04020130 CITY OF CUPERTINO t%*77
BUILDING DIVISION PERMIT 1ATOU�NCYFRM`AaT
aI :
BUILDINGADDRESS: JUST WATER HEATERS INC PERMIT"04020130
OWNER'S NAME: - PERMRSSUEDATE
ONE: SANITARY 0. CONTROL NO.
ARCHOTCI'/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
o p LICENSED CONTRACTOR'S DECLARATION Job Descrl �AA @I
1 hcmby atrrm Nal 1 am licensed under provision.M Chapter 9(commencing ��. VVV®�Yid{ d �
rti with Section 70 ).(Division 3.f the Businuaand Professions Code,and my[feeue is Wig'
<< to fun tome and Officer.
sq: License Cities Lte.M REPLACE WATER HEATER
�'p Dam Contractor (50 GAL GAS) AUG Z�Q4
Y�i� ARCHITECTS DECLARATION
Y•dT 1 understood my plans shall M used as public records y
5 D U Bu'/
G Licensed Professional ��tA.
p OWN ran exempt
LDER DECLARATION ,Y
E0 F . I hereby affirm this 11. exempt Goer Ne Comms Co License Law for the
E02 o allowing mason. emit t IIDl.4 Buainass and uns.de oli Code:Any oily in county
$ which requires a permit so cmurmL a@c improve.demolish.or repair any stroerum
to
prior to its iuumme,also requims the applicant for such permitto rile a signed statement
£~£ C That he is licensed position to the provisions of me Convector's License Law(Chapter 9 Sq.Ft. Floor Area ValuaI0077
C $ (commencing with Section 70(t))of Division 3 of m,Business and Profcuioms Code)or 4�'L
Egg mat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 1031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occas ane ' e
not more man five hundred dollen00)
($5 . P y l'7y P
❑I,uowner.finepmpeny,ormyempl.ycuwimwa umeirsolecompenudon, . 36947022 00
will do the work,and thestmctu a is not intended m.@red fosaau(Sea?044.Busmen
and Professions Cale:The m
Chmuara License nm Law doe apply to an owner of Required Inspections
property who bu ilds or i m prove themon,end who dms such work himself or thmugh his
awn employees,provided that such improvemenuere nollmmuded or offered factors.If,
however,the building or improvement issald within can year of completion,me owner.
builder will have the burden of proving that M did not Wild.r improve for purpose of
tile.).
❑1.as Owner of to propeny,am exclusively contracting with licensed contractors to
convect dm pmjca(Sec.1044,Business and Professions Code)The Chummier.Li. .
cense law does misapply in an owner of property who Wilds or improves%croon.sed
who contracts for such projects with a contractor(s)Burned pursuant to the Contractors
License Law.
❑I am exempt under Sen .B d:P C for this ration
Owner Data
WORKER'S COMPENSATION DECLARATION -
1 hcmby air,.under penally of perjury ane of the following declarations:
1 have and will maintain a CeniGeatoof Consent in sel6insum for WarlocesCompen-
moton.a provided for by Section 3100 of the Labor Code.for dm performance Of the
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,as required by Section
37M of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance center and Policy number as:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(These tion midnotbccompleled lithe permit isforonc hundred dolhn(SIOI)
less.)
I mniry this in me performance of the work for which the permit is issued,l shall not
employ any power in any mannerso as in become subjects.the Workers'Compensadon
Law,of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Ccnificam of Exemption,you should
become subject to the Worker's Compensation previsions of the Labor Code,you mum
.J OI forthwith comply with such provisions or this Permit shall be occurred revoked.
.Zi y CONSTRUCTION LENDING AGENCY
I•n Thereby affirm met
morl,1 iuc.nsuuctinn?,Ch lending ageney for the performance of
Fri >' the work fur which this permit i,imumd(Sec.3090.Civ.C)
Q Lender's Nunc
=z Lender's Address
O Q 1 comfy met T have read this application and stem that the above information is
w F chnCLL I agrCe to chmply wit all City and county oNlnantta and arms laws mating to
pU building convection,and hereby anomia representatives of%is city m enter upon the �T
W ahovmmentionedpropcny for inspection puToma.
y (We)agree to save,indemnify sed man harmless me City of Cupertino against
U T� incoiseq acro menueBurnand of thisceramics
pe which may in any way accrue against said City
C)a7 Aconsequence of UNDERSTANDS AND
permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicuVCommetor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or ruttier Wilding occurrent Rare or handle haasrdous material
as dented by the Cupertino Municipal Code,Chapter 9.12,and the Health sed Safety
'dilthc.do,Section 25m2(a)? - All roofs shall be inspected prior to any roofing material being installed.
oY.a ❑N.
Will me applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Fit havardnu air contanammus as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ON.
1 have read the hasaNrrus materulsmquircmeeu under Chapter 6.95 Orme Califor-
nia Meet"SafctyCods,&doas 25505.25533 and 25534.1 understood thuifthc Wilding
docs not currently hove a mount,mat is is my resp usihility to notify me ottupant of the
requirements which must he mer prior an iasumce are Ccui6cam or Occupancy. Signature of Applicant Date
Owner or authorized agent Dam All roof coverings to be Class"B"or better
r
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 20290 Pinntage Parkwy Date:�_2 �o/
Owner's Name:---Barham Caroline
Phone No.(408)257-4021
APN#: 369-47-022 Project Valuation: $ 1,.077.00
Building Permit Info: Bldg---------- Elect----------- Plumb------X----- 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)293-2022
Address: 1764 National Ave. E-mall: 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. �f
Expiration Date: 9/05
Visa MasterCard
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