04060238 4
CITYOFCUPERTINO ,fir
BUILDING DIVISION pE)L MT WO�iT"GTORINFO IATION. "
I BUILDINGADDRESS: JUST WATER HEATERS INC ""'cb4060238
OW HER'S NAME: PERMTI MUEDATE
DAN MAY
NE: SANITARY NO. CONTROL NO.
(510) 293-9901
ARCHITECT(ENGINEER
10 293-
ARCHITECT(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Op
LICENSED CONnsedunderpDECLARATION JObDe@Cr
1 beeby affirm that 1 am licensed under provisions of Chapter 9(commercial Pti -'i
x whh Section 7gq)of DiWSlon3of Ne Business uk Profeulum Code,and mylicensc la {�
< Of
FiforceandelFaci, REPLACE WATER HEA- fL 1
uanw elM, tie.•
c Dam
Contractor (5 0 GAL GA !/
3 ARCHITECTS DECLARATION
I undersand my plain shall be used as public memtlt
3
era Licensed Professional
OWNER-BUILDER DECLARATION
I hereby Mflma that 1 am exempt from dm Contractors License Law for the
F.D Efallowing mann.(Section 7031.5,Business and Pmrualom Code:Any city or county
$ which militha a permit in com uct,alum,improw,demolish,or repair any structure
FZ12
ind"10 issuence.elw mqulms theappitinat forsuch permitta RleasignWsumrsem
< tMtheislicensed pennant wthe provieomof
lfContractorsU.m.faw(Chapter 9 Sq.Ft. Floor Area Valuatit61850
m5M (commencing with Section 7000)of Division 3 of the Business and profession,Cade)or
Nat he LL exempt marchers and the buil for the alleged exemPdm.Any velulun of
SeNW 7031.5 by eery applicant fa a permit subjects the applicmn to s civil pemlty of APN Number Occupancy Type
nm mom Nan Five nundme dollars(=). 36230094 . 00
❑1.uowner of the property,or my employees with wages as their nolo compensation,
will do the work end thestmmua is not Intended or.11cred foralo(Sce.7044,Busineu Required Inspections
and Profession,Code:The Conuactnrs License Law dam not apply to an awmr of q p
property who builds or improwa thereon,and who does such work himself or through his
own employees.provided Net snob improwmants are not Intended or offered for ale.if.
however.Ne building w improvement is sold within on year of completion,Ne owmr-
builder will haw the burden of proving that he did not Wild or Improv far purpose of
ale.).
❑1.as owner of the property am exclusively contracting with licensed contractors in
construct the pmica(Sec.7044.Business and Profession Cade:)The Conmwwr'a U.
cam law dons not apply in an owner of property who Wilds or Improvm thween,and,
who contracts for such project with a cantacmr(s)licensed pursuant w the Contractors
License Law.
O 1 am exempt under Sec B&P C for this reason
Owner Data
WORKERS COMPENSATION DECLARATION
I hereby aBlrm Wrier penalty e(perjury Ole of we fallowing declarations:
1 haw and will mainWn a CW Rantof Convent w self-ince fan Wod¢r'sCompen-
1337100of
hm,a provided fan by Section 37M of the tabor Code,for the performance of ins
rk for which this permit Is tasted,
1 haw and will maintain Worker's Compensation Insurance,as required by Section
rhe labor Cade,for the performance of the wank fan which Nis permit is issued.y Workers Compensation Insurance carrier sed Policy number see:
rticr. Policy No.:
CERTIFICATE OF MEMP 1ON FROM WORKERS'
COMPENSATION INSURANCE
(Thismotion mord nor b tcompleted time permit is foram:hundred dollen($IM)
or lux)
1 unify that in the performance of the work for which this Permit is Isanod.I shall nate
employ any person in any manner an ss in become subject to the Warkeri Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this CeniOam of Exemt you should
became subject
omp y it Worker's Compensation emiiL mai of Ni labor Cede you muse —
z0 forthwith comply with such provisions or NLLpermitsAJl adcemW rooked. !�/A/n� f
.'Z.tOmilin CONSTRUCTION LENDING AGENCY /
ILI o-�+ kfurhomwthdu Net Nemiaimed(Sm.30 len ding agemy for dor performanceof
Ret ,� the work fur which Nis permit h issued(Sm.J097.Civ.C.)
aQ Lender's Name
=z lender's Address
C)Q 1 cenify Neu I ban mad this application and sum Nn Ne aWw information is
D. cmmm,l apea in comply with all city and county ordinances and sate laws mating w
Q V Wilding comuuction,arta hereby audience mpmunudvu of this city to enter upon dm
UJ move-mentioned property for impaction purpwos
R. (We)agree to sew,indemnify and keep harrolnsa dm City of Cupertino against
h liabilities,judgments,coats and expenses which may in any way accee against said City
in consequence of the granting of this Perini,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
Re-roofs
Sismau ,of ApplianJConuwtor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant mom or handle hazardous material
as,dented by the Cupertino Municipal Cade.Cluster 9.12.end the Health and Safety
code, rlyea ONO ea2ss32(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Y
Will the applicant or future Wilding occupal um equipment or dcvim which If a roof is installed without first obtaining an inspection,I agree to remove
it haardom air cmumainams a defined by the Bay Arca Air Quality Management all new materials for inspection.
isnot?
❑Yin ON.
ve mNe
I contend huudommmcruisrequimm uunder C7upter&95ofNo Califor•
nu Hulth&SefmyCode,Swd=25505.25533a 25734.iun@rsmand thmif Ne Wilding
dao rot currently haw a mnant,Nat It u my espouihility w notify dm occupant of the
requirements which must a mea pilar w issuance of a Ccnifsam of Occupancy. Signature Of Applicant Date
Owner or authorircd agent Dam All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
1 , Cupertino CA 95014
Telephone(408)777-3228
• CITY OF Fax(408)777-3333
CUPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
7512 Shadowhill Ln.
OWNER'S NAME: Me ber , Dan PHONE # 408-873-9787
GENERAL CONTRACTOR: Just Water Heaters FAX # 510-783-6360
I am not using any subcontractors: DA`Q- �40`+akL)M� 6/28/04
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
Owner/Contractor Signature Date
10/28/03
0
City of Cupertino Building Permit Application
E-Mail
Jobslte Address: 7512 Shadowhill Ln. Date: 6-28-04
Owner's Name:---Mayberg, Dan
Phone No.(408)873-9787
APN#: 362-30-094 Project Valuation: $ 850.00
Building Permit Info: Bldg_-----_-- Elect----------- Plumb------K_- Mech--_________
fob 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# 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.
Expiration Date: 9/05
Visa MasterCard ® 6
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