04020024 CITY OF CUPERTINO �-
BUILDING DIVISION PERMIT CONTRAGTnR INFORMATION ;i,
BUILDING ADDRESS: PERMIT NO,
JUST WATER HEATERS INC 04020024
s OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY N OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
OGG LICENSED CONTRACTOR'S DECLARATION
=� I hereby affirm that 1 am limned under pmvisimix M Chapter 9(commencing lob Description
with Section 7")of Division 3 ofthe Busineasand Professions Code.and my license is �IEMS 0
YS0 ���a
r „ in muromeamerr REPLACE WATER HEATER N�lfi
j z License Class-
cs Do. Crosscut (4 0 GALLON
44 ARCHITECTS DECLARATION FEB 2 4 2004
�i k< I understand my plxns shall W used as public round,
sil:o
o l.iccnud Pnsfczsional
3 OWNER-BUILDER DECLARATION BUILDING a 1 hcmhy affirm on 11. exempt from Nc Contractors :Any c law for the g� W °tl Atl
i p O following..on.(Section](131.5,Business and improve.
Professions Cod,:Any city or county
$ which u.Ups a permit o mnsuucl,altar.improve,h purniit 1 nr tapir any structure
f?i pnotoitscensed walwntto RM lrovishivartt for Sucf he Ctmusconitmiume awdsummenl
sx o that(�om incingwithSection7lh)ofDivisionorthe usincsnwcnslaw(Chapmr9 Sq.FL Floor Area Valuati�D941
rcF (commencing will Section 7")of Division)of the Business and Professions Cnac)Or
i $ that he is exempt therefrom and She basis for fee alleged exemption.Any violation or
Section 7031.5 by any applicant for a permit subjects the applicant o Acivil penalty of APN Number Occupancy Type
not mom than five hundred d011srn(5500).
❑I,as Owner of Ibe property,or my amploycu with wages as Inch sore compensation. 36221041 . 00
will do the work and the structure is not intended or offered for sal.(Sec.7066,Business
and Professions Code:The Contractor's License Law docs not apply o an owner of Required Inspections
property who builds or improves Nemon.and who does such work himself or through his
own employees,provided Wisuch improvements art notintended or offered for Sae.If.
however,the building or improvement is sold within one yur of eompl.d.m.be owner-
builder will have the hurden of proving Nn he did not build or improve for purpose of
salt.).
❑h as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7064.Business and Professions Cade:)The Common's Li-
mns,raw dos not apply m in Owner of property who builds or improves themem.and,
who contracts for such projects with a contractors)licensed pursuant to he Convector's
License law.
❑I am exempt under SeO .B&P C for this msson
Ownu Dale
1'37" WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury,one of the following declarations:
1 haw and will maintain a Cartihmm of Conant o self-insum for Worker's Comp ot-
00
ion,as provided for by Section 37W of the Labor Code.for the adores nx,of She
rk for which this Permit is issued.
I have and will maintain Worker's Compensation bounnu,as required by Section
of Ne labor Code,for due performance of the work for which this permit is issued.
y Workers Compensation losurana canner and Policy number M:
rrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS' .
COMPENSATION INSURANCE
(Thu section need notbecanpleted if the permit is forone hundred dellarxDI0B
or leu.)
I unify Nat in Ne perfo crane.Of the work for which Nis Permit is issued,I shall not
employ any person in any Mo mer u as o become subject to the Workers Compensation
Laws Of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Cenifieam of Exemption,you should
become subject to Ne Worker's Compensation previsions of the labor Code,you must
Z fookwith compo,with such lintsbuns or this permllshot]v deemed revoked.
Z O� CONSTRUCTION LENDING AGENCY t ,v- - • D s��
I.,which
b Nat there issued(Sec.3M.Cis,agctry for Nc arwnmee of /({%'AV/'I,"n_il_.
<Y
the wurk fur which but permit is issued(Sec.)119].Civ.C.)
W Q Lcndcr's Name
:D Lenders Address
V O 1 unify Nal 1 have read his application and sum Net Ne sinew information is
gg F coned.I agree m comply with all city and county ordinances and vete laws relating to
O V building construction.and hereby authone representatives of this city to enter upon the
r [k7 shout-mentioned property for inspection purposes.
(-+ G (We)agree to eve,indemnify and keep harmless Ih,City of Cupenino aUiml
f/1 liabilitiu,judgments,costs and expenses which may in any way access,against mid City
f
U Z APPLICANT UNDERSTANDS AIND WILL COMPLY WITH ALL NON.POINT Issued by:9102� Date
SOURCE REGULATIONS,
Re-roofs
HAZARDOUS
Signature of ADDlicaDam
HAZARDOUS MATERIAfS DISCLOSURE Type of Roof
Will be applicant Or(mum Wal Code.
Chapter
store o handle Health and Safety nal
az defined by Nc Cupenino Municipal Codc.Chapmr 9.12,and the Health and Safety ,
ode.Section 2592(x)?
❑Yes ON. All roofs shall be inspected prior to any roofing material being 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
mit haranbus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Itudees
istrict?
❑Yea ❑No
I haw read the hmaNmm materials requirements under Chafer 6.95 of the Califor-
ia rMalm&Safely Codc,Sun..25505,25533 and 25536.1 undersand Nat if the Wilding
not currently haw a¢nano that it is my responsibility to notify the Occupant of the
quiremenm which must be met poor m issrale.(a Certifcam of Oocupancy. Signature Of Applicant Date
wner or anthonvca agent Date All roof coverings to be Class"B"or better
1 J � oa csOa�
t
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 1092 Derbyshire Dr. Date: 1-22-04
Owner's Name:---Wang John
Phone No.(408)446-4570
APN#: 362-21-041 Project Valuation: S 941.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----- Mech-----------
Job Description
Replace 40 gallon 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# 591 329 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
Name on Card: just Water Heaters Inc. 4_4
Expiration Date: 9/05
Visa MasterCard
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