08110094 CITY OF CUPERTINO
BUILDING DIVISION PERNIIT #CONTR`[�.0"TQR IN1�pQ.Y,RMA,T_ION :
BUIIDING ADDRESS: PERMff NO.
10903 CANYON VISTA DR JUST WATER HEATERS INC npiinilq4 .
R'S NAME: PERMIT ISSUE DATE
CONTROL NO.
(510) 293-9901
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�OZp LICENSED CONTRACTOR'S DECLARATION
Job DeSCrIp000
e Vi heathy adust 1 ans IimnsW under pmvWo"of Chapter 9(commencing
e with Seelarm lion 7000)of Dividan Sof the Business and Prefetimu Code.and my license is
?ZsN in full forms and effect. REPLC 40 GAL WATER HEATER
ani Liemse Caw Lle.0 .
F Dam Contractor
eARCHrrECI'S DECLARATION
U I undersand my plans shall ha used as puhlic records
sato Licensed professional
5 OWNER-BUILDER DECLARATION
s� 1 hereby M.that 1 em exempt Item the Contractor's License law for the
C❑O following mason.(Section 7051.5.Business and Pmfessium Code:Any City of county
+d$ which.,.I=a permit to construct,alter.improve,demolish.ar repair my structure
_I< prior in is issuance.also lcquima the applicant for such permit to File a signed statement
mm
that he is licensed pursumtmthe provisional ofthe Contractor's Uccnse Law(Chap=9 Sq.Ft.Floor Area Valuation
yF-S (commencing with Section 70M)of Division 3 of the Business and Profauinm Code)or 833
andhe is ezempt Ikrtfrom and the basis far an,alleged exemption.Any violation of
Section 7031.5 by my applicant far a permit subjects dove applicant to a civil penalty of APN Number Occupancy Type
am team was BK hundred dollars(SM 35628007 . 00
❑I,uowar of de pvpony,ormy araployca with wagaas Nev tele cmnpewuay.
will da Nc wade and Ne avuetwe is not intended or elfeta l far oak(Sec.TUs4,Bnvrcas
amd Profetdom Cam The Comming's Lk.Taw does sal apply le an ower of Required Inspections
property aha build.oriespmwn thereon,andwM doessuchwark Ignaci err Nmugh his
ownemployces,provided that such improvement mc notimsoded oroamaed forule.U.
however.the building or lopmvemmt is mid within arc year olcanpkuen,the ewmr-
builder win law the burden of proving that K did tet Nuld or improve for Paryt n of
ak.).
❑1.as owner of the property,me exclusively contracting with named common m
csmtmct the project(Sec.7014.Business and Raf naris Code:)The Contrmtor's U-
ceve law does not apply to an owner a property who builds or improves Neuron,and,
who contracts for such projects with a contractor(s)licensed pursuant N the Contrmtor's
license Law.
❑l afa aempn order Sea ,B d P C for this won
Date
WORKERS COMPENSATION DECLARATION
1 be aby afRam under penalty of perjury arc of the following drelanuorae
I ban and win min ainua cert! roCommon m of Coself-image Ter Wortrte
h Compe
sedon.as provided for by Secuan 5700 of the Labor Code.fm the performan o of dr
wok for which this permit is issued.
1 haw and will maintain Worker's Compensation heruance.as m,tured by Section
S71pa(Ne labor Cade,for Ne perfarmauce of Ur.work for which Nu permit is issued
My Workers Compensation Insurer artier and Policy number tie:
GMer. Policy No.:
CERTIFICATE OF EXEMPRON FROM WORKERS'
COMPENSATION INSURANCE
(This sanlan recd not he camplced lithe permit Is forms hurt& Wnm(SIM)
or loss)
1 eoufy that in that pc+iegram a of the work for which this Frrmlt is issued 1 shall out
employ any person in my maner m as to became subject to the Woakot Cemperuatian -
laws of CaliforniL Dae
Applicant
NOTICE TO APPLICANT:If.alfa making this Cenifiau of Eamption.You should
became subject to the Warker's Compensation provision of Ne lahm Cock,you mus
.�z fonhwhth comply with such provisions or this permit shall he deemed mvnked.
z CONSTRUCTION LENDING AGENCY
[+ Ihembyam.taw dlert is a answcunn loading agency fm the perform.of
Cli ti the work far which this permit 4 issued(Sec.3097.Civ.C.)
Ua Q lenders Name
z Lender's Add. '
U Q I certify Na 1 have read this application and sum than the Man iNmmatiun is
I,!' correct.I agme go comply with ill city and county oWi..F s and scale loses mlaung M
0 r1^J building commando.,and hcmbymNotlm rtpmaenuuwa of this city to Mlerupnnt
LTJ above-mentioucd property for inspection purposes
C (We)agree to an.indemnify and kap harmless the City of Cupertino against
(•n Iiabilidu.Judgments.cow and upmrts which may k my way oma a gave said City
U z in conrqurncc of the gonung of this Perak.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplianUCamrcmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will ase appiicmt or fuwge Wilding aaupmt sum or handle havaxdoas material
de0ad by de Cupertino Municipal Code.Chapter 9.12,and the Heahih and Safety
Section 25552(.)? All roofs shall be inspected prior to any roofing material being installed.
0Ya ON.
WIN the applicant or future building occupant use equipment or dcviw which If a roof is installed without first obtaining an inspection,.1 agree to remove
II baardous air cortamimnu as defined by the Bay Ara Air Cagily Mmegcmem all new materials for inspection.
atria?
Gya ❑No
I Nn read the hanadws materials aequigemenu under Chapter d95 of the Califor-
rig Health&SgoyCede.Sections 25505.25555 and 2555x.Iundenun0 tut ifthe building
dao net cuncmly have.Manor.that in is my responsibility um mLify Ne menton or the
requirements which must W fact paler to imxauc of a Certificate of Occupancy. Signature of Applicant Date
Owner or autharind agent Data All roof coverings to be Class'W'or better
CITY OF CUPERTINO
• 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: pdtg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . . 35628007 . 00
DATE ISSUED. . . . . . . : 11/25/2008
RECEIPT # . . . . . . . . . : BS000006692
REFERENCE ID # . . . : 08110094
SITE ADDRESS . . . . . : 10903 CANYON VISTA DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : SHAHVAR SANDRA
ADDRESS . . . . . . . . . . : 10903 CANYON VISTA DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3908
RECEIVED FROM . . . . : JUST WATER HEATERS
CONTRACTOR . . . . . . . : GILROY, JOHN LIC # 15128
COMPANY . . . . . . . . . . : JUST WATER HEATERS INC
ADDRESS . . . . . . . . . . : 3400 INVESTMENT BLVD
CITY/STATE/ZIP . . . : HAYWARD, CA 94545
TELEPHONE . . . . . . . . : (510) 293-9901
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- -------- ----
1BSEISMICR VALUATION 833 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1PPERMITFE FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1PRWHEATR UNITS 1 . 00 24 . 48 0 . 00 24 .48 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 .79 0 . 00
TOTAL PERMIT 106 . 56 0 . 00 106 . 56 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- -----------
CREDIT CARD 106 . 56 MC
---------------
TOTAL RECEIPT 106 . 56
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- -- --------------
-- ------- ----------
518 WATER HEATER
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
OCUPEkTINO
Building Department
JOB ADDRESS: PETMI #
10903 Canyon Vista Dr.
OWNER'S NAME: Shahvar, Sandra PHONE # 408446-0196
GENERAL CONTRACTOR: JustWater Heaters FAX # 510-783-6360
I am not using any subcontractors: 9-am- 11/25/08
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
• D-xk � �4c"NtO-QJc-A�-3 11/25/08
Owner/Contractor Signature Date
\ 10/28/03
o ell, 0 C)
•
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 10903 Canyon Vista Dr. Date: November 25, 2008
Owner's Name:---Shahvar Sandra
Phone No (408)446-0196
APN#: 356-28-007, 0 C�' Project Valuation .S 833.00
Building Permit Info: Bldg__ Elect Plumb----X-- Mech
Job Description
Replace 40 gal water heater
Contractor Information
Company: just Water Heaters Inc. Phone: (510)293-2012
• Contact Name: Dulce - Fax: (510)293-2022
Address:3400 Investment Blvd E-mail: permits®justwaterheaters.net
City,State and Zip: Hayward,CA. 94545
State Contractor's License# 591329 Exp. Date: 3/31/10
Worker's Comp#: C45096282 Carrier: ACE Exp.Date: 4/1/09
Credit Card Information
Credit Card #: INEW
Name on Card: Just Water Heaters Inc.
Expiration Date: 6/11
Visa MasterCard
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