05090078 (2) CITYOF CUPERTINO
BUILDING DIVISION PI✓RIVIIT CONTRACTOR INFORMATION''>
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT NO.O5090078
1,,TTM4 VT4TA nP
OWNER'S NAME: PERMIT ISSUE DATE
DENISE COLLIER 3400E 2005
NE: SANITARY NO. CONTROL NO.
510) 293-9901
ARCHITECrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
=1111 LICENSED CONTRACT'OR'S DECLARATION
x u C I hereby affirm that I am licensed under previsions or Chapter 9(commencing Job Description
Szin with Sccsion7")of Diviuon Sof the Business and Professions Code,and my license is
in mumneandeffect. REPLACE WATER HEATER
�? License Clan Lic.is
t 0m Dam contractor 40 GAL GAS
ARCHITECTS DECLARATION �8{}(I�� (r rte®
y' I mider.Gand my plans shall IM used as public RCor14 rl\\ r� a �t{l fL'Irlby9,
�yU
3
'Cin
Licensed Professional y
OWNER-BUILDER DECLARATION
.�<f 1 hereby affirm Nat 1 am exempt from the Contmnors License Law far 0lo
Co following reason.(Scctiun7031.5,Business and Professions Codc:Any city orcounty SEP 1005
K which requires a permit to cnnsruct.alter,impmw,demolish.Or repair any suunom
.in_�, P60Tto its issuance.also require the applicant for such permit to file a signed sediment
<
that hcislicensed purman to On,provisions;nrthe Contractor's License Law(Charter 9 Sq. Ft. Floor Area Ualuatio$822
¢ (commencing with Section]0n0)nf Division 3 or NC Bisirusand Professions Crede)sers
- i
$ thin he or exempt therefrom and Um ha ds for the alleged exemption.Any violation of l. 1 NaisM Tr�T
SaBon]031.5 by any applicant for a Permit subjects the applicant in a civil penalty of APN Number "' "' "'Occt3"erste' TYP' •e-�V'
not mom than five hundred dollars($500). P Y
I ssmwner ter Nero 35616024 . 00
❑ p Dmciuccmyempended withcmdImahevec.compewness
will neo the wok,and the he Con is not intended s or Law
do forsak(Sec.ina4,Buser of
and Proresslom Code:The cmnmxmrs License uw axe trot apply m an reverser ter Required Inspections
propcny who Wilds orimDrorcs Nemon.and who doessuch work himself err through his
ohowever,the building or improvement
mprmwmenn
u mid within oneyear of completion,the ower.
Guilder will ham the Wrdcn of proving that k did not Wild or improve for purpose of
sale.).
❑1,as owner of alo property,am exclusively convecting with licensed contranars to
consumer IN,project(Sec.7044,Rusiness and Professions Cade:)The Contractor's Li.
cense Law docs not apply in an Owner of propcny who Wilda or impmms Merton,and.
who somans for such pmjccs with a conuactorfs)licensed pursuant in the Convectors
License law.
❑I am axempt under See. .B&P C for this vson
Own Dat
WORKER'S COMPENSATION DECLARATION
1 hereby aRlno under penalty of perjury one of the following dxluations:
I Its and will maintain a Certificate of Consent to ul6insum for WokcrsCompen-
1E33737.'
on,u provided for by Section 3]00 of the Labor Code,for the Performance of tW
rk for which this permit is issued.
1 haw and will maintain Workers Compensation Insurance,as required by Section
00 of NC labor Code,for Ne performance of Ne wok nor which Nis permit is issued.
Workers Compewtion Insurance artier and Policy number am:
mcc Policy Na.:
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
This section need not W complemd it the permit is fmranc hundred dollm($1011)
or Ice.)
I emmfv that in the performance of Ne work for which this permit is issued.I shall net
employ any person in any manners as to become anhecuo the Workers'Compemuion
laws ofcelifri ia.Date
APPlicam
NOTICE TO APPLICANT:If,after making this Cenifiate or Exemption,you should
become subject in not Worker's Compemarien provisions of the Labor Code,you most
,J O foMwuh amply with such prcvisiom or this Permit shall W dcemcd revoked.
Z CONSTRUCTIONceisaconstruction
LENDING ngagerAGENCY
F Thor which thi thmdtere issed(Se.imnlending agcney fm tilo perfurmana of
C the souk for which this pernit is issued(Sec.J09],Civ.C.7
W� 0 Lenders Nam.
z Lender's Add.
V Q 1 certify Nar 1 have mad this application and sum thn the about information is
fL Fcovets I agree m comply with all City and county ordinances and sum laws relating to
C) building construction.and hereby auNmrix mpresenedircs of this city to color upon the
tancel
r aWve-m.nudghunmp.nr randepcmes which
may
(we)agree to saw,indemnify and keep harmless the City of Cupertino against
.�•t h liabilities,judgmcnta.coss and expenses which may in any way accac against said City
V z APPLICAnce Of this permit.DS
eNT UNDERSTAof the NtAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Signature of Applicaua
nVConcmRe-roofs
r Dem -
HAZARDOUSMATERIALS DISCLOSURE Type of Roof
Will the applicant or forum building occupant mm or handle havardous material
as dcEncd by the
Cupertino Municipal Code,Chapter 9.12.and the Health and Satiny
cmde.Section,25532(a)9
0Yes 0 N All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
it haeardnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
ismer?
❑Yes ON.
1 have mad the honrdnus materials requirements under Chapter 6.95 of the Califor-
maHealth&Safety Code,Sections 155115.M533 and 25534.1 understand Nat if the Wilding
dors net currently ham a tenant that it is my responsibility to untily the occupant mf oc
mquuemens which must W met prior to issuance or a Certificate of DearNer' Signature of Applicant Date
Owner or authorized agent D,te All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
t �.� Cupertino CA 95014
Telephone(408)777-3228
CITY 01 Fax (408)777-3333
,CUPEkTINO
Building Department
JOB ADDRESS: PERMIT#
11066 Linda Vista Dr. rD�-7) s 0/
OWNER'S NAME: Collier, Denise PHONE # 408-253-4332
GENERAL CONTRACTOR: Just Water FAX # 510-783-6360
Heaters
I am not using any subcontractors: ���cR. � � 9/12/05
Signature Date
Please check applicable subcontractors and complete the followinginformation:
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
,.xs�r�' 4 �gvCAQt-sCCiv�� 9/12/05
10/28/03
o S'D
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 11066 Linda Vsta Dr. Date: 9-12-05
Owner's Name:---Collier, Denise
Phone No.(408)253-4332
APN#: 356-16-024 Project Valuation: 5 822.00
Building Permit Info: Bldg— Elect Plumb__ 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)783-6360
Address:3400 Investment Blvd. E-mail: permitdept®sbcglobal.net
City, State and Zip: Hayward,CA. 94545
State Contractor's License# 591 329 Exp. Date: 3/31/06
Worker's Comp#: 1626288-OS Carrier:State Compensation Insurance Fund Exp. Date: 4/l/06
Credit Card Information
Credit Card #: 5474-6390-0047-8660 `�(a
Name on Card: Just Water Heaters Inc. 3
Expiration Date: 06/08
Visa ❑ MasterCard ®
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