05030170 (2) CITY OF CUPERTINO
BUILDING'DIVISION PERMIT . CONTRAkCTURINORMA.TION -
f
aUILDINO ADDRESS: JUST WATER HEATERS INC PERMIT..05O3O17O
441 qTnXPq A17
OW NER'S NAME: PERMn'ISSUE DATE
ONE: SANITARY N0. CONTROL NO.
10
ARCH=IENOINEER: BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
3Oo LICENSED CONTRACTOR'S DECLARATION IOb DOSCIlpt1OD
1 hereby afRrm Wt 1 me I�nsed under provisions of Chapter 9(commencing
n� with Sectlan lIXll0 of Division Sof the Business atM Professions Code,and mYlicense b
mm.Cirs,ll to= ercect REPLACE WATER HEATER
License Clw Lk.g
Dam Contractor (5 0 GAL GAS)
dARCHITECTS DECLARATION
a 1 understand my plane shall M trend as public meortls -or
3cath Licensed encs ianal �j
5 OWNER-BUILDER DECLARATION
to 5i I hereby alarm on I ao exempt from iM CuonsCo :My c law for the 5
3:O O following mason. arch 1 703 1.5, L arm, and Professions demolish.-1:My city fir county
$ which mqusu a penmio re cnnmrtmt tlmr,Improve. ,nittnr mpNg try statement�^ pdmtoiuimmedo,also requithe line applicant o to,the Contractor's
ominse Law(Chapter
t:b< thsthe blkemotlpursuantto the 70OMdDiai.of the Conmctor'sLIcnse law(Clupmr9 Sq.Ft.Floor Area Va 41
F (cot Met exempt ensforenandof,basison3 oft he Burircfeudon.Any viCode)fir
Net Met"exempt themfmm and the baa for the alleged exemption.Any violNun of
Section 7031.5 by any applicant for a permit Objects the applicant to a civil penalty of APN Number Occupancy Type
not mom then Itt.hundind dollen($500).
01.as owtwofthe property,or my employees with wages as thulr Ole compenvdon, 32647030 . 00
will do the work,and tunuucwm is not Intended a offered forsam(Sec.70/4,Buunu Required Inspections
and Poefesslons Code:The Contractor's Lt..LA.does not apply to in ownere ns of q p
property who builds neimprows Ournean.and whodecs suchwork himaalfarthro iOlds
own employees.provided that such improvements me not nmMed moBemd fnesale.11.
however,the building or imp owmut Is Old within one yem of mmplcdon.the owner. .
bulkier will have the burden of proving that he did not Wild or improve for purpose of
oak.).
0 1,as owner of the pmpmy,am exclusively contracting with licensed conuaenms to
convect the project(Sec.TOO.Business and Professions Code)The Contractor's Li.
center law does not apply to an owner of property who builds or Improves thereon,and,
who contracts for such projecm with a contractor(,)licensed pursuant to the Commerce,
License Law.
0 1 am exempt under Sec. .B k P C for this moan
Owner Data
7031. WORKER'SCOMPENST71ON DECLARATION -
1 hereby affirm under penalty of perjury one of the following dmaotima:
I have end will maiwin•C"Ecme.f Covent to self-imm.for WmlteYs Camper
W
0on.u provided for by Section 3700 of the Labor Cade,ren the performance of the
rk for which this permit is issued.
I haw atl will maintain Workees Compeseadon humonce,u inquired by Section
of the Labor Code.fm the performance of the work for which this permit le Issued.
y Wmirse.Compewd.lneuMa carrier and Policy number mc:
rrier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
ebb mien need amt ba completed Ifthc permit Is foram hundred dollan($100)
m Into.)
I certify that in the perfameanee of the work for which this permit is imucd,I mail not
employ any person in any matter an as to became subject to the Worked Compensati0n
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.spur making this Certificate of Exemption,you mould
become Object to the Workees Compense mar provisions of the labor Code.you most
0 forthwith comply with such powisimu or this permit shall bme
e drummed revolted.
Z rya CONSTRUCTION LENDING AGENCY ` I/
[--: IherebyIMMthemthemisacomtrucdnnlendingagencyfortheperformanceof
adu work fm which this permit b issued(Sec.3097,Civ.C.)
Q LendeYs Name
::1 z Lender's Addreas
U Q I certify that I have mad this application and sum that Oc above information It
Iy U coram.I agree 0 comply with all city and county onlinsnaea and sae law,mlaung to
0 building convection,and hereby authodu mpmenmatim of this city to mar upon the
1p move-mendoned property for Inspecdon purposes.
L>, (We)agme to save,indemnify and keep hearm2as the City of Cupertina against
IA liabilities,judgmmnu,costs and expenses which may In any way acme against mid City
t,)7 in consegmna of the sooting of Nb permit
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApptlesHAZARDO Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII thea Cu( mfirfuer bulling necupanutomfir handle Health
and
u de0m0 by Ue Cupmine Municipal Cade,Chaper 9.13,and the NcaiN ani Safety
a k.Saurian 1'e Cu(
All roofs shall be inspected prior to any roofing material being installed.
❑Yes ON.
WIII 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
emit hauNom air contaminants as defined by the Bay Am Air Quality Management all new materials for inspection.
Dittrich
O Yes 0N
I have mad the hux mus materials requirements under Chapter 6.95 of On Califor.
nia Hmlth@.Safety Cade.Socuom 15505.35533 and 25530.1 understand that lines,building
dors out currently have a tenant that It is my responsibility to notify the Occupant of the
mquimmenu which mum be met prior to issuance of a Certificate of Occupancy. Signature Of Applicant Date
Owner mauthorized agent Dam All roof coverings to be Class"B"or better
Community Development
s 10300 Torre Avenue
a Cupertino CA 95014
Telephone(408)777-3228
� CITY OF Fax(408)777-3333
CUPEkTINO
Building Department
JOB ADDRESS: PERMJ1 #
10441 Stokes Ave. o3-a 3 o / 7
OWNER'S NAME: Phil Deaver PHONE # 408-257-9720
GENERAL CONTRACTOR: Just Water Heaters FAX # 510-783-6360
I am not using any subcontractors: U,` . '4e"`takOaA--) 3/16/05
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
3/16/05
Owner/Contractor Signature Date
10/28/03
i
�S-v3 � 12 �
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 10441 Stokes Ave. Date: 3-16-05
Owner's Name:---Phil Deaver
Phone No.(408)257-9720
APN#: 326-47-030 Project Valuation: S 1,041.00
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 /
Name on Card: Just Water Heaters Inc.
Expiration Date: 9/05
�g� a
Visa MasterCard
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