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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CONTRAGTSQR IPtFORM ATION� ,
BUILDING ADDRESS:
JUST WATER HEATERS INC
PERMIT NO 04020119
NER'S NAME:
JOE I)OMTTROWTC'T4
17r4 MATToT\TAI. A17R
PERMIT ISSUE DATE
Q'2 /1 -Z C) ()4
ONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
d under provisioof Chapter 9 (commencing
1 bemby affirm that l sum licenendns
with Section 7") of Division Sof the Business rod profemom Cade. and my license is
effect. LICg
L
REPLACE WATER HEATER
ismefo0^`and
Date contractor
p [tea
(4 0 GAL GAS)
ARCHITECTS DECLARATION
1 understand my plans shall W used as public rtCurtis
MAR n 1 2004
Licensed Profcssi... I
OWNER -BUILDER DECLARATION
I hc,chy drhm WI 1 i m exempt from the Contractors Beene Law for the
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following resson. (Soetion 703 1.5, Business and Profoodons Code: Any city or county
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demolish, at ¢pair any sel
which mquims a permit m mnuruet, alma Impmw, dmwum
uu..r
prior m its issuance. also fegaiief the appllcanl for such permit to file a signed surmount
Ft. Floor Area
Valuatic$699
that he is licensed pursuant to the previsions of the Contractors License Law (Charter 9
Sq.
(commencing with Section ](X0) of Division 3 or she Businea and Professions Cork) or
that he is exempt therefrom and the bassi for the alleged eumpt.n. Any violouon of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicanuo a civil penalty of
not mom than five hundred do1Ws (S50)).
36917033.00
.
01, as owner of do, props y. m my employee with wage a a their ole compenudam
Required Inspections
will dhr the work and the swcturt is not intended or named for We (Sm. 1061. Business
and Por essians Code: The Geometries License law does not apply to an owner of
Property who builds or improves thereon, and who does such work himself or Rmugh his
own employem. provided that such improvements arc not intended or offered for We. If.
however. the building or improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
0 1. as owner of the property, am exchrowly contracting with licensed Corroommrs to
construct this project (Sec. 7W. Business and Promotions Cade:) The Conuacmh Li
cone Law does ata apply to an owner of property who builds or improwa thriean, and
who conuacu for such projects with a contractor(s) licensed pursuant in the Contractors
License law.
I ao exempt under Sec. B & P C for this rtasan
m, Dam
WORKER'S COMPENSATION DECLARATION
I hereby Orion under penalty of perjury one of the following decimations:
1 haw and will maintain a Cerifiam of Consent m elf -insure fa Workcr'sCompcn-
ation, as pmvidcd for by Sseuan 3700 of the Inter Code, for the performance of use
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, as mquirtd by Section
3700 of the labor Code, for the pesimmanec of the work for which this pemtil is issued.
,
My Worker's Compensation Insurance Cartier and Policy number am:
Camcr. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section need not hecomplemd if the permit is farce hundred dollars ($10(p)
Iess.)
I Cmify that in the performance of the work for which this permit is issued, I shall nut
employ any person in any manner sat as in become subject to the Workers Compenation
Laws of C.lirom r. Date
Applicant
NOTICE TO APPLICANT: If. arm, making this C.rurie te of Exemption, you mould
became subject an tot Workers Compensation provisions of the Labe Code, you in=
' foMwith Comply with such provisions or this permit aha][ W dcemcd noted.
CONSTRUCTION LENDING AGENCY
I hereby affirm that then is a construction lending agency for Ne performan r of
' the work for which this permit is issued (Sec. 3097, Civ. C.)
Lmder's Address
j 1 coolly that 1 haw read this application and sum that the above information Is
' cameo I agree in comply with all city and county ordinmces and sum laws misting to
Wilding construction, and hereby aumome mpreentstws of this city to corer upon We
above-mentioned property for inspection purposes.
(We) .,me to save, indemnity and kcep bootless Ne City of Cupertino against
j liabilities. judgments, costs and cxpensu which may in any way accme against said City
in consequence of the grouting of this permit.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:9 Date
SOURCE REGULATIONS.
Re -roofs
Signature of ApplicaDateHAZA
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
aousoaterial
Will applicant or future buildingC asome handle N
He
ter 9.11, end the Health and Safety
defined by Ne Cupertino Municipal Code..Charter
otic, Sccu.n 25332(.)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yns El No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant tie equipment or devices which
emit harardous air contaminants as defined by Ne Bay Area Air Quality Management
all new materials for inspection.
District?
C Yes ❑ No
1 have rad the hanallous materials requirements under Chapter 6.95 of the Califar
nice Hcalth & Safety Code, some. 15505,15533 and 25534.1 undersand this irthc building
docs not currently have a tenant. that it is my responsibility to nou fy the oceupanl of the
requirements which must W met poor in issuance or a Certificate or Occupancy.
Signature Of Applicant Date
All roof coverings to be Class "B" or better .
Owner ., ..ih.H.d agent Date
s
•
Ci
E=Mail
of Cupertino Buildinq Permit Application
Jobsite Address: 833 Cottonwood Or
Owner's Name: --- Domitrowich Joe
Phone No.(408)255-1259
APN#: 369-17-033
Building Permit Info: Bldg___________
7 z�
Date: -1-2-09-03_ /
Project Valuation: S 699.00
Job Description
Replace 40 gal gas water heater
b_ -___X----- Mech___________
Contractor Information
Company: Just Water Heaters Inc.
Contact Name: Dulce
Address: 1764 National Ave.
City, State and Zip: Hayward, CA. 94545
Phone: (510)293-2012
Fax: (510)293-2022
E-mail: permits@justwaterheaters.net
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
Name on Card: just Water Heaters Inc.
Expiration Date: 9/05
Visa 11
MasterCard
Comments
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