05090082 (2) clTv of currxTm° PERMIT
aC0NTRACTOR�INFORMATIQN
BUILDING DIVISION
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT NoO 5090082
21760 LOMITA AVE
OWNER'S NAME: PERMIT ISSUE DATE
BIRAN DORIT 3400 INVESTMENT2005
ONE:
SANITARY NO. CONTROL NO.
(510) 293-9901
ARCHITECT'/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
F__1
(�
yOp LICENSEDCONTRACIOR'SDECIARATION JobDescri tio—ir
C I hereby affirm Nat 1 am licensed under provisions of CM1apter 9(commencing
wish Section 7")or Division 3 of the Business and Professions Code.and my license is
n_ow m full rarteand effect. REPLACE WATER HEATERtj_.`IT,'L�pT.
a? Liccnv Clav Lk.N P� `k�`v^�'++®
Z—c Date Cmmalor 50 GAL GAS
ty ARCHITECTS DECLARATION SEP
�-r 1 uMu erstand my plans shall W used public meafds 20
0
C
�yU J
30.E Licensed Pmfeuiunal ���+++���,,, Fl F�
^oI OWNER-BUILDER DECLARATION �� T-TiA'g$A I ,f�ybs
d00 1 meteerebyaffirm that exempt from the Cssions o :Anycense Law for the IfadPll✓a]ry iCj�✓,'(ry{���s`�Sm��.`+'n.
p o following mason.Permit
t 7031.5.Business and Professions Cude:Any city m county C�
K m which requires a pernit us cnnswcL alter.Improve,demolish,or repair any swcwm
prior u its iuuancc.alw rrqunsitc applicant(orsueh permit to plc asigned statement
That W is licensed pinsom to din provisions of the Contractor's License taw(Chapter 9 Sq. Ft. Floor Area ValuatioO 918
C,- (commencing with Section 700B of Division 3 of the Business and Profeuia sCode)or
i $ Nal be is exempt tbcmfrom and one basis for the alleged exemption.Any violmion of
Section 7031.5 by any applicant fon permit subjects On applicant to a civil penalty of APN Number Occupancy Type
not mom than live hundred dollar:(S5O0). 35718040 . 0 0
Ido the wcr .the property, remy otinuncee with wages u theiSec.mmpenm0an,
will do the work,and the swam:is user Li eed oro mored s nate(Sect oa6,wner of
and er,whioW Gude:The canmcwrs ucene law deet not apply lf rt rough or Required Inspections
own eny who builds provided
Oat
ech imps and who am not
workerhimelfor through sad his
awn employers,provided Nal vemimproscmenu arc not xist o c or leered for Owner.
however,the building bu improvement is ab within one year of completion,the owwr
builder will have the burden of proving Nat he did not Wild or improve for purpose of
salt.).
❑h as owner of the property,am exclusively contracting with licensed contractors to
construct de project(Sec.7044.Business and Professions Code:)The COntruwr's Li-
,,s,taw does not apply to in owner of property who Wilds or improves demon,and
who contracts for such projects with a conmetof(s)licensed pursuant in the Convector's
License law.
❑I am exempt under Sec. .B h P C for this Cooked
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the fallowing Qchosioru:
I have and will maintain a Certificate of Consent ti elf insure for Worker's ComKn.
ration,as provided for by Section 3700 Of the labor Code.for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Inwmbec,m required by Section
37W of the Labor Code,for NC Performance of Ne work for which this permit is issued.
My Wmkcr's Compcusatiar Insurance Cartier and Policy number art:
Carrier. Policy No.:
CERTIFICATE OF EKEMMON FROM WORKERS'
COMPENSATION INSURANCE
ODds section need not W completed if sbe permit is portion hundred dollars(Sl W)
or loss.) ,
I ccnify thus in the perf torsts c of On work for which this permit is Wood,I shall not
employ any person in my mortician u to Wcome subject to the Workers'Compensation
Laws of C.1if anis.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate Of Exemption,you should
become subject to the Worker's Comp nsiolon provisions of Nr.Labor Code,you mum
poMwi0 comply with such previsions or this Permit shall W deemed mvoked.
Z O CONSTRUCTION LENDING AGENCY
't•+� IWfehy eRon Nat Vert iso construction lending agency for ft performana of ^ (�
C � the work for which this permit u issued(Sec.309],Civ.C.)
W 25 Lender's Name
a Z Lender's Addreks
U O 1 ccnify that 1 have mad this application and music that Ne move information is
ry correct.I agree to comply with all city and county ordinaries and some laws relating to
O U building consimaLion.and hereby millpond rcpreumative of this city m cater upon Nr.
�W above-mentionW pa,eny for inspection purposes.
C (We)agree to save,indemnify and keep hi mlev the City Of C9PCf1100 against
y Iiabilitie.judgmenu,coms and expmue which may in any way accrue against mid Ctry
orthe
U Z in r.
APPLICANT eUNDERSTANDS AIND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicanUCanDate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Oe applicant or fuwrt W ilding aceupantmort orhandle hamNous material
e dC1ned by the Cupanino Municipal CoQ,Chapter 9.12,and the Health and Safety
ewe,secties 2ss3x.)] All roofs shall be inspected nor to an roofing material being❑Yea ❑Na P P Y g g installed.
Will thea scant or future building Occupant tie equipment or devices whim If a roof is installed without first obtaining an inspection,I agree to remove
pp g p .AirQn
it havrdnus air conominanu u QOncJ by On Bay Arta Air Quality Managcmcnt all new materials for inspection.
IaIfICI]
❑Yea El No
I have mal the yomminus materials requirements under Chapter 6.95 of the Califor-
niaHC.1 &Safety Cade,Sccuoro 25505.25533 and 25534.1 undersand tho roe Wilding
d.not eurenlly haw a tenon Out it is my respoasibility m routy the occupam nI Ne
rccomments,which must W met poor it)issuance ofa Certificate of Occupancy. Signature of Applicant Date
Owner Or authorircd agent Dale All roof coverings to be Class "B" or better
Community Development
C ` 10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax (408)777-3333
®CUPEkTINO
Buildin9 Department
JOB ADDRESS: PERMIT#
21760 Lomita Ave. p O U
OWNER'S NAME: Dorit Biran PHONE k 408-257-6173
GENERAL CONTRACTOR: Just Water FAX # 510-783-6360
Heaters
I am not using any subcontractors: 9-)--dco- �-t& Ckk0a/v - 9/12/05
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 1 _ n
9/12/05
10/28/03
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 21760 Lomita Ave. Date: 9-12-05
Owner's Name:---Dorit, Biran
Phone No.(408)257-61 73
APN#: 357-18-040 Project Valuation: S 918.00
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: permitdept@sbcglobal.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/l/06
Credit Card Information
Credit Card #: 5474-6390-0047-8660 I o
Name on Card: Just Water Heaters Inc.
Expiration Date: 06/08oC�l
Visa MasterCard ®
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