05060041 (2) P
ITY OF CUPERTINO T�1.,�T x^>1 �roa7rk �t+try.' -y+'�F
BUILDING DIVISION PERMIT VQk1ry�41'QiI� �LVYll'jl'/ll v^
LDING ADDRESS; JUST WATER HEATERS INC PERMITNO.O 5080041
921 S STELLING RD
OWNER'S NAME: PERMrr ISSUE DAIS
JAMES KAN 3400 INVEST 05
NE: SANITARY NO. CONTROL NO.
(510) 293-9901
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BO ELECT PLUMS MECH
O
jo0 LICENSED CONTRACTOR'SDECLARATION Job De �I do
1 hereby alflrm Nu 1 am licensed under provision,of Chapter 9(commencing Ply
with Sudan 7M)of Division 3 of the Business and Profession,Code.and my licence is N �®
immimeceaodeRem REPLACE WATER HEATER v.. -•.
z Danmmclan ace.•nager 50 GAL GAS _
3 D.m catDECL
ARCHITECTS Wm DECLARATION ���6 �J 7005
I untlenunJ my Ptsn shall he used u public rtcnds
Q
,tt; Lmacd Professional
3 v OWNER-BUILDER DECLARATION -�f ;j •a
<E I hereby al i m Not I am exempt from the Cantrectur,License Law far the
o fallowing reason.(Soda 7011.5,Butirrest and Pw(estion Cale:My city or county
A'02A which requires a Permit m constrat,ebur.improve,demolish,or repair my structure
Zr, prim to its issuence.abu require,the applicant forsuh permit to file a signed su¢ment
zFF< that he is rumored pursuant in the provision of the Contractor's Lmnse,Law(Chapter 9 Sq.Ft.Floor Area Valuatio 850
6$ (commencing with Section 7000)of Division 3 of the Business and Profismau Code)or
a
that he It eaempt therefrom and the basis for the alleged exemption.My violatfa of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
act am than fiwhundred dollars Wild). 35906019 , 00
0 1,n own.of the pmpay,or my emPloycu with wale u Neirmle napenudon,
mid dothewasur Co thus o Cont a nutinLicom Law dean
last a(Son.ION,owner of
and property
Code;Tha Conmcm'a Lune Law doe, or apply lf rt owner of Required Inspections
own em whebuildsar Mprnwch impr andwhodonauh wank Mmselrertformichrough his
own employees,padded Net vemimpmwmenuare not imandW ma0ercd the owner.
Wilder
however,mebuildingthe
buMpmwmanttsmidwWi.ur year of completion,the o=of
builder wiB have Ute bulla of paving than he did rot Mid m improve fa puryose of
um.).
❑1,as owner of the property-am uelu Lively contrmtinl with licensed contromm in
construct the prelut(Sec.704,Business and Profestiau Cade:)The Contractors W-
come Law,dos not apply to an own.of property who builds or impresses thereon.and,
who contracts for sub projects with a eantnctm(s)licensed parwanl m the Communes
License Law.
Olameaneam nderSx ,Bk PCfmths.
Owner Data
WORKERS COMPENSATION DECLARATION
I hereby arlitm under penalty,of perjury ane of the following d.lantiou:
1 ham soil will maintain a Cenificam of Covent an self-igen for Wuske"Compa-
7311W
on,u provided for by Sado.3100 of the labor Cade.for Ne performance of the
k for which this permit Is issued.
1 haw and will maintain Wake's Compensation Inurmm,u required by Section
of the laborCodc,for the performance ofNe work formich this permit u Issued.
Worke's Comp enation Insurance carrier and Policy number am:
rtier: Policy No.;
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
Missaton rood not W completed If the parmah is farom hundred dollen(Stool
or lass,)
employ certify than sur thein my meux of Ne work Tor which t to permit k rs'Co l shall non
lAwno any pcnon i.my manner m u m became wbJuua the Warken'Compewton T
LawsApplicant omit Date
NOTICE
NOTICE TO APPLICANT:If.after Commaking Iib CeNncaor of Exemption,you should
become subject y the Worn pro ComPemdon provision,of Ne Labor Cade,you must
.JO foMwith comply with such provWnnmthis Permit Mill hedamed rtwkee.
tiCONSTRUCTION LENDING AGENCY
F I hereby alma Net there Is a cuuuuctinn lending aoercy,for the performence of
lYi the work for which this permit is broad(Son.3197,Civ.C.)
GQ Lender's Name
a z Lc.de'°Add.
V Q I certify that 1 have read this application end sum that the above information b
cam
e"l qua m comply with all city and county odinanaa and sum[am mlatinl m
OtSJ^ building construction.and hereby authorize represenmivesofthiscity mcarer upon do
W above-mentioned property,for inspection purposes
Ly, (We)some to now,indemnify and keep historical the City of Cupertino Mint
a:n y liabilities,judgments,costs and eapenu which may in my way theme agslnt,ud City
V consequence
UNDERSTANDS eRNof the granting of tAiND
s racrualt.
APPLIWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature afApplicanVCanData
HAZARDOUS MATERIALS DISCLOSURE Type of Roof ,
Will the applicant mfutureWilding axupmtseem oahandle Health and
u dented by the Cupertino Munidpal Code.Chapter 9.13,roil the HeaIN roil Sa(ety
cent.Sccties ns32(.)T All roofs shall be inspected prior to an roofing material beim
Yes ON. P P Y g g installed.
Will the supplicant or future building occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hanrdnu air cauminents as carload by the Bay Area Air Quality Management all new materials for inspection.
DieVictT
❑Yes ❑Nu
1 haw mad the hasaNasmma il,requiremccats under Chapmr6.95oftheC01for-
n1aH.Ith&Se(itYCade.Scab.25305,25533ud25534.1 undcretsndtw l(Ihc building
dos net currently have a moanL that It b my responsibility m unify the occupant of the
tequiremenu which mug be met prior in issuance of a Confess:of Occupancy, Signature of Applicant Date
Owner or authorized agent Dam All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
- t Cupertino CA 95014
Telephone(408)777-3228
8CITY OF Fax(408)777-3333
1UPEkTINO
Building Department
JOB ADDRESS: PERMIT#
921 South Stelling Rd. o S -57"„
OWNER'S NAME: Kan,James PHONE# 408-621L4719
GENERAL CONTRACTOR: Just Water Heaters FAX# 510-783-6360
I am not using any subcontractors: ��` 7/05/05
Signature Date
Please check applicable subcontractors and complete the following information:
R11SUBCONTRACTOR 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
7/05/05
Owner/Contractor Signature Date
10/28/03
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 921 South Stelling Rd. Date: 7-05-05
Owner's Name:---Kan,James
Phone No.(408)621-4719
APN#: 359-06-019 Project Valuation: f 850.00
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#: 1626266-05 Carrier:State Compensation Insurance Fund Exp.Date: 411/06
Credit Card Information
Credit Card #: 5474-6390-0047-8660 a (yS
Name on Card: Just Water Heaters Inc. 3
Expiration Date: 06/08
Visa MasterCard
Comments
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