04060065 I CITY OF CUPERTINO ,� "^'�^ x . ' r H1A"' k � �Y
BUILDING DIVISION PERMITorrrt�,. ToR TNI' .,R1VlATION:
• BUILDINGADDRESS: JUST WATER HEATERS INC PERMIT NO 04060065
552 qT4AT)r)WPTTT IN
• OWNER'S NAME: PERMIT ISSUE DATE
DOUGLAS TSUI =4 NA TnNAT, AUR Qr/n7 /2nn4
NE: (510) 293-9901NISATARYNO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
DO, LICENSED CONTRACTOR'S DECLARATION Job Description
UW I herby affirm Ibm 1 am licensed under provisions of Chapter 9(com
mencing
with Section 7")of Division 3 of Ibe B.M.and Professions Code,md my license i,
e „ infull force and effect. REPLACE WATER HEATER
,R1
License Class Lk.is
J o Dam C.,arma r (4 0 GAL
kt W ARCH=S DECLARATION
Va 71 undcs,mnd my plans shall Mused u public records .
DLQU
C
Licensed PRImUM4l
OWNER-BUILDER DECLARATION
i<S 1 herby affirm mot I am exempt from the Convector's License Law for the
K S OO, following reason.(Section 7031.5,Business and Professions Cade:Any city or county
which` a quires a permit conswct.alter,Improve,demolish,or repair any structure
—�y prior to its issuance.also requires the applicantorsuch permit to file a signed statement
< that he i,licensed pursuant to me provisions of the Contmctur's License Law(Chapter 9 Sq. Ft.Floor Area ValuatiO$899
z�$ (commencing with station 7000).(Division 3 oflhe Busincasand Professions Code)or
i
that he u antho
empl mfmm and the basis for Me alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of APN Number Occupancy e
not more than five hundred dollen($500). P Y EYP
01,as owner ofine pmperry,or my cmployeas with wages as then sole compensation, 362240`5' 6 . 00
will da me work and Bre muelur is notimmnded o o&md forsalc(Sm.7044,Business
and Profesdom Cade:The Contractors License Law does not apply to an owner of Required Inspections
property who builds orimproves thereon,and whodoessuch work himselfor through his
own employees. Out id witarenor houndedrmoRerd(mute.if, INALE
however,thebuildingor deimprovementissaidwithin one y ofcompletion,meowner.
builder
will have me burden of proving that he did not build or Improve for purpose of
tile.).
❑1.as owner of me propcny,am exclusively contracting with licensed contractors In n1
construct the project(Sec.7044.Business and Professions Code:)The Contractors U. U04
canoe w docs not apply to an owner of property who build,or improves there [rs
D 2
on,and [y s a+ a. Ol
who coommis for such projects with a con ractor(s)licensed pursuant m tie Omuacmes
License Law. BUILDING
❑I am exempt under Sm. ,B&P C for Ibis mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 haw and will maimaia a CeNfeam of Consent to self-Insure fur WarkcesCompen-
sation,as provided for by Section 3700 of Me labor Code,for me performance of me
work for which this permit is issued.
❑1 haw and will maintain Workers Compensation Insurance,as required by Section
3700 of me labor Code.for Me performance of me work for which Ibis permit is issued. -
My Workers Compensation lnsuance carrier and Policy number art:
Carries: Policy No.:
CERTIFICATE OF EXEMPDON FROM WORKERS'
COMPENSATION INSURANCE
(fhissection need noted completed time Permit is formmhundrod dollar(SIM)
or less.)
I cenify mat in the perfonnence of Me work for which ibis permit is issued,l shall not
employ any person in any manntree as m become subject to the Worker'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT`.If.after making Ibis Cer ifrcatc of Exemption,you should
become subject m the Workers Compensation provisions of me labor Code.you most
�`L forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[r work
affrm mat@crc issued(Sec.3097. h.agcnry tier the per(ormancc of v �--
C' Le work fur which this permit is iuuctl(Sec.5097.Civ.C.)
W�0 Lenders Name
z Lender's Atldrrss
U 0 I certify that I have rad this application and sum that me above information is
correct.l agree to comply with all city and county ordinances and state laws muting m
0 U building construction,and hereby authonse rcprerenathot of Ibis city to enter upon Me
r G above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
tiVI liabilities,judgment,costs and expenses which may in any way accrue against sold City
in
of Me Shaming of
U rZr APPLICconsequence
NTCUNDERSTANDS AIND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of Applican Dete
HAZARDOUS
US MATERIALS DISCLOSURE Type of Roof
Will me applicant or future building wcupent norc or handle havardous material
m defined by Me Cupenme Municipal Code,Charter 9.12.and me Health and Safety
mac,section zs532(o7
❑Yes ❑No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
Disvin?
❑Ycs ON.
I have mail Ibe hvardous mamriaumquircmena under Chapmr6.95 of d c Califor-
nia Health&SafetyCode,Smdom 25M5,25533am125534.1 undersand thatifine Building
does not cu oody haw a tenant,Mar it is my responsibility m minty Ibc oceupmt of the
requiroments which must be met prior to issuance aft Certificate of Occupancy. Signature of Applicant Date
Owner araamamdaagent Dam All roof coverings to be Class "B"or better
Community Development
a4l -o
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
OYOF Fax(408)777-3333
CUPERTINO
Building De artment
JOB ADDRESS: PERMIT #
7552 Shadowhill Ln. o O
OWNER'S NAME: Tsui, Douglas PHONE # 408-821-9110
GENERAL CONTRACTOR: Just Water Heaters FAX # 510-783-6360
I am not using any subcontractors: 9'dca- 14 �Ly6/4/04
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
(D-%-� 4� CCQr`rco v. 6/4/04
Owner/Contractor Signature Date
10/28/03
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 7552 Shadowhill Ln. Date: 6-4-04
Owner's Name:---Tsui, Douglas
Phone No.(408)821-9110
APN#: 362-24-056 Project Valuation: $ 899.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----- Mech-__-_------
Job Description
Replace 40 gal 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# 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 6/
Visa MasterCard ® 6
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