05050095 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAC3TOR INFORMATION
BUILDING ADDRESS: JUST WATER HEATERS INC PERM1TNo05050095
7"I'll ORANGE Q109PQP4 DR
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO.
ARCHITER/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
X00 LICENSED CONTRACTOR'S DEsim.of hip Job u 1 ion 7 affirm that l am of
ft Bd unof nd Professions
of Chepmr 9 my licencing B
�i� with Sauon]000)ofDivitlon3ofNC Builnecaand ProfWtiam Coo,and mylimnxu L■■�
^tea in fu 11 forme end cffCCL
5EDi= Lmen el Lk.« REPLACE WATER HEATER
o Dam Conuacmr (5 0 GAL GAS)
�',' ARCHITECTS DECLARATION _
w< I understand my plans shall be used as public mcurds J 2005
Dy J
a 1 Licensed Professional ggg��� p
5 OWNER-BUILDER DECLARATION UI I �
f 1 hereby aIt,.Nos I am exempt from Ne Conuacmr'a License Law for the gpWtoa YY
e20 0 following mason.(Section 7031.5,Business and Professions Cale:Any city or munty
which requires a permit to construct,altar,improve,dcmnitsh,or repair any structure
H z< prior to its issuance,also requires 0e applicant for such Permit o file a signed statement
PmC Nat the is licensed pursuant a the previsions of the Contracreri License Law(Chapter 9 Sq. Ft. Floor Area Valua'd TO40
Ce 1- (commencing with Section 70M)of Division 3 of Ne Businessand PrafCasm.Code)or 4
-
that he is exempt therefrom and she basis for the alleged esemption.Any violation of
Section 7031.5 by any appli=Lfor a permit subjects the applicant 0 a civil penalty of APN Number Occupancy
not more Nan Bre hundred dollars(5500). p Y Type
❑I.a owner offm properly,or my employees with wages As their sola Composition, 36611057 . 00
will dothnwolk,end : s o Contranots Livens Law dos Act a(Som.]841,owner o.
And Profusions Code:The Convectors License law does al apply ff an owner is Required Inspections
own
property who buildscur impmwa thereon,andw is dacesorb work himself ed forsam his
own c however,
the uiprovided Nat such improvements art not intended Of M offered for owner.
however,Ne building or improvement is sold within one year of c prove f r the awncP
builder will hese the burden of proving that he did rot build m improve far Purpose of
rase.).
❑1,as owner of the predacity.am exclusively convecting with licensed mnuacmrs to
construct to project(Sec.7064.Business and Im fuEons Cade:)The Contractors Li-
cense law docs nos apply to an owner of properly who wilds or improves Nemon.and
who contracts for such projects with a contractor(&)licensed pursuant ro the Contractor's
LKCve law,
❑1 em exempt under Sec. B&P C far this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following dee amtione
I hive and will maintain aCerliGcam of Cmuem to Ulf-insum for Wmkers Compere
ion,as provided for by Section 37W of the Inbar Code.for the performance of the
137,Y
rk for which this Permit is issued.
1 have and will maintain Workers Compensation Insurance,az mquimd by Section
union.
of the labor Caderform
Carlo.for the pance of Ne walk for which Nrm
Nis,peit is issued.
Workh Coripessolon Inwnece cannot and Policy number art:
rtier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thmacctism need not weomplemd i(the permit is foram hundred dollars(SIM)
of lust
I ecnifr Nat in use performance of the work for which this permit is Wood.I shall not
employ any pcfson in any manner so As In become subject to the Workers Contpcmauon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject the Provisions,
provisions of accrued
labor Cede,you moa
J O forthwith coomplyy with tach pmviaioor N
is permit shall be revoked.
Z rjy CONSTRUCTION LENDING AGENCY
[-� Ihemby affirm Nat Vert is a construction lendingageney far the perfomtaMe of
ai thc ,it fur which this permit is issued(Som.3037,Civ.C.)
Is.
Q Lenders Name
Z)z lender's Address
V Q I Certiry Nat I have read this application and some Nn Nc aww information is
LI, Correct.I agree b comply with all city And county ordinance&And mute laws relating to
0 U building construction,and hereby mNariae mpreconwives of Nis city to enter upon use
awvedmenudgm progeny for inspection whichm.
(We)agree to save,indemnify And kelp harmless the City of Cupcnino eplms
fA incoiuuicrice r me craving expcnmemay in try way attmc Against Aid City
t)z A APPLICANT
ormegranting of this Permit.
'-' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Signature of AppbnHAZAR O Re-roofs
Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will NC applicant or future Wilding occupant slam N
m of hurdle aous material
az dcBncd by NeaCupertino ertino Municipal Cook.Chapter 9.17,taHe
d the Health and Safety
1,1—E
El Y. ON.
Cook.Section 25532(e)?
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant of future wilding occupant use equipment or&vitt&which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants az defined by the Bay Area Air Quality Management all new materials for inspection.
vcR
❑Yes ON.
I have read the hazardous materials requirements under Chapter 6.95 of the Csiifor-
Hcalth&Safety Coo,Sections 25505,25533 and25536.I understand that if theWilding
e¬ currently haw a mnux Nat it u my mspnuibility m notify the occupant of the
uirements which mum be met poor m issuance of a Cenircam of Occupancy. Signature Of Applicant Date e
owner ar Authorized ARCO, D,m All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY Of Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS: PERMIT #
7581 Orange Blossom Dr. as-V .S-o 6 s�
OWNER'S NAME: Tilley, Al PHONE # 408-253-6543
GENERAL CONTRACTOR: Just Water Heaters FAX # 510-783-6360
I am not using any subcontractors: ��` r ) 5/17/05
Signature Date
Please check applicable subcontractors and complete the follow in 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
02-LZkQ' � 5/17/05
Owner/Contractor Signature Date
10/28/03
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 7581 Orange Blossom Dr. Date: 5-17-05
Owner's Name:---Tilley,Al
Phone No.(408)253-6543
APN#: 366-11-057 Project Valuation: S 1,040.00
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: 4/1/06
Credit Card Information
Credit Card #: 5474-6390-0026-5679
Name on Card: Just Water Heaters Inc. 2,/ G ��
Expiration Date: 9/05
Visa ❑ MasterCard ® �Y
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