05040107 (2) CITY OF CUPEWI'INO P `• ,.x-r•.•.
BUILDING DIVISION PERMIT ,nCONTRACTQR�INFORMATION ;
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT NO 05040107
1036
DW NER'S NAME: PERMIT ISSUE DATE
DONANLD NEWTON
ONE:
SANITARY NO, CONTROL NO.
(510) 293-9901
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Lop LICENSED CONTRACTOR'S DECLARATION I
F❑ 1 w.by affirm Nal I am licensed under provisions of Chapter 9(commencing Job Description" _ r
with Smuon]000)ofOivision3ofthas eeusireand Professions Code.and my license is
inmOto=and effect- REPLACE WATER HEATER
j to Liecirsc ClassI Lk.Is
o Dam Can'.., (4 0 GAL GAS) ! 2005
ARCHITECTS DECLARATION
1 understand my plums shall W used as public.mods
Mot
;o' Licensed Professional
g OWNER-BUILDER DECLARATION
M. IJ 1 I I
. I I hemby aIlial I am exempt from We Cmaraaors License Law for the
00 following mason.(S txm 7(n I.S.Business and Profession Cock:Any city or county
K m which myuims a pc.I,in construct site,imprmw,demolish,or.pair any amarum
Four to its issuance.also mi,jims lW applicant for such Permit o Ella a signed sulemcnt -
< that he isliccnxdpursuanothe provisions OfWeContractor's UMOXLaw(Chapter 9 Sq. Ft. Floor Area Valuatio$812
dii- C pursuant(commencing with Sation7")of Division 3 of the Business and Professions Code)or
to
that he is a..,,thacfmm and the basis far We alleged exemption.Any violation of
Section 7031.5 by any applicant for.permit subjects the applicanno a civil penally of APN Number Occupancy Type
not mom than five hundred dollars($500). P Y YP
❑L as owner of the propary,or my employees with wages as these sale compensation, 36912011 . 00
will an We wart,and We structure is not intended or offered image(Sec.7064,Business
and Professions Code:The Contracwfs License Law docs not apply m an owner of Required Inspections
property who wildsmr impmvu Ihercon.and whodues such.,it himself orddmugh his
awn employees,provided Na such improvements art not intended oroffred forsale.If,
however.We Wilding or improvement is writ within one You of eaundcuon,We owner-
builder will have 0e Wrden of proving Nat W did not Wild or improve for purpose of
salt.).
❑1,as owner of the property,am exclusively contracting with licensed contractors in
construct We project(Sec.7066.Business and Professions Cade:)The Contractors Li-
cage Law does not apply to an owner of property who Wilds or improves Woman,and,
who contacts for such projects with a conwetor(s)Iicemed pursuant in the Contractor's
License law.
❑1 am exempt under Sec. .B d:P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I ham and will maintain a Cenificam Consent of Conseno self-inaum for Workcr'sCampcn-
ration,as provided for by Section 3700 of We Labor Code.for We performance of We
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for We perrom arce of the work for which this Permit is issued.
My Workers Compensation Insumna carrier and Policy number am:
Carver: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W complcud if the permit is formic hundred dollars($1(X))
or less.)
1 certify Thal in the performance of the work for which this Permit is issued,l shall nut
employ any person in any manner so as m become subject o the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:if,after making this Cer ilicatc or Exemption,you should
become subject m the Worker's Compensation provisions of We Labor code,you must
.J 0 forthwith comply with such provisions or this Permit shall W deemed rovokcd.
z' CONSTRUCTION LENDING AGENCY
1 he.by affirm that them is a construction[ending agency for Performance of
FL the work for which this p.it Ts issued(See.3097,Civ.C.)
411 Lender's Name
Z l<nder's Address /
U Q I certify Nat I ban mad this application and sum Nat the above information is
1L (•-' torten.l agree to comply with all city and county ordinances and sum laws Blaring in
0 building construction,and hereby authorim.prexnutiws of this city to chief upon We
>' C above-mentioned property for ingriOd n purposes.
(We-)agree to save.indemnify and keep ham lass the City o(Cupemino against
,F.i rn Iiabilitias,judgments.costs and expenses which may in any way acme againsuaid City
of tha ximm,of
U z in
.
UNDERSTANDS AIND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplieuDatar O.
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIINe-applicam or fMuni bpalCode,Chding apt¢w.or handle Health
mand Safety -
ll
u def red by the Cupertino Municipal Code.Chapter 9.11,and We Hdth and$afny
ade,secwh2s5u(3 All roofs shall be inspected nor to an roofing material being❑T ON. P P Y g g installed.
Will We applicator or fora.wilding..part sax c,.ipmcnt or devices whim If a roof is installed without first obtaining an inspection,I agree to remove
it harallous air contaminants;as dcBned by the Bay Arca Air Quality Management all new materials for inspection.
7mDiauicL7
❑Yes ❑No
I have real Ne huarmddms alerialsfcionre a:ns underChap.r 6.95 ofthe Califor-Hear"SmafctyCode,ScetiongM505.]S533 xm,IZ536.1undcrsund thv iflW Wilding
cs trot ci ant,ha ,a enanL Word iI u my maomihility.notify the atiromupam of ui. tsmronwhimmuNWfametpooronissuanceoGandhiofacupa•cT'. Signature of Applicant Date
wner oramhmi cd agent Dam All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
ICITY OF Fax(408) 777-3333
CUPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
10369 Lindsay Ave. OSS 6 ( o
OWNER'S NAME: Newton, Don PHONE # 408-252J1362
GENERAL CONTRACTOR: Just Water Heaters FAX # 510-783-6360
1 am not using any subcontractors: �� � Cn ) 4/18/05
Signature Date
Please check applicable subcontractors and complete the followinginformation:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
S 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
U.)"� 4-i¢� ��r2n� � 3/18/05
Owner/Contractor Signature Date
10/28/03
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 10369 Lindsay Ave. Date: 4-18-05
Owner's Name:---Newton, Don
Phone No.(408)252-1362
APN#: 369-12-011 Project Valuation: $ 812.00
Building Permit Info: Bldg----------- Elect----------- Plumb------K---- 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: 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 cq,
Name on Card: Just Water Heaters Inc. oZ l3S /
Expiration Date: 9/05
Visa MasterCard
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