04040121 (2) 't CITY OF CUPERTINO '
BUILDING DIVISION PERMIT CO? :.T T0WINhO'RMATION:
u
BUILDING AD DRESS: JUST N WATER HEATERS INC PERMIT N004040121
OWNER'S NAME: PERMIT ISSUE DATE
Ah SHERELL LAUDERBACH 1764 NA'T'IONAL AVE 04/20/2004
ONE: SANITARY N0. CONTROL NO.
(510) 293-9901
ARCHITECfIENGINEER: ❑I11LU1 NO PERMIT INFO
Bi.l C ELPCTa PLUMB MECH
0
uop LICENSED COWMACIUR'S DECLARATION
r 1 botchy affirm that 1 am Roomed under provisions or Chapter 9(commencing Job Desert)tl
Z tUo cath sooton701107 n[Divlslon Sol the Huai....add P,ofcsslnns Code,and any hot..is
,a„ i.fell force andcrrem. REPLACE WATER HEATER
>E2= Licatenae Glass Lie,a
Contractor. (4 0 GAL) OCT A 2004
D
!n!~pp ARCI II ILCTS DECLARATION
I p n
g y R undcalmW my plans shall he sed as public ,card, V �D ❑ V
JyU
t w y Licensed Profco conal
� OWNER-BUILDER DECLARATION
<� 1 unchy mfrm that I am exempt from the Contractors License Law lint the
0 o following reason.(Section 7031.5,Business and Professions Code:Any City or county
K m which requires a permit In construct,cher,improve,demolish,an repair any ehuomre
y remains li.nance.alsomqulresllleoppllcam forsnch,erent In lllca.ilgadrooement
that heislicunndpanmplootmpmvhsinnsnrehecomraomrsLieanaelaw(CM1npmre Sq. Fl. Floor Area Valuatic$936
It5-R (hot he I, Incarnation
ad
of basisnf3 am alleged
ommaPe.An,f Crnat,of
i�� thio M1c is em Ft thcrefmm antl We basis for the alleged cxemphiun.Any vinlwinn of
Section 7031.5 by any applicant fur a remail suhjems the apphounl to a civil lxnally of APN Number Occupancy Type
ooh are than Five hundred dollars($500).
El 1,as owner oflbe pmperty,or my employees with wages res kind,erre Communique, 35931056 . 00
will do the work,and the structure is not intended or offered for sale(Sec.701,1,Business
and Pronasions code:rhe Cameroon's License Law does not apply to an owner of Required Inspections
property who builds at improves Ounce ,and who does such work himself.,through his
own employees,provided thatruch improvements arc nut intended or offered for sale.If,
however.the building or improvement is sold within one year of completion,the owner-
holder will have the burden of proving that he did not build or improve for purpose of
auto.).
❑1,as owner of dm p.pert,am exclusively Command,with licensed Comment to
eonstmed the project(see.7014,Business and Prafessiofs Code:)The Commerce Li.
arse law docs net apply man awne,of property who bares or improves thereon,and
who ambama for such projects with.i comractor(s7 licensed pursuant to the Commetor's
License I.'w.
❑I am exempt under sec. ,B At P C far this reason
Own Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of pe jury one of the following declsom ane:
`J I have and will maintain a Certihcamof Consent In self-insure for Worker's Compeer
x don,as undal fur by Section 37W of the Labor Carlo,far the performance of IM1e
work far which this permit is issued.
❑I have and will maintain Worker's CamPensahim,Insurance,as required by Section
3700 of am labor CnlIt.for the performance of the work far which this permit is issued.
My Worker's Cam persution Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTEFICATEOFEXEMMON FROM WORKERS'
COMPENSATION INSURANCE
(This section food ooh he emoplend Ethe permit is Rinne Ia n fled dollars($IIX)
,r loss.)
1 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 became subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:II,alto,making this Ce ni force of Exemption,you should
became subject to the Worker's Co.romen en provisions of the Labor Code,you must
,J Z farthwihh comply with such provisions o,this Farm it shall he deemod revoked.
tiO
CON
ulfthe is aeneNLENDING AGENCY V
jr rte. work
rwhichithi Wmano I,
ssued( ee 30U, gency no,the perfurmmccof
7 Le work for which this permit is issued(Sec.JlyJ7,Co,Civ.CJ
C Q Lender's Name /{
z Lenders Address
V Q I comfy that 1 have road this application and suite that the above information is
Hcorrect.1 agree to comply with all city and emanty omhunces and sham laws poising to
V building construction.and hmchy anthem,expresenmtves of this city to enter upanthe
W ahovcmopromed property far inspection purposes.
>1 W (We)acme to save,indemnify and keep harmless the City of Cupcdino against
N liabilities,judgments,descrand expenses which may in anyway accrue against said Cily
V z in currappencc of the grating of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roars
Signatureof APFlicaI IAZAR clnr Dam
INZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant nr future building le Chater re or handle allouimamrim
a.tlefncJ by the Cupertino Municipal Code.Charter
He
ter 9.12,and the Health and Safety
crone,Semina zss3z(an All roofs shall be inspected prior to an roofing material bei.
❑Yea E]No P P Y S g 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
ri,hm.amaDe air r:anmminants so defend by the Be,Arca Ail Qmmlly Management all new materials for inspection.
❑Yes L]No
I have read the baaadoes asholuls re rommcnui name Chapter 6.95 of the Caliber
Hculth&Safny Coda.Scnions 255!15,25533 pod 25594.1 unticrsmnd that W o huiltling
1e�;-wmn,
es no,currently have a tenenh that it is my responsibility m army the recupant al'Ne
ploophmmwlaoh must be met prim la ismsrec of a Cenidcam mf Ocenpaney. Signature of Applicant Date
or anthml]etl r,C[ Date All roof coverings to be Class "B” or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
:UPEkTINO
Building Department
JOB ADDRESS: PERMIT # 6-Z� `5- v 2--/1132 Kentwood Ave.
OWNER'S NAME: Lauderbach, Sherell PHONE # 408-657-4900
GENERAL CONTRACTOR: Just Water Heaters FAX # 510-783-6360
I am not using any subcontractors: " � � ^ 4/19/04
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
U.�ro- 440'^+ ^ 4/19/04
Owner/Contractor Signature Date
10/28/03
1
city of Cupertino Buildi.nq Permit Application
F
il
ddress: 1132 Kentwood Ave. Date: 4-19-04
Name:---Lauderbach,Sherell
Phone No.(408)657-4900
APN#: 359-31-056 Project Valuation: $ 936.00
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: 1764 National Ave. E-mail: permits@justwaterheaters.net
City,State and Zip: Hayward, CA. 94545
State Contractor's License# 591329 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 �S 2
Name on Card: just Water Heaters Inc.
Expiration Date: 9/0500
Visa MasterCard
Comments