05040103 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT ' CONTRACTOR I_.NFO„R�MATION
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT N'b5040103
21920 DOLORES AV
OWNER'S NAME: PERMIT ISSUE DATE
dh DAVID SHEN 3400 INVESTMENT BLVT) 04 /19/200S
ONE: SANITARY NO. CONTROL N0.
(510) 293-9901
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
t 0
Ito, LICENSED CONTRACTOR'S DECLARATION
WU EI hereby affirm that I am licensed ander pmvismma Or chapter 9(commencing lob Description
ish Section 70M)of Division 3 o(dm Busincssand Professions Code.and my license is
_=„ REPLACE and effect. REPLACE WATER HEATER
D v3 z License Class Lic.g
—c DO —¢ Cantracwr (5 0 GAL GAS)
� ARCHITECTS DECLARATION
4P� 1 undersmnd my plans shall be sad u public ascotsT-�
7
3
Licensed Professional L
,ca3 OWNER-BUILDER DECLARATION �� I� �;
<F I Licitly amen that 1 am exempt frum the Contractor's License Lew for the ` • JJJ\,
i p o following mason.(Section 7031.5.Business and Professions Cade:Any city or county T
'�$ 'which mquires a Permit re construct.Blur,improve.dcmulisb.or repast any Inaction
rZsprior tar its issuance.also requires the applicant for such Permit to rile asigned statement
that he is licensed pursuant to provisions of me Contractors License Law(Chapter 9 Sq.Ft. Floor Area G�1968
'FC Commencing with Section 70M)of Division 3 o(IW Business and Profeados Code)or
.I
y that the is cumin mertlrom and the basis for do alleged assumption.Any violation of r '
Section 7831.5 by any applicant for a permit aabjecv the applicant to a civil penally ofs
not mom man five hundred dollars(55W). APNNumber �_ Occupancy Type
cro(mepmo ayge
,mmycmploytuwimwasuftirwlecompenudon, 35714060 . 0035714060 . 00❑1. �o
will da Ibc work and me structure is notimeMed oroRcrtd Tarsals(Sec.](144,Business I
and Prefessimv cods:The Comtranmr&Liana law does not apply to an owner of Required Inspections
progeny who buildsor improves Merton,and who doessuch work himselforthrough his
Own employees,provided that such improvements arc not intended or oR4red for ask.If,
however,me building or improvement is sold wiNin one year of completion,the owner.
builder will hue the burden of proving that he did not build or impiew:for purpose of
salcj.
1,as owner of the pmpeny,am exclusively contracting with beeped contractors to
consumer the pmjem(Sec.7044,Business and Professions Cade:)The Contractors Li-
serve law docs not apply to an owner of property who Wilds or improves Merton,and
who contracts fonueh pe jecv with a contractor(s)licenced purwant to the Contactors
License law.
❑1 am exempt under Sec. .B&P C for this rtazon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby afum under penalty of perjury am of me following dalaranions: -
I have and will maintain a Cerifia¢of Consent o self-insure for WorkcrsCanpcn-
sation,an provided for by Section 37W of me labor Code,for me peefmmance of the
W
ork for which this permit is issued.
❑1 haus and will maintain Worker's Compensation Luxuriance,as requited by Section
J]W of me taboo Code,for me porfmmanee of the work for which this permit is issued.
My Workers Cam pensation Insunna carrier and Policy number art:
Carrier. Policy No.: _
CERTIFICATE OF E)(EMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This action need not be completed Lima peemit is for one hundred dollars(SIM)
Lir less.)
I anifv that in the perfornance of the work for which this permit is issued.I shall our
employ any parson in any manner an as to become subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Ceniricaw of Exemption,you should
Rxame aubjecl to the Worker's Cmnpmwlion previsions of me L,Mr Code,you must
.J Z forthwith comply with such pmviaimas or this pmmil&hall be created avnked.
z� CONSTRUCTION LENDING AGENCY
(-+� I hereby affirm that inert is a construction lending ayemy,for me perfuemance of
2'> me work for which this permit is issued(Ser.3091,Civ.C.) C
Q L rtu
ndcr's Names
=z Icndcr'&Addll
U Q 1 ttN(y that I have read this application and sine that the a W0.'infixmat on Is
F comet.I agree to comply with all city and county animators and state laws relating to
0U building construction,and hereby aulhorre representatives of this city to enter upon the
(clove-mem and property,for inspection purposes
(We)agree to save,indemnify and keep harmless the Cily Or Calcium)against
fA
Liabilities.judgments.costs and expenses which may in any way acme against saidCity
U z in cmnsegvanct mf the granting of this perm it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:s4ta� Date
SOURCE REGULATIONS.
Re-roofs
Signmurc of ApplicaDale
HAZARDOUS
US MATERIALSOISCLOSURE Type of Roof
Will tapplicantar future Wildingoccupant storeord allousmaterial
u defined byyme Cupenin)Municipal Code,Chapter 9.11.and the HeHcalm and Safety
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
�Ye& �Na
Will me applicant or future buildingaccupan nae equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil haurdnus air contaminants as derfined by the Bay Area Air Quality Management all new materials for inspection.
Dimrict?
Yes C]No
1 have road me Imoardnus materials requirements under Chapter 6.95 of the Cali for
nia Health&Safety Code.Satiom 15505.25533 and 15534.1 undersand this ifmc Wilding
docs not eurently have a tenant that its my responsibility w noury me uxupam Of the
requirements which mug bemlLatin,wnoncurrent.Cenif¢ateafOccupancy. Signature Of Applicant Date
Owner or aummiyed agent Date All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
CITY OF Telephone(408)777-3228
Fax(408)777-3333
�UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
21920 Dolores Ave. p s v 0
OWNER'S NAME: Shen, David PHONE # 408-836-9384
GENERAL CONTRACTOR: Just Water Heaters FAX # 510-783-6360
I am not using any subcontractors: 0` co- 4/18/05
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
� Q 3/18/05
Owner/Contractor Signature Date
10/28/03
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 21920 Dolores Ave. Date: 4-18-05
Owner's Name:---Shen, David
Phone No.(408)836-9384
APN#: 357-14-060 Project Valuation: S 968.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----- Mech-----------
Job Description
Replace 50 gal gas water heater.
Contractor Information
Company: Just Water Heaters Inc. Phone: (510)293-2012
Contact Name: Dulce Fax: (510)783-6360
Address: 3400 Investment Blvd. E-mail: permits@justwaterheaters.net
City, State and Zip: Hayward,CA. 94545
State Contractor's License# 591329 Exp. Date: 3/31/06
Worker's Comp#: 1626288-05 Carrier: State Compensation Insurance Fund Exp. Date: 4/1/06
Credit Card Information
Credit Card #: 5474-6390-0026-5679
Name on Card: just Water Heaters Inc. a/��S /
Expiration Date: 9/05
Visa MasterCard
Comments
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