05120060 CITY OF CUPERTINO •'•`� as {
BUILDING DIVISION PERMIT C,ONTRACTVRANF,ORNUT ONES
BUILDINGAODRESS: JUST WATER HEATERS INC FERMI INO.05120060
•10580 WHITE
OWNER'S NAME: PEM9T ISSUE DATE
FANG WU 3400 INVESTMENT 12 /13 /2005
NE:
SANITARY NO. CONTROL NO.
(510) 293-9901
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
' BLDG ELECT PLUMB MECH
0 0 0 0
i
00 LICENSED CONTRACTOR'S DECLARATION
lu C I hereby"em that 1 am licensed under pmvWora of Chapter 9(cammcheing Job Description
til with SectioncDiviven]of the BuvnesrW Profrssiuru Code.and my liceneu
rt
sPN in full foe arid ndcfferect. REPLACE WATER HEATER '
Dam Clan Contractor
k,
Dam TSDECr 40 GAL GAS
ARCHITECTS DECLARATION
I in I unwrwnJ my plats sMll W used u public rtrnNs /��
)yu ✓
c LLo Lictnued Pmfesswnal - 1
5 OWNER-BUILDER DECLARATION
Conte ON
<� 1 Wmhy,alTirm that I am exempt from the Contractors License Law for the [OO(a
D o following mann.(section 70]IS,Business and Profession Code:Any city or county
which requires a Permit to eonsmcL alar,improv,demolish.or mpsu my suumure
prior to its issuance.Mae requires the applicant for Rich permit to file a signed sutcment Slz ggg
Nat he is licensed pursuant to the provisions of the Contractors License faw(Chapter9 Sq.Ft.Floor Area zla'giib 99
e�c (commencing with ScctionlOW)ofDivisionJofthe Businm and Prafrssi.m Cawl err Q'g
iib
9$ drat he is exempt therefrom and ths,buffs for the alleged assumption.My violation of !9 l Q�
Section 7031.5 by any APPOant for a permit subjects the applicant a a civil penalty ofane pj�N Number Occu e
ria mom that fw hundred d.11.($5M). 35905122 . 00 p yTyp
0 1,as owner of the property,or my Employees with wager u their sole compwation.
will do the work and the structure u not intended or offered for aside(Sec.7W4,Busircss
and Professions Cade:The Contractors License law dna an,apply to an owner of Required Inspections
property who Wilds or improves themon,and who does such work himself or through his
own employees.Provided that such improvements are net intended aoRend for sale IL
however.the Wilding or improvemml'u sold with.az year of mmpledon,the owner-
builder win]have the Widen of proving that W did wl Wild or improv for purpose of
sale.).
0 1,A owner of the pmpcny am mclmiwly contracting with Banded cenvantom to
construct the pmjen(Sec.70x4,Business and Professions Code:)Tim Co desctors U.
come law don not apply to an owner of property who Wilda or improves thereon,and
who contracts for such projects with a canuaersR.)licenced pursam to the Continence,
Licence law.
0I am ucmpt under See ,B&PC for this reason
Owner Due
WORKERS COMPENSATIONDEC RATION
1 hereby t1Etm under penalty of perjury rine of the following melmuion e
I haw and will maintain•Certificate fC...,to self-insure fa Warkefs Courtlier.
7C17)'M
in,as provided fa by Semaa]700 of ere War Code.fa the p�Aon .of tW
rk for which this permit is issued.
1 have and will maintain Workers Compensation Imuran¢,u required by section
of the lobo Code,fm the peRormance of the work fur which this permit u issued.Workers Compensation Insurance carrier and Policy number art:
rtier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section wed nothecomp cu d if the permit is forms hundred dollars(5100)
.r ICA.)
I certify that in the performer¢of the work for which this permit is issued,I shall not
..•.ploy ,anypeoan in any amerau.u to become subject,.the Wanton'Campensatium
Laws or California Dere
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
Weems subject to the Workers Compensation previsions of the labor Code,you most
.J O foMwiN comply with such previsions or this Permit that be wemed rtrvoked.
Z" CONSTRUCTION LENDING AGENCY
(-v Ihereby affrnat that there is a construction lending agency for the performance of
Cli the work for which this Permit Is issued(Sec.3097,Civ.C.)
C0 lanwrf Name
=z Lenders Adder..
U Q I certify that 1 haw read this application and sate that Ne aWw informathon is
L eo.eel.I agree to empty with all city and county ordimartcad and sine laws minting to
0 Wilding coosmction,and hereby authanre representatives or this city to enter upon the
rte aWwtmcnuawdpropertysc for inspection whichimansima
(We)agree to Ave,indemnify add keep humless the City of Cupertino agaimt
tU
tel in
oxpcmu which may In ery wyamue agmnstamd City
(„)z A PLICArnce of thegranting of thisD WIL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Signature of Appliraanter Date Re-roofs
HA,AR
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the a Cuant or future Wilding aceuperl store handleorhandlehanmate
rEans rial
u defined by the Cupertino Municipal Code.Chapter 9.13,and!the Hdth and Safety
codARLe,sem❑Yes ❑Noen zss]z(o)? All roofs shall be inspected prior to any roofing material being installed.
11 Will tW applicant or More Wilding occupant use equipment a dcvisv which If a roof is installed without first obtaining an inspection,I agree to remove
mit hvaN.us air conuminanu a inclined by the Bay Ana Air Quality Management all new materials for inspection.
District?
OYm ON.
I haw mail the by rdtassmatorials mquiremens underchaptcr6.95 of tW("Airory
On Health&Sarety Cow.Secuom35505,255]]and 255]4.1 undcrswd thaifdrc Wilding
docs tot conemthy have a tenerl that it is my responsibility m ttoufy the occupant of the
requiremcmu whim must W met Our tocanonicals cerurmte or Occupancy. Signature of Applicant Date
Owner ammarindagent Date All roof coverings to be Class"B"or better
10F
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408) 777-3333
ICUPEkTINO
Building Department
JOB ADDRESS: PERMIT#
7626 Hollanderry Pl. O Z, cruS��
OWNER'S NAME: Janszen, Norm PHONE# 408-314-7374
GENERAL CONTRACTOR: Just Water FAX# 510-783-6360
Heaters
I am not using any subcontractors: �� � 12/12/05
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
12/12/05
10/28/03
vJ� 2 �o
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 7626 Hollanderry PI. Date: 12-12-05
Owner's Name:---Janszen Norm
Phone No.(408)314-7374
APN# 362-29-003 Project Valuation: S 993.00
Building Permit Info: Bldg___ Elect___—_ Plumb__x__ Mech_—_
Job Description
Replace 40 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: permitdept®sbcglobal.net
City,State and Zip: Hayward,CA. 94545
State Contractor's License# 591329 Exp. Date: 3/31/06
Worker's Comp#: 1626288-05 Carrier:State Compensation Insurance Fund Exp.Date: 4/l/06
Credit Card Information
Credit Card #: 5474-6390-0047-8660 /
Name on Card: Just Water Heaters Inc. #
Expiration Date: 06/08
Visa MasterCard
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