04020028 CITY OF CUPERTINO • `•
ONi
BUILDING DIVISION PERMIT „�-" R'7 01MAT .A'.'
BUILDING ADDRESS: PERMIT NO.
JUST WATER HEATERS INC 04020028
r OWNER'S NAME: IRIGA PERMIT ISSUE DATE
CJNE: SANITARY OL NO.
ARCHITECfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
,"iooLICENSED CONTRACTOR'S DECLARATION lob Description
F I hereby affirm that I am licensed under provisions of Chapter 9(commencing
6y with Section 7000).f DiAson Sof the Dust..,and Professions Code.and my license in
u, in full foam and effect.
0 Lie...Class Lie.I REPLACE WATER HEATER FINALE®
i Date Co"moctor (4 0 GALLON )
YII ARCHITECTS DECLARATION
Y'rZ Iunderstandmyplansshallheusedanpublicmehrds MAR 0 12004
..,Gt; Licensed Pmfessianal
I OWNER-BUILDER DECLARATION
A I hereby affirm that 1 am exempt from the Commotion's License Law for the BUILDING
p O following mason.(Section 703 1.5,Business and Professions Code:Any city ter county 1 V
X m which mquircs a permit In construct,alter,improv,d,molksh,or repair any atmcture
prior in its issuance,also requires the applicant for such Permit to rile a signed statement
Nal he is licensed pursuant to the provisions of the Connector's License Law(Chapter 9 Sq.Ft.Floor Area Valuatio�798
,+ $ (commencing with Section 700W)of Division 3 of the Business and Professions Cods)at
Rig that he I.exempt therefrom and the basis for me alleged exemp0on.Any violation of
Section 7031.5 by arty applicant Imo a permit subjects the Applicant o a civil penalty of APN Number Occupancy Type
nm more than foo,hundred dollars($500).
ml,asowneraftheproperty,army employees with wagmasdainolecompensmlon, 36939030 . 00
will do the work and doxarm ore is not immrdodoraQemd forsake(Sec.7001.Business
and Pief eamu,Cade:The ComracMr's Litems Law dors not apply In an Owner of Required Inspections
pmperty who builds or im proves thereon.and who does such work himself or through his
awn employees,provided that Inch improvements are not Intended reoffered for sale.If.
however.me building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
0 1.as Owner of dm property,am exclusively contracting with licensed contractors to
construct the project(Sec.7066,Basin.and Professions Cade:)The Contractor's Li.
cense law does not apply in an owner o(propeny who Wilda or improves themon,and,
who comracts for such projects with.cunuwlods)licensed pursuant to tbe Connector's
License Law.
0 1 am exempt under Sec. .B&P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury mm of Rat following dalarauons:
I haw and will maintain a Cartilage ufConsenua self-insure for Worker's Corepen.
nation,as provided far by Section 3700 of me labor Code,far the p,rfumo nce of the
W
ok for which Nis permit is issued.
❑I haw and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code.for the performance of the work for which this Permit is issued.
My Warkees Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(thin section need not be completed If the Permit is faros,hundred dollars($1(0)
or Mss.)
1 certify that in the perfurtnanee of fee work for which this Permit a issued,l shall nut
employ any person in any manner an as in become subject to the Workers''Compensation
Law=of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Cenifrcam of Exemption,you should
become subject to the worker's Compensation provisions of the Labor Code,you most
,J O faMwith comply with such provisions or this permit shall M deemed revoked.
zrte~.
CONSTRUCTION LENDINdingAAGENCY
(r I for which this
that them issued( ec.3W7nding agencyfar me Performance of
44 ti the work far which this permit u issued(Sm:.3097,Civ.CJ Y\�
0..Q Lender's Namc
;:)z Lender's Address
V C 1 certify that 1 haw mad this application and sum that the show information i.
VL E come,.1 agree to comply with all city and county ordinance and suM laws relating m
C U building construction,and hereby authorize mpresentedws of this city 1,enter upon dm
a above-mentioned property far Inspection purposes.
(We)agree to saw.indemnify and keep harmless the City of Cinnamon against
fA
a.judgments,costs and expenses which may in any way same against said City
V Z in consequence of the gmnling of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signanurc of ApplicaHAZARDOUS
Dem
HAZARDOUOU S MATERIALS DISCLOSURE Type of Roof
Will the applicant or fMuni building ing e.Chapter
or handle Health and
az defined by me Cupertino Municipal Code.ChaPmr 9.12.and the Health end Safely
code.S Ran 25532(.)' All roofs shall be inspected prior to any roofing material being installed.
ItEyes C]No
Will the applicant or future building occupant use equipment or dcvicea which If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous air cnntaminens as defined by m,Bay Arca Air Quality Management all new materials for inspection.
hiet?
toys C]No
1 have read the huzaNnus materials requirements under Chapter 6.95 of the Califor.
nia Health&Safety Code,Sections 25505,25533 and 25536.1 understand thin Ru,Wilding
dues not curenily haw It tens.that it is my responsibility m hour,the occupant of m,
requirements which must W met prior to issuance of a CeNfcam of Occupancy Signature Of Applicant Date
owns ar aalnorisea.stnt Dam I All roof coverings to be Class"B"or better
1
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 20234 Pacifica Dr. Date: 1-22-04
Owner's Name:---Lee Diane
Phone No.(408)252-8886
APN#: 369-39-030 Project Valuation: $ 798.00
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: 1 764 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. XJ-
Expiration Date: 9/05 t� /
Visa MasterCard
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