07060269 CITY OF CUPERTINO T
BUILDING DIVISION PERMIT
PERMIT NO.
Bu1LD1NG.ADA(xE VIA CAMINO CT JUST WATER HEATERS INC 07060269
L G l ZS 4 V PERMIT ISSUE DATE
OWNER'S NAME:
BERRY HAROLD E AND BEVERLY M 3400 INJESTMENT BLVD 06/29/2007
SANITARY NO. CONTROL NO.
NE: (510) 293-9901
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
0 0
p o LICENSED CONTRACTOR'S DECLARATION Job Description
v
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
zUJ with Section 70(if))ofDivision3oftheBusinessandProfessions Code,andmylicenseis REPLACE 50 GAL. WATER HEATER.
r H in full force and effect.
t n? License Class Lic.#
p Date Contractor
a
ARCHITECTS DECLARATION
i a Q I understand my plans shall be used as public records
)a.0
a N Licensed Professional
a OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
jp O following reason.(Section 703 1.5,Business and Professions Code:Any city or county
m which requires a permit to construct,alter,improve,demolish,or repair any structure
N prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
?a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $1584
4 l`_$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 32646009 . Number Occupancy Type
not more than five hundred dollars(5500)_
❑4 as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Conuactoes License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
L]1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued
My Worker's Compensation Insurance carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars(SI00)
or less.)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Codc,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked
Z OCONSTRUCTION LENDING AGENCY
CNf) 1 hereby affirm that there is a construction lending agency for the performance of -
> the work for which this permit is issued(Sec.3097,Civ.C.)
w Q Lender's Name
0 z Lender's Address
U O I certify that I have read this application and state that theabove information is
L:+ r-+ correct.I agree to comply with all city and county ordinances and state laws relating to
O J building construction,and hereby authorize representatives of this city to enter upon the
a above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
�i liabilities,judgments,costs and expenses which may in any way accrue against said City
U 2 in consequence of the granting of this permit. Date
►4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b): _
wit
SOURCE REGULATIONS.
Re-roofs
Signature of Applicant/Contractor Dare Type of Roof
MATERIALS DISCLOSURE yP
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
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
emit hazardous air contaminants as dclined by the Bay Arca Air Quality Management all new r Iaterials for inspection.
District?
❑Yes ❑No
1 have read the hazardous materials requirements underChapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of Occupancy. Signaturc of Applicant Date
All roof coverings to be Class"B"or better
Owner or authorized agent Dale
CITY OF CUPERTINO
3 ITEMS OF 6 PERMIT' RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blh: Lot:
APN 32646009 .00
DATE ISSUED. . . . . . . : 06,'29/2007
RECEIPT #. . . . . . . . . . BS000001850
REFERENCE ID # . . . : 07060269
SITE ADDRESS . . . . . : 22:_84 VIA CAMINO CT
SUBDIVISION . . . . . . .
CITY CU'.?ERTINO
IMPACT AREA
OWNER . . . . . . . . . . . . : BERRY HAROLD E AND BEVERLY M
ADDRESS . . . . . . . . . . .
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1032
RECEIVED FROM . . . . : JUST WATER HEATER
CONTRACTOR . . . . . . . : GI:�ROY, JOHN LIC # 15128
COMPANY . . . . . . . . . . : JU3T WATER HEATERS INC
ADDRESS . . . . . . . . . . : 34 )0 INVESTMENT BLVD
CITY/STATE/ZIP . . . : HA: WARD, CA 94545
TELEPHONE . . . . . . . . : (5L0)293-9901
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BENERGY PERMIT FEE 1. 00 34 .86 0. 00 34 .86 0. 00
BPWHEATER PER HEATER 1. 00 10.79 0. 00 10.79 0. 00
PPERMITFEE FLAT RATE 1. 00 38..37 0. 00 38.37 0. 00
TOTAL PERMIT - 84 . 02 0. 00 84 . 02 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 168. 04 MC
---------------
TOTAL RECEIPT 168. 04
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- --------------------
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
0-70(o 02— q
CITY OF CUPERTINO
WATER HEATER
CUPEkTINO PERMIT APP]-JICATION FORM
APN# �z 4� --�. O C Date: I Z C1
Building Address:
Li Y 4- 0(-�- GSA m k q0 C .
OOwner's Name: ` ✓ 4A� Phone#:73 Z �SZ
Contractor: Phone: License#:
Contact: Phone Cupertino Business License#:
Building Permit Info:
Bld ❑ Elect CZL'' Plumb Mech B�
Job Description: � -F >1) 6, (4/)A �zu1'1`Tvt_
Residential 4D' Commercial ❑
Cost of Project:
Strapped $ On Platform 0' Bonded
New Location ❑ Replacement
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPE FEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
C
,14