05020098 (2) CITY OF CUPERTINO
r
PERMIT � �aa°�� �BUILDING DIVISION 1
BUILDING ADDRESS: JUST WATER HEATERS INC PERMITNIb 5020098
OWNER'S NAME: PERMIT ISSUE DATE
CA
ONE: SANITARY NO. CONTROL NO.
510 293-9901
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELP.CI' PLUMB MECH
+�o LICENSED CONIRACIITR'S DECLARATION O O O
b I hemby afmm that I am licensed under provisions of Clrap sur 9(ammeneing Job Description
with Section 70(0)of Dhimon 3 of dm Business and Profesuou Code.and my license Is
mfall inseam eHeet.
IJcenmCwLk.O REPLACE WATER HEATER
gz
y.- Dme Canlr.aNr 5 0 GAL GAS)
3 ARCHITECTS DECLARATION
1 understand my plans shall An used as public mends
3 0 Licensed Professional
m OWNER-BUILDER DECLARATION
Coni ION
Q S I hereby affirm that 1 1. exempt from the Cssions Cods:
:my c Law for the
1-Q O following reason. erralt i 7 acture t,Alivas and Prow,de ties Cade:My city or aunre
$, which reyuirm•permit ac ver ssuet,alwr,wprove,h Permit t lir repair any umcwrt
F-Zi paartoialensedpalm acquires Novisios ofthecant auchpermit tomem,La (chaps em
< thuwie ingwidpuruanun the provisions of Ne Consacess Liavcamm Chap¢r9 Sq.Ft.Floor Area Valua$gIg00
,SF$
(cannotMein,ming wit Sudan 70ndth Divaionrn(Ne Bualnwmton.My rat CrMa)or
3. Uva io b n1.5 b any Applicant
Mendfrali and the beers for Na cts ed e¢mpnt in Any l penalty
of
Section?031.5w huydeddollaforapormlt subjects Ne applicanttoacivil pcnelry a( APN Number Occupancy Type
net mare than Ow hundred dellen(f300). p
01.AS owner of the property,tar my employees with wages u their sole mmpensetian, 366 1.31Vr4�8 ' 0
will On,Ne work.a ad the rropale is net lowered moffared for sale(Sec.70u,Bmi�•• 'r ��/� squired Inspections
mory, pw N
and Pereoloude:CaThe Contractor's Uttnes Law dens net apply An an owrwof r !,r qI� �b
mewho builds.imeereonW,uwhodoessuchwork himvlforthemigh his fPfY/ /
own employees,provided tatsmentsintendeduch Improveanot inded molfmnd for sal.IL Y O
however,Ne building or improvement issold within am Levof completion,Ne ownew �oO
Wilk,will have Ne burden of Proving Nat he did net Mid or improve fm purpose of rj
um.). Q v
❑L as awner of the property,.Business sinad PmfcW ng with Iicewd conaaoe, i. /p _/�
eauwA the es not (Sec.70 nncrfsad rty who
Code:)The Comrvmra odd OIOIOI!!!q„�vltlp//_ �I
cease IJw drca not apply e ts owner of propery who builds or Impewa Norton.end, 11`v/�
whoa.Lacontracts;for such projects with a contractor(s)licensed pursuant to we ConaMOM1
0 I me Law.
❑I am uanpt undo Se. .B 8 P C(m Nis moon
Owner Dare
WORKER'S COMPENSA77ON DECLARATION
I hereby affsm under penury of perjury am allies:following declarations:
1 have and will maintain•Ceodifiam ofCcummu mlf-imam forWorlmea Comperr
137M
ion,u provided for by Section 3700 of the Labor Code,for Ne performance of the
ak for which this permit is ivaed.
1 haw and will malmain Weyers Campewtion Inauranm,u required by Smdon
cram labor Code,for the performance of the work for which this permit r issued.
y Workers Compensation Insrance ca ner and Policy number art:
rtier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(The acmim need Out wmmple odd If flan permit Is foram hundred dollars($100)
Or kat)
1 modify Net in the performance of to work for which this permit is issued,I shall not
employ any person in my motor an As An become subject to tie Worker'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT.If.after making this Cer iOam of Exemption.you should
become subject As the Worker's Compensation provisions of Na Labor Cade,you most
.,O forthwith comply with such provinces or this permit shall w dccmed revalue.
z. CONSTRUCTION LENDING AGENCY
[-. 1 hereby affirm that Nee is a construction lending agency for the performance of V�.J
IX? the work for which this permit is bound(Sec.3077,Civ.C.)
QLenders Name
a z Lenders Add.
V Q 1 certify that I haw mad this applleuian and main that the above information is
correct.I&gee to comply with all city and county aNirwa.es arm slate laws miming to
building convection,and hemby auNumn representatives of Na city to enter upon Ne
le awve mentiomtl progeny fm inspection purP=L
LL (Wc)Agree to taw,indemnify and kmp homeless,the City of Cupertino alsiur
In liabilities,judgments,cow and expenses which may in my way accrue against said Cry
in
of the
V r'+ APPLICANToUNDERSTANDS Acusing Of rND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signawrc of ApplicauntACOninamor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will we applicant Or fMuni building e.Chapter
time orhandlethe
hvudms material
As define0 by Ne CupnNm Municipal Code.CMpwr 9.13,and dw Hulth and Safety
cave,soman zss3z(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes Ohio
LWill Ne Applicant or future wilding occup&m ae equipment or deaicc,which If a roof is installed without first obtaining an inspection,I agree to remove
t hammnus air canumhanw As defined by the Bay Area Air Quality Management all new materials for inspection.
Disuict7
Oyes ON.
Ihave mad Ne hvsrdousmawdaa requirements undcrCMpmr6.95ofNc Califer. '
nia H.IN6:SafctyCo ,Scmau33505.21533md35534.1w&,Mn thvifthe wilding
den err comedy haw a onset.Nat It a my responsibility in nedfy the occupant lir de
mqumnecna which mut An met prior to Issuance of a CaUkaw of Occupancy. Signature Of Applicant Date
Owner or Authorized agent DOW All roof coverings to be Class"B”or better
t Community Development
p: 10300 Torre Avenue
f - Cupertino CA 95014
CITY Of Telephone(408)777-3228
PE I�TINO Fax(408)777-3333
SCU
Building Department
JOB ADDRESS: PERMIT #
11791 Sierra Spring Ct. D S-V Z o o 4y"
OWNER'S NAME: Chang, Caroline PHONE #408-996-3698
GENERAL CONTRACTOR: Just Water Heaters FAX # 510-783-6360
I am not using any subcontractors: ��' � 2/11/05
Signature Date
Please check applicable subcontractors and complete the following information:
rA Xj
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
D�, � F-t 2/11/05
Owner/Contractor Signature Date
10/28/03
• City of Cu ertino Building Permit Application
E-Mail
Jobsite Address: 11791 Sierra Spring Ct. Date: 2-11-05
Owner's Name:---Chang, Caroline
Phone No.(408)996-3698
APN#: 366-53-049 Project Valuation: ' S 1,100.00
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: permits®justwaterheaters.net
City,State and Zip: Hayward,CA. 94545
State Contractor's License# 591329 Exp. Date: 3/31/06
Worker's Comp#: 1626288-04 Carrier: State Compensation Insurance Fund Exp. Date: 4/1/05
Credit Card Information
Credit Card #: 5474-6390-0026-5679 n �
Name on Card: Just Water Heaters Inc. 7 � l
Expiration Date: 9/05 C
CJ f
Visa ❑ MasterCard X
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