04020027 (2) CITY OF CUPERTINOBUILDING DIVISION PERMITaCONTRA.CTOXtT1�TFURMA'CN .
BUILDING ADDRESS: PERMIT N0.
I JUST WATER HEATERS INC 04020027
?11r iTNDA UiSTA P1.
OWNER'S NAME: PERMIT ISSUE DATE
DNE: SANITARY @gtOL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
50o LICENSED CONTRACTOR'S DECLARATION Job Descriptit�tN����
1 hominy affirm that I em licensed under provisions of Chapter 9(commencing
with Swoon 7")of Division S of the Business and Professions Code,and my licenu is
m in full force and affect.
i g License Class Lm.a REPLACE WATER HEATER MAR 2 Jr 2004
p Date
Contractor (4 0 GALLON )
B_ ARCHfTECTS DECLARATION
1 understood my pians shall x used as public records R
Licensed Pmfeasionel '
BUILDING
OW NEm BUILDER DECLARATION
i I hereby a(Sec the 11. exempt from the Connector's Co License Law for lx
veeO following memo (anion ]1omme t,Businessand
ve,de inns Code:Any city mcounty
><m which requires a permit m cnnswct.elteG impmw,demolish,or repair any svucmm
m Z'^ prior 0 im issuance.also requires the applicant for such permit m file a signed smmmeni
that he is licensed pursuant the provisions of the Contractor's Liunu Law 9 Sq.Ft. Floor Area Valuatioft
F?t h'
Ho (commencing with Section]1100)of Division 3 of the Bmiinexa nd Promotions Code)or 674
5 9 that he is exempt therefrom and the buts for the alleged exemption.Any violation of
Semon 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mon Nan firs bonded dollars(5500).
❑I,u owner of the property,or my employees with wages u their sol°campensstion. 35608010 . 00
will do the work and theswctue is notimanded ar onered forsale(Sec.701M.Business
and Professions Cade:The Contractor's Licaue law docs Out apply to an owner of Required Inspections
property who builds or Improws thereon.and who does such work himself or through his
ownemployees,provided Netsuchimprovementsarenotimmdedaroffe foraale,if,
hawever,the building or improvement is sold within one year of completion,the owner.
builder will have the human of proving Net he did not Wild or improve for promm of
sale.)
❑I.as owner of the property,am exclusively contracting with licensed contractors On
construct the project(Sec.7W,Business and Professions Code:)The Contractor's I.A.
rope law docs not apply on an owner of property who Wilds or improves thereon,and.
who contracts for such projects with a contract°r(k)licensed pursuant m the Convector's
License Law.
0 1 ton exempt under Sec. .B&P C for this name
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby aRsm under peulty of perjury one of the following declarations: -
I have and will maintain a Cer ificate ofConsem to self-insure for Worker's Compere
IC331'W
ion,u provided for by Section 3]00 of the labor Code,for Oe performance of the
work for which this permit is issued.
1 have and will maintain Workela Compensation Insurance,as required by Section
of the labor Cox.for dte performance of the work for which this permit is issued.
y Worker's Compensation Insurance carrier and Policy number am:
rrier Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thiswction recd not Its completed if the permit is porous hundred dollars(SIM)
or less.)
I certify that in Ne performance of the work for which this permit is issued,I shall not
employ any person in any mortar so u te become subject o the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become suhjmi to the Worker's Compenxation previsions of Ne Labor Code,you must
.JO forthwith comply with such provisions or this permitshall xdcemed revoked. / v
—_
r CONSTRUCTION LENDING AGENCY )
4 I hereby alTum that Nem is a couwcthm lending agency for Ne performance of
a Ne work for which this permit is;issued(Sec.3097.Civ.C.)
rat Q Lendar'x Name
z Lender'sAddess -
V 1 mnify that 1 have read this application and state Net the above informaliun is
Iy
comet.I agree to comply with all city and county ordinances and state laws elating to
C V Wilding convection,and hemby meborim representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
(We)agme m save.indemnify and keep harmless the City of Cupenino against
y liabilimsjudgmenta.costs and expenses which may in anyway accme against said City
V z in consequence of the granting of this permit.
�-t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of AppiicanU ontnctor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant sem or handle ha ardous material
as defined by the Cupemna Municipal Code,Chapter 9.12.and the Health and Safety
Amlictndc. 25372(a)? C,He
All roofs shall be inspected prior to any roofing material being installed.
❑Yet
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agr11 ee to remove
it hammus air contaminants u donned by the Bay Area Air Quality Management all new materials for inspection.
Disum,?
0yev GNo
I have tend the hamm�ue materiels requiemenss under Chapter 6.95 of dm Caliper
niaHolth&SaRIy C°dc.SccG x25505.25533 a"d25534.1undemani Nuirthe Wilding
does not cuecully haw a mount.that it is my responsibility m omfy the occupant of the
requirements which must x met prior to issuance or a Cenircam of Occupancy. Signature of Applicant Date -
owner........
r aamarned asant Dam All roof coverings to be Class "B"or better
v
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 22116 Linda Vista PI. Date: 1-22-04
Owner's Name:---Goorvtch David
Phone No.(408)257-9041
APN#: 356-08-010 Project Valuation: S 674.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----- Mech---_------
Job Description
Replace 40 gallon 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/l/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679 ��[[
Name on Card: just Water Heaters Inc.
Expiration Date: 9/05 G G
Visa MasterCard ® I
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