04020122 (2) CITY OF CUPERTINO ONTRAGT�IR INk'U.�A.`fTCJN
BUILDING DIVISION PERMIT „ �, ,s, �
• BUILDING ADDRESS: JUST WATER HEATERS INC PEaMIr"'04020122
s OWNEWSNAME: CANT DdARTNn PERMIT ISSUE DAT'
DAVID MIT 11 1 7r4 TTATTnTTAT AwE Q0 11 '2 12QDA
ONE: SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p 0 0 0 0
Y00 LICENSED CONTRACTOR'S DECLARATION
IJpLa 1 Wmby,affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
^�`uj with Section 70011 .1Divislon3af the Business and Professions Code,and my license is
pp� in mu muse and ef(an. REPLACE WATER HEATER' FINAt�E®
y Pa Z License Class Lie.X
z tete COmracrof (5 0 GAL GAS)
1q- ARCHITECTS DECLARATION
1 undcommd my pions shall M used as Public maids MAR U 9 2004
JyQ
Licensed Professional
OW NE. WLOER DECLARATION
1 hereby affirm thus 11. exempt from she Contractor's License Law for the NG
p O following mason.(Section Z ostr Business and professions Cole:Any city r county
$O` which im issuance,
n permit m c ms,the alter,improv,demolish,m opsit any someone
�, Matprioheiniensedpakumuo Me theappof Me
such Contrartor'sUt to nsc signed statement
�m�m< (comma licensed puntion7 Nc of Division
of Ne Conlsiness and
Prot law(Chapter Code)
Sq.Ft. Floor Area Valuati Of1740
~$ (eat he Is
(commencing therefrom
7000)ofheadsafro(Neeged commotion.
Profession Cndc)of 4
�.� Net he Is exempt Nein(rom and the baso far the alleged cumplion.Any violation of
Section 7031.5 by airy applicant for a permit subjects the applicant o a civil Penalty of APN Number Occupancy Type
not marc than five hundred dollen($500)
❑I,as owner of the property,u my employees with wages as their sok compensation, 31601202 , 00
will do the work.and the structure isnot intended or offered formlc(Sec.7041,Business
and Probations Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who buil N or im proves NemOn,end w ho dons such work himself or through his
own employees,provided thosueh imprownhomue not intended or offend forsale.If,
however.the building or Improvement Is sold within one year of completion,Ne owner.
builder will have she burden of proving Nu he did not build or Improve for purpose of
tie.).
❑1,as owner of the property.am esclnively contracting with licensed co enclose to
construct Ne project(Sec.70".Business and Profusions Cade:)The Contrmmrs Li.
cone law dons not apply To an owner of property who Wilds or improves thereon,and
who contracts for such pmjeco with a co metor(s)licensed pursuant in Ne Conmcmes
License Law.
❑1 Or.exempt under See. .B&P C for this mason
Own. Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of the following declarations:
1 haw and will maintain a Certificate of Consent a self-insure for Worker's Compcn.
as pro
vided rovided for by Section 3700 W
of Ne Iar Cade,for the perfonmme nof the
rk for which this permit is issued.
1 haw and will maintain Worker's Compensation Insurance,as required by Section
of Ne labor Code,for Ne performance of Ne work for which Nrmis peit la issued.
y Wmkees Compensation Insurance carrier and Policy numkr arc:
Canner: Policy No.: _
CERTIFICATE OF EKEMMON FROM WORKERS'
COMPENSATION INSURANCE
(rhissectlan need no,W completed flux Permit is for one hundred dollam(5100)
or less)
I certify that in the performance of the work for which this Permit is issued,l shall not
employ any Person in my mmnerm at to become subject to the WorkersCompensallon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to Ne Worker's Compensation provisions of Ne LaMr Code,you must
Q Z forthwith comply with such provisions or this permit shall k deemed invoked.
„zO CONSTRUCTION LENDING AGENCY
[—i I booby aRmt Nat Nen is a construction lending agency for the performance of
lYi> Ne work for which this permit is issued(See.3097,Ci,C.1
Q Lanes Nunc ..
�z
Lender's Address
U Q I certify Nat 1 have read this application and mute Net the above information is
ly F correct.I agree TO comply with all city and county ordinances and stem laws relating to -
DU building construction,and hereby automm representatives of this city to enter upon the
[11, aWve-men-lend
progeny ITT Inspection purposes
(We)agree to saw,indemnify and keep harmless the City of Cupertino against
cG liabilities.judgments,costs and expenses which may in any way accrue against said City
U in his rmit.
APPLICANT Spending of the of IAND
ANTUNDERSTANDS WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature a(ApPlicaDem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Municipal
Co e,Chapter
of handle hassrdoun material
as de.Sctl by the Cupertino Municipal Cade,Chep¢r 9.11,and Nc Ncalth and Safety
Code.
Scatim1s53z(+)?
❑Yrs ❑Nn 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 Arm Air Quality Management all new materials for inspection.
District?
❑Yes ON. '
I have mad Ma hwardova materialsrequimm ids under ,Chapter6.95 of me Califor-
niaHealth&SaretyCode,Secdon25M5,15533mdz553a.l unticrsund Nuims,Wilding
does not currently haw a tenant,Nat is u my responsibility no no i Ne Neup res of Nc
mquiremcmc which must be met prior no issuance of a CeNOcam of Occupancy. Signature of Applicant Date
Owner or eurhofi.d agent Dam All roof coverings to be Class"B"or better
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 20409 Via San Marino Date: 1- 4
Owner's Name:---Chiu David
Phone No.(408)257-0327
APN#: 316-01-202 Project Valuation: $ 740.00
Building Permit Info: Bldg__________ Elect_----_--- Plumb----_K___ Mech________---
Job Description
Replace 50 gal gas water heater
Contractor Information
Company: just Water Heaters Inc. Phone: (510)293-2012
. Contact Name: Oulce 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: 4/1/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679 L)
Name on Card: Just Water Heaters Inc.
Expiration Date: 9/05
Visa MasterCard Y U
Comments