04020115 (2) CITY OF CUPERTINO a^, 'T;v '� ss(� }
BUILDING DIVISION PERMIT CONTRA`� ^"' lly-P—A "^"^ �
BUILDING ADDRESS: JUST WATER HEATERS INC - PERMIT NO04020115
OW NER'S NAME: PERMIT ISSUE DAIS
ONE:
SANITARY 0. CONTROL NO,
ARCHITEQ7ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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+=+Op LICENSED CONTRACTOR'S DECLARATION Job Description
0Z ith S1 hereby aff ng that 1 am licensed under pmvisiona of Chapter 9(commencing P
'n<
with 7")of Division 3 of the Business and Professions Code.and my license is
<ry`
infull effect.
infulllt Cissa cunu.mr REPLACE WATER HEATER (�sa
ARCHITECTS DECLARATION (119 GAL ELECTRIC) 7
�i I understand my plans shall Wants!u public records AUG 1 2001
0
3 G Licensed Pnafcssianel
OWNER-BUILDER DECLARATION
0I I hereby affirm that 1 am1. exempt from the Conon Ca License Law for the S Af fl we
p O fallowing mama.permit
a co L;B.altar, and ve.den0ns Cad):Any city 0r county @t/ 1ta (J�'j
which requires a Issuance,Also re)animal,alter Impmw,h Permit t ter repair any tWment
F3 pdarmits enseppursuant
requires prthe isiois of for such Permit to Pilca Law hapwrm
i:Qthat he(commesccenwJ pSectio7010)previsions 3MConlnnur'sWmnse Law(Channr9 Sq.Ft.Floor Area Valuatiot697
$❑a 'ham he
axe pt erefro70nd th but,for
the
exemption.
Any
or
3.. Net he is exempt t0em(rom and the bssb for Jin alleged eumpdon.Any violation of
Section 7031.5 by my applicant fora permit subjects the applicant he a civil penally of APN Number Oe
Am mom Ihm five hundred dollars($500). Occupancy Y EYP
❑Las own"ufthe property,army employees withwagesas theirsolemmpensadan, 34241020 . 00 -
will do the work,end ahexwmum u nalinlend)d oreere l forsale(Sec.7044,Business
And Professions Code:The Comentiars Lt..Law dean not apply m an owner of Required Inspections
property who builds or improves thereon,and wha does such work him.l f ar through his
ownemployms,provided the a.h improwmants are not intended mortared forsale,if.
however,the building or improvement Ismid within one year of completion,the aw.r-
bullder will have the burden of proving that he did not bodd or improve for purpose of
axle.).
El 1,as owner of the property,am exclusively contracting with licensed convectors he
construct the project(Sec.Trans,Business and Profnsrions Code:)The ConlncmYs W.
manse law docs not apply to an owner of property who Wilds or improves themon,and,
who contracts for such pmjects with a canoacmr(s)licensed pursuant o the Contractor's
License Law.
O lamexemplmder Sea ,B&PCImthismamn
Owe
ner Da
WORKER'S COMPENSATION DECLARATION -
I hereby grim under penally of perjury one of the following dmlorafions: _
1 haw end will maintain a C<r0lege of Consent.self-inauro for WarkeraCompen-
nation,u provided for by Section 3700 of the Labor Code.for the perfmmanm of the
work for which this permit is issued.
❑I have and will maintain Wurkcrs Compensation Insurance.as required by Section
3700 of the Labor Code.far the performance of Ne work for which thin permit is issued.
My Workers Compensation In.nnce artier and Polity number am:
Cartier. Polity Na.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tuanced n need not be completed lithe permit in faro.lumdroddnllars(51(X)
0r loss)
1 unify that in the performance of the work for which this Permit Is issued,l shall not
employ any person in my manner.As in become subject 1.the Workers'Compensation
Laws of Califomia.Data
Applicant
NOTICE TO APPLICANT:IL after making this CeNficnc of Exemption.you should
become subject t9 the Workers Compensation previsions of the Labor Code.you must
O forthwith comply with such provisions or this Permit shall Ito deemed mw1md.
„'Z,► CONSTRUCTION LENDING AGENCY
I hemby r�
(—h eRthi Natmere
lYi ialending agency for hmrfurmancc of
e dark for which this permit is issued(Se.3M, V —
Civ.Cd
Q Lenders Name
�z Lenders Addrcsa ,
U Q 1 cenify that 1 have read this application and soon that the above information is
kr F cancel.l agree to comply with all city and county ordinances and sun lawn relating he
Q U building construction,and hereby authoring,mpresematiwe of this city to enter upon the
14 above-mentioncel property,for inspection purposes.
g}.,h LL (We)agree to saw,indemnify and keep homeless the City of Cupertino against
i..h cn liabilities,judgments,costs and expenses which may in any way accrue against mid City
U 7 in consequence of the granting of this Permit.
r� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature af Applic _wr HAZARDOUS MATERIALS DISCLOSURE Data Type of Roof
Will the applicant or future building.cupam stem or IMM11c hazardous material
ns dcB.d by the Cupertino Municipal Code,Chapter 9,12,and tin Heald and Safety
sae.section 2ssu(a)?
❑Yes ❑Na All roofs shall be inspected prior to any roofing material being Installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
7dmx
QYcs ❑NuI have read 0m hamNrws materials requiromems under Chapter 6.95 of the Colifor.
Health&Safety Cada Scctimu 25505,25533 and 25534.1 understand that ifthe Wilding
not ammo ly haw a Isom,that It 4 my responsibility m n0til'y this moment 0f dseuiremems which must be met Poor m issuance of a Certificate of Occupancy. Signature Of Applicant Date
ner or authorized agent Dart, All roof coverings to be Class"B"or better
r _ /
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 10079 Ridgeway Dr. Date: 2-16-04
Owner's Name:---Watson Carol
Phone No.(408)252-4420
APN#: 342-41-020 Project Valuation: $ 918.00
Building Permit Info: Bldg---------_ Elect__-_---- Plumb------X----- 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)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 z�f �s 2-
Name on Card: just Water Heaters Inc. /
Expiration Date: 9/05 6�, '
Visa MasterCard
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