04020121 CITY OF CUPERTINO corikc�rnli (riRAmci `� ;
BUILDING DIVISION PERMIT
. BUILDING ADDRESS: JUST WATER HEATERS INC PERMITN%4020121
NER'S NAME: PERMIT ISSUE DATE
NE: SANITARY N0. CONTROL NO.
ARCHITECDENGINEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LOO LICENSED CONTRACTOR'S DECLARATION 7bDescri tion
z 1 hereby affirm NoP
at 1 am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of NC Business and Pmfassinna Code,and my license is i('s1
mfell
amseto.and eBeol REPLACE WATER HEATER q
5�? License Clsss Lim.p
Dam Goa (4 0 GAL GAS)
DEC
ARCHITECTS DECLARATION ,
�i 1 understood my plans shall be used as public records 4&n a ,}
a Licensed Professional i&4 OTC
OWNER-BUILDER DECLARATION B/A® O
<f 1 hereby affirm that 1 am exempt from dm Conuacmrs License Law for theii: `��,Jw
e O following reason.(Section 7031.5.Business and Professions Cade:Any city or county 1 U*T0
$ which requires a permit to construct.alter,haprove,demolish.or repair any structure
zz prior to its issuance,also inquires the applicant forsuch Permit o file a signedmiament
g=gq� that he is licensed remains to the previsions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area ValuatiJ928
y+ (commencing with Section 7W0)of Division 3 of the Business and Professions Code)in
E N$ that lacti.exempt Ihemfrom and du bssts for due alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy e
not mom Nan five hundred dollars($500). P Y 'T I 7 P
❑1,as ownerofthepropeny,on mycmple,ce with wagmas d¢trtole compensation, 35703047 . 00
.tilde the work.end the sumetu e is not Inmndedaro@red forsale(See.7044,Business
and Professions Code:The Compactor's Liceve Law dors tet apply in an owner of Required Inspections
property,who builds orimproves memon.and whodoestuch work himulforthrough his
own employees,provided that such improvements arc notinmrtded or offered fertile.if.
however,the building or Improvement Is sold within one year ofcompletion.the owner.
builder will have the burden of proving that he did not build or Improve for purpose of
sale.).
❑1.as owner of the property,am exclusively contracting with licensed anuazbrs to
construct the project(Sec.7044.Business and Professians Code:)The Contractor's Li.
came Law does not apply to an owner of property who builds or improv thereon.and
who contracts for such projects with a con racmKs)licensed pursuant to the Contractor's
License Law.
1 aretempt under Sec. .B k P C for this won
nor Dao
WORKERS COMPENSATION DECLARATION
1 hereby alfinn under penalty of perjury one of tiro following declarations:
�I haw and will maintain a Carolers ofConsent to self-insure for Worker's Camper-
terms,ss provided for by Section 3700 of the Labor Code,for the Performance of the
work for which this permit is issued.
❑1 have and will mandate Worker's Compensation Insurance,as required by Section
37W of the labor Code,for the perfomunee of the work for which this permit is issued.
My Workers Compessalion insurance carie and Policy number sure:
Cartier. Policy No,: _
CERTIFICATE OF EKEMPDON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed time Permit it forone hundred doilua(510d)
or lass.)
1 certify that in the performance of the work for which this Permit is issued.I Shall not
employ any person in any mannerso as m become subject 10 dte Wmkers'Compensali in
Law,of California.Delo
Applicant
NOTICE TO APPLICANT:IL after making this Ccntficam of Exemption.you should
become subject m on Worker's Compcuation provisions of the Inbar Cuda,you most
.7Q forthwith comply with such provisiau or this Permit shall be deemed revoked.
ti CONSTRUCTION LENDING AGENCY
f+ 4 I her which
Net there imxed(Sec.3097. agemy l'nr the Pcrfurmance of '^
CG theLa work for which Nle permit it uswd(Sec.7097,Co.Civ.C.)
Wti A Lenders Name
= z Lender,Addmas
U 1 anify that 1 have read this application and seem that the above information is
V. F correct.lattice to comply with all city and county nethermost and sum laws misting to
0 building construction,and hereby authentic mpasemativ of Nis city to enter upon me
W above-mentioned property for inspection purposes.
LL (We)agora to save,indemnify and keep humless the City of Calandra against
,.y,n Itabtlifies,judgments,costs and expenses which may in any way seems against said City
t) 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
Signature ofApplic HAZARDOUS C.o_AZARDOUS MATERIALS DISCLOSURE tierDam Type of Roof
Will am applicant or future building oaupard
ns store or handle hmaous material
defined by Om Cupertino,Municipal Code,Chapter 9.11,and me Health and Safety
odes Section 15532(a)?
❑Yes ❑Nu 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
mit havamnus air contaminants as defined by me Bay Area Air Quality Management all new materials for inspection.
Dis ict?
❑Yes ON. -
1 have mad the haradoes maa:rialarequiremen s under Chapter 6.95 of the Califor-
niaHralthgrsafmyCode,Secdom 25505,25533 and255J4.1 undcrseentl Netif the building
dins nos curcedy ham a tenant.chain u my responsibility to nodly me occupant of the
mgnlamcnlawhichmust herectpnorteoaaaemofacemdcalmo(occupancy. Signature of Applicant Date
Owner or aamariaea stent Date All roof coverings to be Class"B"or better
r i
City of Cupertino Building Permit Application
E-Mail
O p� 7 o I
Jobsite Address: 22481 Walnut Cir. Date: ,23 4
Owner's Name:---Siu Ryan
Phone No.(408)668-2593
APN#: 357-03-047 Project Valuation: $ 928.00
Building Permit Info: Bldg__-------- Elect----------- Plumb------X----- Mech-----------
Job Description
Replace 40 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: 9/05G� 6�
Visa MasterCard
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