04020169 CITY OF CUPERTINO r.�> ti�z�xs, • a� sv:� ;
BUILDING DIVISION PERMIT aCONTRACTOR INF.QRMA'I�iOI 'w
_a BUILDING ADDRESS: JUST WATER HEATERS INC PERMITN.04020169
OWNER'S NAME: PERMIT MUD DATA
Ig h CHILLIES RESTAURANT9 01,
NB: SANITARY NO. CONTROL NO.
510 293-
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BO ELECT PLUMB MEOCH
4406 LICENSED CONTRACTOR'S DECLARATION JbDescri tion
I hereby affirm Mail am licensed under pm o
duces of Chapter 9(commencing p
with Scotian 7000)of Division 5 of ere Businessland Professions Code.and my Iieeue is
^ in full fame and Offal.
_
M� keue class Lk.
a REPLACE WATER HEATER
L
Date Conuscmr (7 5 GAL GAS)
YARCHITECTS DECLARATION
Y I understood my plans shall be used u public records
aC'3 Licensed Proftegrul
.7 OWNER-BUIIAER DECLARATION
1 hereby affirm that 1 am exempt from dee Contraction's License Law for the
O O following regard.(Section 7(151.5,Businus and Bof.sians Coda:My city car ceunry
�3�i which requires a permit m cresu au.alcor.amount.demolish,or repair my someone
N� pdano its issuance.sizes requires tWapplicant for such ocmaiuo file a signed strema
mga N.theialkcomadpursuant iMepm tioexaftheContmamraucenseLaw(Chapter9 Sq.Ft.FloorArea---_I .- Valuati*
gf,SC merge ncing with Section 70110)of Division S of Ne Business and Professions Cons)or 500
3$ that be is except Nucfrom and Mc basis for the alleged exemption.Any vehadon of
Section 7051.5 by any applicant fora pamrh subjects dee applicant to a chdi penalty of -„,;/AP INUmbCr I Occupancy Type
not a m than low hundred dollar(S300).
❑I,uowur of tite property,mmy employees with waguu Heir cele co natio
36 00
11
will do the work.ane Mesuesctum Isnot intended or offered Image(sec.7'. ,Bvtl
arel Professiuu Code:The Contractors License Law does not apply tn owner �... Ired �SpeC6 s
property who Wilda orimprowa Meager.and whodrczsuch work himself orlNough his
awn employees,provided Net such impmwmenu am not intended arrRered mortals.If.
howuu.Ne Wilding or Impmvaneu it cold within one year of completion.Ne owner- -
builder will Mw the burden of proving Nat W did not Wild or improv for purpose of
sok.).
❑1.as owner of Ne property,am eacluYwly contracting with licensed mmnerore m
construct de project(See.7044.firmness and P(ofeWons Cade:)The Coneracterl U.
cense Law does not apply in an owner of property who Wilds or improve,museum.and,
who cont.cu for such projects wide a consacber(0 licensed pursuant to the Cantrumrs
License Law.
❑I am exempt under Sec .B&PC fm this morn
Owner Dam
WORKERS COMPENSATION DECLARATION
1 hardly,air=timer porosity of perjury one of um following Machinations:
I haw and will mdnuin a Certificate of Conant to aelf-Into.for WoM1sr'aCompcn-
adding,as provided for by Section 57M of ere Labor Cade,for Ne performuce of the
work for which this permit is Issued.
❑I haw and will maintain Workers Confirmation insurance,as required by Secure
5700 of the Labor Code,for dee performance of the work for which this peredt is issued.
My Workers Compensation Insusme carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMFnON FROM WORKERS
COMPENSATION INSURANCE
mcis section need not bo completed it the Permit is for one handled dollam(SIM)
or less.)
1 unify Nat I.the pmfarmaneo of the work for which this Permit Is Issued,I shall not
employ any person in any counter an u to become subject o ted Wm1mrV Compensation
Laws of Califamia.Date
Applicant
NOTICE TO APPLICANT:IL after making N4 Certificate of Exemption,you should
bocmne subject an Ne Workers Compeuation provisions of dee Labor Code,you most
Oforthwith comply with such provisions at Mis Permit shall W deemed revoked.
rrye., CONSTRUCTION LENDING AGENCY
EI Wreby affirm this them era ceumrtuon lending agency for new performance of
DG the work for which this permit It issues(Sec.71197.Civ.C.) tl
0O tenders Name
O.
Z)z Lenders Add.
U O 1 codify that 1 haw mad this application and mm dip este&bow information is
It.F co reel l agrce to comply wide all city load county ordinances and tate laws relating to
O U boilding construction.and hereby sumoriu represenudves of this city in emu upon dee
f37 shove-mentioned property for inspection purposes.
a (We)agree as new,indemnify and keep harmless 0e City of Cupertino against
fq
liabilities.judgmcnan casts and expenses which may In any way werge against said City
U Zin consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITII ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of Applicaactm Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wituere applicant or loWilding at port m handle huuu domamai
uhb
riac
ed by the Cupertino Municipal
cipal Crile.e.Chapter 9.12.and the Health and Safety
ode.Section 255324)7 All roofs shall he inspected prior to any roofing material being installed.
❑Yes ON.
Will the applicant or future Wilding occupant use said meet ar do0cm which If a roof is installed without first obtaining an inspection,I agree to remove
it har/amoes air contaminated,u dcBud by the Bay Ares Air Quality Management all new materials for inspection.
District?
❑Yes ❑Nes
I how mW the haommus materials requirements under Chapmr 6.95 of the Califon
niaHul”SsfcayCodc,Sccdms25505,25537and25534.lmdcmzndthstifde Wilding
docs not cudentiy haw a Mu.L Not it is my MPonsihility m nadry este mcupua of dee
requirements which mug be act prior m issuance of a certificate of occupancy. Signature Of Applicant Date
Owner esr.amesdysaagent Date All roof coverings to be Class"B"or better
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 20060 Stevens Creek Blvd. Date: 1-25-04
Owner's Name:---Chilies Restaurant
Phone No.(408)257-4664
APN#: 369-03-003 Project Valuation: S 4,500.00
Bullding Permit Info: Bldg—_—_— Elect—__-- Plumb__-72__- Mech----_—
Job Description
Replace 75 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-mail: permlts®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/l/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679 1 4-4- 6Y '
Name on Card: just Water Heaters Inc. /
Expiration Date: 9/05
Ic-
Visa MasterCard X
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