04060064 CITY OF CUPERTINO '« �' `� T
BUILDING DIVISION PERMIT CONTRACTOR T FORMIATT01+4
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BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT"D04060064
OWNER'S NAME: PERMITISSUEDATE
ROBERT STERNnr /n712004
1764 NATTONAT, AV7 HE: SANITARY NO. CONTROL NO.
'
(510) 293-9901
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BL ELECT PLUMB MECH
�00 LICENSED CONTRACTOR'S DECLARATION
r�iFy 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description ,
n<S with Section 7M)of Division 3 ofthe Business and Profusions Code,and my license is
ow mfull
ce Class and
Class erceet. REPLACE WATER HEATER Uz
Z�l LicenLie.a
o Dam Gnmra CL (5 GAL) whilf
,eQQ
ARCHITECTS DECLARATION ®®/ 2po
y a I unticnunJ my plans shell M used a public tocnNs !�
JyU
LL I' Licenced Professional ' p�'
0 OWNER-BUILDER DECLARATION 1
I hereby affirm that I am exempt from the Contractor'&License Law for the
EGO following mason.(Section 7031.5,Business and Professions Code:Any city of county
5%� which requires a permit to cm stmc,.alcor.improve,domoliah,or repair any strumum
prior m its issuance,also requires the applicant for such permit to file a signed salement
—sac that W is licensed pumbrion to me previsions of the Contractor's I-manew Law(Chapter 9 Sq.Ft.Floor Area Valuatjpll 0 9 8
yl-r (commencing with Section 70DO)of Division 3 of NC Business and Profrasions Code)or
$ Net W u exempt thetofmm and 0m baa for the alleged exemption.My violation of
Section 7031.5 by arty applicant fare permit subjects Ne applicant to a civil penalty of APN Number Occupancy Type
not more Nen five hundred dollars(MOO).
31601041
❑1,as;owner ofthe property,m my employees with wages a their solo compensation,
. 00
will do the work end the structure is not intended mothered forum(See.7044,Busaase
and Profession Cum:The Communes Licmne law don not apply W an owner of Required Inspections
property who builds or i m proves thereon,and who does such work hWsef f or through his
own employees,provided that such improvements an,notimmnded oroRered formic.if.
however,the building or improvement is old within one your of completion,the owner.
builder will have the bu den of proving that he did not build or improve for purpose of
sale).
❑1.as owner of tim property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business end Professions Cade:)The Contractor's Li
coarse law don not apply to an owner of property who Wilda or improve thereon,and
who contracts for such projects with a conuactu(s)licensed pursuant to the Contactor's
License Law.
❑l am exempt under Sec. .B&P C for this mason
Owner Data
Am WORKER'S COMPENSATIONDECLARATION
1 hereby dam under penalty of perjury ow of Ne fallowing declarations:
1 here end will mainutn a Ccnifum ofCaaent a aelGiesure for Worker'sCompen-
sation.a provided for by Section 37M of the later Code.far the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the labor Code.for the performance of the work for which this permit is usual.
My Worker's Compensation Insuran.carrier end Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Missaction need not be completed if the permit is foronc hundred dollars(510)
or leu.)
1 certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any mannerse,an in become subject to the Workers'Compcaation
Laws of California.Dam
APPllesenl
NOTICE TO APPLICANT:If,after making this Ceni lease of Exemption.you should
become subjectinit Worhebvismpenr this provisions of thereed revoke.you mull
Z forthwith comply with such or this permit shellNdeemed revoked. `v^✓^—'
.Zi Q
v CONSTRUCTION.I,aoLENDINGAGENCY
Thor which
Listft.iasued(See 307.Cing agencyfor the performance of
ai theLa wurk for which Chia permit is issued(Sec.3097.Civ.C.)
QLender's Name
�z Lender's Mdmsa
V Q 1 certify that I have mad this application and sum that the above information is
IT,!+ comi l agree be comply with all city and county ordinances and was laws relating to
5 SCJ Wildingcons.umn,and hereby scurries:representatives of Nis city to enter upon Ne
{S7 above-mentioned property far inaNcdon puRaws.
gy (We)agree In now,indemnify and keep harmless the City of Connoted against
h
liabilities,judgments.costs and expenses which may in any way accrue againstaaid City
r)Z in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signature of Appliactor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne Cupererr future Wilding occupant erre orhandleHealth and
a defined by the 32(s)?na Municipal Lode,Chapter 9.@,end the HceIN and Safety
10wmar
da. 0 es zss3x(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑NuWill the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree tG remove
it hoxardnes air contaminants a defined by the Bay Ama Air Quality Managemenl all new materials for inspection.
trict?
❑Yes ❑Nu
1 have mad the hacardnus materials requirements under Chapter 6.95 of the CalifonHcalth&SafetyCede,Sccdons25505,25533 and 25534.1 undesand Nat if dm Wilding
s not currently hava a mnanl,that it is my responsibility a notify dm occupant of Ne
uimmcna which must Im mm poor to issuance df a Cenifiesm of Occupancy. Signature of Applicant Date
or authorized agent Dam All roof coverings to be Class "B" or better
Community Development
10300 Torre Avenue
apyr,01
Cupertino CA 95014
Telephone(408)777-3228
Fax(408) 777-3333
ICUPEkTINO
Building De artment
JOB ADDRESS: PERMIT# G
11000 Via Sorrento
OWNER'S NAME: Robert Stern PHONE # 408-257-9482
GENERAL CONTRACTOR: Just Water Heaters FAX # 510-783-6360
I am not using any subcontractors: 9AM- 6/4/04
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
-ato' 140A--tC&0aA---) 6/4/04
Owner/Contractor Signature Date
10/28/03
r
C
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 11000 Via Sorrento Date: 6-4-04
Owner's Name:---Stern, Robert
Phone No.(408)257-9482
APN#: 316-01-041 Project Valuation: $ 1,098.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----- Mech-----------
Job Description
Replace 50 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# 591 329 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
Name on Card: just Water Heaters Inc.
Expiration Date: 9/05
l�
Visa MasterCard
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