05050096 r CITY OF CUPERTINO
BUILDING DIVISION PERMIT �CONT.I2ACT0RrIN'FORMATION:
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT"'05050096
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY ff,577CONTROL NO,
ARCH[EC MNGIN ER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Sop LICENSED CONTRACTOR'SDECLARATIONJobDescri tion
I Wrathy affirm Wt 1 am licensed undo pmvidons mC cute. 9(commencingsI, N�L E
Z
with llfamnlB Cff=Diviaian3of Ne Budw and Pmfcasiam Cede,aM mYlkenmu
p` in full(time and eRcct.
'�z Lianan elasa Lie.« REPLACE WATER HEATER
q Dalc Convector (5 0 , GAL GAS)
7W ARCHI'TECT'S DECLARATION
U I understand my plana Nall W used u public records 2005
3 tad Licensed Professional
OWNER-BUILDER DECLARATION
AX 1 hereby affirm that 1 am exempt Bum ilm Contractors Liao Law for the
00 following mason.(Section 7031.5,Business and PMAWllns Code:Any city or county
$fLi which require a permit W construct,alme Improve,demolish,or minor my structure
Fain prior to its isvuame.also require the applicant forsuch permit to Glc asigned statement
ggg C that he is licensed pursuant to the provisions of the Contractor's Lee'Law(Chapter 9 SQ.Ft. Floor Area Valua%CT630
(ammeneing with Section 7000)of Division 3 of the Business and Pmfessimns Code)or 4 t.
that he Is exempt therefrom and the basis fa tie alleged eu mptimn.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy e
not mom than five hundred dollars(S500). p y Typ
❑I.uawner of Wprpmy,nmy wployeas with wmaasthe'vmleeompetiton. 36633001 . 00
will do the work,And the amosue is out intended moffacd for We(Sec.70".BW^-•• Required Inspections
and Panfeasioas Code:The Contractors Licensee Law deant apnsply to an owner of Q p
property who builds of i mpmwa thereon.and who does such work himself or trough his
own employee,provided thatsah improvements art not Intended or offemd for We.IL
however,the building or improvement is mid wiWn ore year ofcompleton.the owner.
Wilder will have the bundm of proving Nn he did not build or improve for purpose of
ick.).
❑T,As owner of to property,am exclwivcly contracting with licensed comumWrs to
construct the proem(Sec.7044,Business and Professions Code)The Contractors U.
ceti Taw doe not apply to an owner of proper who builds ori arrows,themon.and,
who contracts for such prjems with a contractor(s)licensed pursuant to the Contractors
License Law.
❑lameaemptunder Sec ,B&PCfwthismmn
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of to following dech rasions:
I low and willm intsin a Cenifiate of Coont to self-insumforWorkers Compen-
137,00
ion,u provided for by Section 3700 of the labra Cade,for the performance of the
rk for which this Permit is issued.
I have and will maintain Workers Compensation loran¢,as Marched by Section
of the labor Code,fm to performance of the work for which this permit ts Issued.
Workers Compensation W unme carrier and Policy number are:
rtier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thla merlon aced not M completed if the permit is for one hundred dollars($IM)
car kaa)
I cenify that in the performance of Ne wart for which this Permit is hived,l shall nm
employ any person In my summer an as W become subject to the Worked Competition'
Law of Califomin.Data
Applicant
NOTICE TO APPLICANT:If,after making this Com ficele of Exemption,you should
become subject W the Worker's Competition provisions of the Lahr Codc,you most
.,O forthwith comply with such provisions m this permit shall W domed revoked.
„zr 7) CONSTRUCTION LENDING AGENCY
[—r Ihembyafllrm that them ins construction kningagency for the Performance or
ai the work for which this Permit la Issued(Sec.3097,Civ.C.)
aQ Lander.Name
J z Lenders Address
U Q I cenify tha I have read this application and slow that the show Information is
IL. correct.T agree to comply with all city and county ordinances nd sate law misting to
0 building construction,and bemby authority repdsenmives of this city W enter upon the
W show-mentioned pmpeny for Wpccums perform.
�g,.rr LSr (We)agree to taw,indemnify and keep harmless the City of Cupertino against
it y Ilabilide,Judgments,costs and expense which may in my way acre against said City
t.)Z in comm Bence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signswre ofApplicteWCortursetar Dew
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF
Willto Applicant or future buildingoccupant icoraro h allommawnal
As dctined by the Cupertino Municipal
(h
pal Cade.Chapter 9.11,and the Health and Safety
,sssLcretin,SceY2ss3z(an
Y. ❑Nu All roofs shall be inspected prior to any roofing material being installed.
❑Y
Will the applicant of future building occupant use equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
It hmardnu air contaminants as defned by the Bay Arca Air Quality Management all new materials for inspection.
7dium
.Vlcl7
❑Yes ON.
1 haw read the hasafdossmaenala requirements umkrChapterd.95 of tan Califor-
Health&Safety Coda Secams25505,25533 ud25534.i umle mend thetifthe building
Out curntly haw•versant,that it is my neprodbility W notify thm oxoP lin of the
ulrcmcnts which mica be met prior W issuance of a Cenifwaw of Occupancy. Signature Of Applicant Date
.at.1 ULh.i.cdagent Dam All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
CITY Of Telephone(408)777-3228
$UPEkTINO Fax(408)777-3333
Building Department
JOB ADDRESS: PERMIT # /
11660 Re art Canyon Dr. p -7, 7 6
OWNER'S NAME: Walker,Jim PHONE # 408-252-1288
GENERAL CONTRACTOR: Just Water Heaters FAX # 510-783-6360
I am not using any subcontractors: Q--`� �-Io"*at3 � 5/17/05
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing Just Water Heaters 591329
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile 1
U"-Uo' 5/17/05
Owner/Contractor Signature Date
10/28/03
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 11660 Regnart Canyon Dr. Date: 5-17-05
Owner's Name:---Walker,Jim
Phone No.(408)252-1 288
APN#: 366-33-001 Project Valuation: S 1,630.00
Building Permit Info: Bldg_-------_- Elect--------—_ Plumb------K___ 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)783-6360
Address:3400 Investment Blvd. E-mail: permitdept@)sbcglobal.net
City, State and Zip: Hayward, CA. 94545
State Contractor's License# 591329 Exp. Date: 3/31/06
Worker's Comp#: 1626288-05 Carrier: State Compensation Insurance Fund Exp. Date: 4/l/06
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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