09080095 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21336 RUMFORD DR (ONTRACTOR:JUST WATER HEATERS PERMIT NO:09080095
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(` "ER'S NAME: VILAS MADAPURMADH 3400 INVESTMENT BLVD DATE ISSUED:08/11/2009
(�,:VER'S PHONE: 4085170748 ILAYWARD,CA 94545 PHONE NO:(510)293-9901
❑ LICENSED CONTRACTOR'S DECLARATION [WILDING PERMIT INFO: BLDG ELECT r— PLUMB
License Class __ Lic.# MECH F RESIDENTIAL r- COMMERCIAL
Contractor Date
,i OB DESCRIPTION:REPLACE 40 GAL WATER HEATER
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the Sq,Ft Floor Area: Valuation:$775
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by CPN Number:32641016.00 Occupancy Type:
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Date:
granting cf this permit. Additionally,the applicant understands and will comply Issued by:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18
C cure _Date-- RE-ROOFS:
(� All roofs shall be inspected prior to any roofing material being installed. If a roof is
❑ OWNER BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
I hereby affirm that I am exempt from the Contractor's License Law for one of
Signature of Applicant: Date:
the following two reasons:
1,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, ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE
I hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements under Chapter 6.95 of the
declarations: California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain a Certificate of Consent to self-insure for Worker's compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should 1 store or handle hazardous material.
performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
I have and will maintain Worker's Compensation Insurance,as provided for by maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Section 3700 of the Labor Code,for the performance of the work for which this Health&Safety Code,Sections 25505,25533,and 25534.
permit is issued.
I certify that in the performance of the work for which this permit is issued,1 shall Owner or authorized agent:
Date:
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must CONSTRUCTION LENDING AGENCY
forthwith comply with such provisions or this permit shall be deemed revoked. I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued(Sec.3097.Civ C.)
APPLICANT CERTIFICATION Lender's Name
1 certify(hat 1 have read this application and state that the above information is Lender's Address
correct. 1 agree to comply.with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
''w above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
I is ,mfv and keep harmless the City of Cupertino against liabilities,judgments, I understand m plans shall be used as public records.
1 costs,and expenses which may accrue against said City in consequence of the Y
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18,
ISignature Date
wog D 9 5
City of Cupertino Building Permit A lication
E-Mail
Jobsite Address: 21336 Rumford Dr. Date: August 7, 2009
Owner's Name:---Vilas Madapurmadh
Phone No (408)517-0748
APN#: 326-41-016 r C7 _:�' Project Valuation S 775.00
Building Permit Info: Bldg—_—_ Elect----_-- Plumb---JC-- Mech___�
fob 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/l/09
Credit Card Information
Credit Card #: 5474-6390-0047-8660
Name on Card: ,Just Water Heaters Inc.
Expiration Date: 6/11
Visa El MasterCard
Comments
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CI AA'' Fax(408)777-3333
CUPEKTINO RQST BOB-JIM 408 219 2935_
Building Department
JOB ADDRESS: PERMIT #
21336 Rumford Dr. (� -1 o� 0 0 9 7�>
OWNER'S NAME: Vilas Mada urmadh PHONE # 408-517-0748
GENERAL CONTRACTOR just Water Heaters FAX # 510-783-6360
I am not using any subcontractors: V4 CLX� 08/07/09
S ggnature Date
Please check applicable subcontractors and com Tete the followin information:
SUBCONTRACTOR BUSI SIESS 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
K 4' c c - 08/07/09
Owner/Contractor Signature Date
10/28/03