04020129 CITY OF CUPERTINO a — s � '
BUILDING DIVISION PERMIT C0TRACTORINFO fATtON %
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT N004020129
OWNER'S NAME: HIMAITISSUBDAT9
RRSSAN MQPT4TAnRR 1764 ISTATIONA1 ANTE !2 11 !7 1200 A
ONE: SANITARY NO. CONTROL NO.
I� Ltcemsc
CHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p 0 0 0 0
LICENSED CONTRdunderSDECons of CON Job Descri tion
1 hereby affirm lhm 1 un licensed i nMr provisions of sCode, 9(commencing Phllmtian90flo)ofDivisian3of Ute Business antl Plafessions Code,and mylicenm is
ull for aontleffectq� aass Com REPLACE WATER HEATER
Date Commoner
DEC (4 0 GAL GAS) j
gg� ARCHITis, An DECLARATION
1 understand my plana shall be used as puhlic rtcnrdr
3
Licensed Ploom,so,aal
5 OWNER-BUILDER DECLARATION
I hereby
.sola Ihm I . exempt flan the Contractor's Licence taw for lbe Q,
i p D following mason.(Sutton 7(131.5.Budntaa and Pmfccxion¢Code:Any city ter county
3:$ which squire,a permit to mnstmd alcor,improve,demolish.or repair any swclum
Fly
He,1.its issuance.all.requima the applicant for such permit to file a signed Statement
gzcathetheislicensedPorsuanttotheprovisionsoftheContraclor''sLicenseLow(Chapter9 Sq.Ft. Floor Area Valuatio�1800
app (commencing with Section 7000)of Division 3 of NC Business and Prornminos Code)or -
my 3 ohm hem exempt therefrom and On bash for the alleged exemption.Any violation of
Section 7031.5 by any applicant fore permit subjects the applicant in a civil penalty of APN ane Number Occas
Act atom man five hundred dollars 155001. Occupancy Type
❑1.as Owner of the property,or my employees with"gas u Weir sole compensation, 31636041 . 00
will do the work,and the¢nYmure isnot intended or offered for sale(Sec.7044,Business
and Professions Cade:The Communist's License Law does not apply to an owner of Required Inspections
property who bui lds or improves themon,and who doe s s uch work him sel f ar through his
awn employees,provided that such Improvements me not Intended"offered formic.if.
however,the building or improvement is cold within one year of completion.the owner-
builder will have the burden of proving thal ha did not build or improve for purport of
salt.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
convect the project(Sec.7044.Business and Professions Code)The Connectors Li-
cmue law does not apply to an oven of property who builds ar improves themon.and
who contracts for ouch projects with a comracnr(s)licensed pumuam an the Canteemr's
License Law.
❑Ierrtaemptunder Sec. ,B&PCforthismsron
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to mIf-inure f"WarkeYCCompen-
tlun,as provided f"by Section 3700 of the labor Code,for the permornwa of the
7ME331,
rk for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section
.Ali...
of the labor Code,far the performance of mwork
e for which this permit is issued.
y Workers Compensation Insurance carrier and Policy number am:
rtier. Policy No.: _
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thhmetim need not bccompletcd lithe permit is haranc hundred dollars(SI00)
or lass)
1 certify that in the performance of the work for which this Permit is issued,I shall not
employ any person in any manner M as to become subject o the Workers'Compensation
Laws of California-Dem
Applicant
NOTICE TO APPLICANT:If,after making this Certificate or Exemption,you should
became subject 10 Ne Worker's Compensation provisions of the Labor Code,you must
. .J 0 forthwith comply with lash provisions or this permit shell be dermad rcvnketl. �— V
ZCONSTRUCTION LENDING AGENCY
555 I hereby affirm that there is a UCTIOconstruction ENDING A ENCYagency f"the perfurmmcc of
the work for which this Permit is issued(Sen:.3097,Civ,C.)
W Q Lenders Name
aZ Lenders Address
V C I certify that 1 have mad this application and tun that the above fief smmunt is
Un F correct.1 agree n comply with all city and county ordinances and sum laws totaling to
V building construction.and hereby authorise representatives of this city to enter upon the
W
above-mentioned property for inspection which ms.
G (We)agree to esus,indemnify and keep harmless the City of Cupertino against
f/J
in
judgments.of On journal;
ex tenspo which may in any way ascot against aid City
Aconsequence of me granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
Re-roofs
HAZARDOUS
Signawrc of ApplicaDen
HAZARDODO US MATERIALS DISCLOSURE Type of Roof
Will On applicant or fumrcipal ooccupantnorcor handle Health anmalarial
as dcfine0 by the Cupertino Municipal Code,Chapter 9.12,and olio Health and Safety
Code.Odors 25332(a)? � All roofs shall be inspected prior to any roofing material being installed.
tics Na
If a roof is installed without first obtaining an agree to remove inspection,I
Will the applicant or future building occupant use equipment or Devices which P
it hanodous air conmmimmu as Jcfrned by the Bay Arca Air Quality Management all new materials for Inspection.
7dm
ttrich
C]Yes ❑No
I have real the haaardous materials nequimments under Chapter 6.95 of the Califor-
Health&Safety Code,Sec6aos 25505,25533 and 25534.1 undcsamnd that if IM building
not currently have a mmol that It is my responsibility m notify the OoCamrt of me
uimmcnm which must beset prior n issuance of a CcNficam ofOccupancy. Signature of Applicant Date
ner or amhorimd agent Dan All roof coverings to be Class nBn or better
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 20101 Northwood Dr. Date: 2;304
Owner's Name:---Moghtader,Hessan
Phone No.(408)962-0999
APN#: 316-36-041 Project Valuation: S 800.00
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)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/l/04
Credit Card Information
Credit Card #: 5474-6390-0026-5679
Name on Card: just Water Heaters Inc.
Expiration Date: 9/05G�. 6�
Visa El MasterCard
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