04020118 (2) CITY OF CUPERTINO Y-t
BUILDING DIVISION PERMIT 'CON'TRA.CTOR Il�k'U12MATION:
BUILDING ADDRESS: JUST WATER HE INC PERMIT"04020118
OWNER'S NAME: PERMIT ISSUE DATE
HUM MASON 17f;4 MATTnDIAI AWR 12-4-1-2 /2004
NE: SANITARY NO. CONTROL NO.
ARCHIW=/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION Job Descri h n
�+F I hereby affum that 1 am licensed under previsions of Chapter 9(commencing O
`j with Section 700 of Division Sof Ne Busincsaand Prefcasinns Code.and or,he...is l.( �U-11 L1��
^ ,w in full from and effect.
5 z L;ttramclaas Lie% REPLACE WATER HEATER
Dam ca"tre"ar (5 0 GAL GAS) MAR 112004
ARCHITECTS DECLARATION
1 uMcrstand my plans shall be used as public records p'nt p \I�I SIO
;off Licensed Professional
S OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from Ne Contractor's Licenm Law for the
aO fallowing mason.(Section 7031.5,Business and Professions Code:Any city tar county
s'e m which requires a Permit to construct,aim,,improve,demolish.or repair any atrecmm
m—m
prior o its issuance,also inquires the applicant for such permit o rite a signed statement
?� that he is licensed pursumnun the previsions of the Comment's License Law(Chapter 9 Sq. Ft. Floor Area Valuati ov800
zH (commencing with Section 7000)of Division 3 of the B usiness and Professions Code)or 4
y $ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Nc applicant to a civil Penalty of APN Number Occupancy Type
not more Nan Ban hundred dollars 15500).
❑I,as..or of the property,or my employees with wages as their sole compensation, 35918001 . 00 -
will do Ne work,and Ne swcmre is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractors License Law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and whodi essuch work himself or through his
own employces,provided Not such improvements ve not intended rrrffered forsale.If,
however,Ne building or improvement Is sold within one year of completion,the owner,
builder will have Ne burden of graving that he did not build or improve for purpose of
sale.).
❑1,as owner of the propeny,am exclusively convening with licensed contractors to
convect the pmject(Sec.704,Business and Professions Code:)The Commentsi Li-
move Law does not apply to an owner of property who builds or improves thereon.and
who contracts for such projects with a contractor(s)licensed pursuant in the Contractor's
License Law.
❑1 mo exempt under Sec. .B&P C for his reason
Owner Date
IC3MIWORKER'S COMPENSATION DECLARATION
1 hereby aRrm under penalty of perjury one of the following decluetions:
have and will maintain a Cenificato of Cement to self-insure for Worker's Camper-
!,
n,az provided for by Section 7]Oo of the labor Code,for the performance of the
for which this permit is issued.
have and will maintain Workers Compensation Insurance,as required by Section
rf the Ubor Codc,for the performance of the work forwhich this permit is issued.
Worker's Compensation Insurance artier and Policy number am:
ier. Policy No,:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not hecompleted if the Permit is formic hundred dullars(EI00)
to less.)
1 certify that in the perfmmance of the work for which this permit is issued,1 shall nut
employ any permit in any manner so az to become subject o the Workers Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cenifrcam of Exemption,you should
become subject to the Worker's Compensation previsions of the Lahor Code.you must
.JO forthwith comply with such provisions or this permit a hall be deemed revoked.
zCONSTRUCTION LENDING AGENCY
`
[—t I herebywhich
thatthemi isaed(Sectinnicndis. agency for Ne performanceaf
a ti the work for which Nis permit is issued(Sec.3097.Civ.CJ Ql _
WQ Lender's Name _ (�_✓�_
z Lender's Address
U O 1 certify that 1 have read this application and soon that the above information is
D,.Pcenter.1 agree to comply with all city and county ordinances and state laws relating 10
DU building construction.and hereby auNorim representatives of his city to enter upon the
r 4[1 above-mentioned property for inspection purposes.
G (We)agree to save,indemnify and keep harmless the City of Cupertino against
wto liabilities,judgments,costs and expenses which may in any way accuse against said City
U z in consequence of the granting afrhis permit. Issued b Dale
r-. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT y;
SOURCE REGULATIONS.
Re-roofs
Signature of AW IicaDem
HAZARDOUS MATERIALS DISCLOSURE Type OF ROOF
Will the a Cupam ior mforum building occupant more or handle hmardousdSafrmaterial
as defined by the Cupertino Municipal Codc,Chapter 9.12,and the Health and Safety
oda.settirn zsmxan All roofs shall be inspected prior to an roofing material being❑Yma ON.
P P Y g g installed.
Will the applicant or boom building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
L hm,anrus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
moict?
❑Yes ON.
1 have mad the havardous materials requirements under Chapter 6.95 of Ne Califor-
nia Health&Safety Code,Sections 25505.25533 and 35534.1 understand Nat if the building
does not currently hove a Brant,that it is my responsibility m notify the uccuPmm of the
requircrimus which must be met poor it)issuance of a Certificate of occupancy. Signature Of Applicant Date
Owner tar aathorbcd agent Date All roof coverings to be Class "B" or better
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 20635 Kirwin Ln Date: 2-16-04
Owner's Name:---Hum Mason
Phone No.(408)366-1 710
APN#: 359-18-001 Project Valuation: $ 800.00
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)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: 4/1/04
Credit Card Information
Credit Card #: 5474-6390-0026-567925 S Z
Name on Card: just Water Heaters Inc. /
Expiration Date: 9/05
Visa MasterCard
Comments