE WATER HEATER resed, �q/� ❑
Z peamnae Class Lt..# r
n
ARCHITECTSon DECLARATION (40 GALLON ) Un�16� LFR=4'
1 understand my plans shall he used as public records
�G AUGW 2004
CLicensed Professional
g OWNER-BUILDER DECLARATION
Conte ON
+� 1 hereby affirm on I am exempt from the Contraction License Law for the
i p O following reason(Section 71131.5,Business end improve,
dioo ti Code:Any city nr county O•a��Rv�111 ��y,
which requires a permit ata epos,the alar,improv,demolish,or repair ed swment rae'r9 j�p dd
prior n its issuance.p aim rrquircs the applicant forsuch permit m Ole a signed treatment
�FFm=m< mnhcisliccnseJpursuanttotheprovisionsordo,Contractor''sLiccnsclaw(Chapter9 Sq.Ft.Floor Area Valuat"l44
yFe (commencing with Section 7")of Division 3 of the Business and Pmfeasinna Code)tar
that he is exempt thcmlrom and the busis for to alleged exemption.Any violation of
Section 7031.5 by any applicant for a recruit subjects the applicant in a civil penalty of APN Number Occupancy Type
not more man love hundred dollen($500).
❑I,u owner of the property,or my employees with wages u their sole compensation, 36611068 . 00
will do the work and the suueure is not intended oroffemd nrsale(Sec.7W,Business Required Inspections
and Pmfeatimts Codc The Convectorn's License law donot apply to w owneer of 9 P
pmpeny w ho Wilds or i m proves thereon,and who does suc h work himself or through his
own employees,provided dimsuch improvemenuam not Intended oroffered for ask.IL
however,ma building or improvement is cold within one year of compledon,me owner-
builder will have the burden of proving mat he did not build or impmw for purpose of
sale.).
❑I,as owner of me propartB em exclusively cortraci ng with licensed convectors in
construct me project(Sec.7044,Business and Professions Cade:)The Contractor's Li-
me law does not apply On an owner of pmpeny who Wilds or improves themon,and
who contracts for such projects with a commensals)licensed pursuant in the Commelorb
License law.
71 1 an exempt under Sec. .B&P C for this mason
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain aCenificaw of Consent to self-insure for Worker's Comment-
-
ompe t-
ution,u provided for by Section 3700 of the labor Code,for me performance of the
W
ork for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37M of the labor Codc,for the performance of do,work for which this Permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carrier: - Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nmhecompleted irate permit Is ILrone hundred dollen($10(r)
or less.) „
1 cenify that in the performance of the work for which this permit is issued.l shall not
employ any person in any mannerw as on become subject in the WorkersCompenu0on
I.of Califomie.Date
Applicant
NOTICE TO APPLICANT.IL after making ibis CeniRcam of Exemption,you should
become subject in the Workch Compensation provisions of the Labor Code,you most
.,O fen ivAth comply with such provisions or this permit shall be deemed revoked.
.zi CA CONSTRUCTION LENDING AGENCY
'r+ I hereby artvm Nm them is a construction lending agency Me tiro performance of
> the work for which this permit is issued(Sec.3(97,Civ.C.)
W Q Ieader'a Nam,
D z lender's Address
V 0 1 cattily Net 1 have road this application and slain mal the above information is
Uy r coffee,.)agme In comply wise all city and county ordinances and slow laws miming to
O V building concoction,and hemby authof ea rcprcsenutivu of this city to enter upon me
W above-mentioned property for inspection purposes.
gy (Wa)agree to save,indemnify and keep hsnnleas(be City of Cupertino against
liabilities,judgments.costs and expenses which may in any way scene against said City
f> in consequence of the granting of this Permit.
t� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
SiSignatureof ApPlicaDate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the a Cupertino
or future Municipal
o occupant r 9.1 of handle hauNous material
az defined by the CupeAno Municipal Codc.Chapnr 9.12.and the Health and Safety
otic.gttuon 25532(x)? All roofs shall be inspected prior to an roofing material beim Installed.
❑res ❑Nm P P Y g g
IWill the applicant or future building occupant use equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
II hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ON.
I have mad the hazamousmaterialsrequirements under Chapterit.95 of the Califs
ria Health&Safesy Code,Sections 25505.25533 and 25534.1 unMrsmnd theif the building
does not currently haw a nnen4 that it is my rcmunsibilily n roily do occupant of the
mgmrement which must lc met poor On issuance ora Ccrtineaw of Occupancy, Signature of Applicant Date
Owner or authorised agent Dam All roof coverings to be Class "B"or better
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 7516 Orange Blossom Dr. Date: 1-22-04
Owner's Name:---Smader Scott
Phone No.(408)257-7065
APN#: 366-11-068 Project Valuation: $ 1,144.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----- Mech-----------
Job Description
Replace 40 gallon 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# 591 329 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.
Expiration Date: 9/05
Visa MasterCard
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