04020120^CITY OF CUPERTINO
COR[�,CTflit INS.
BUILDING DIVISION PERMIT
ern;
BUILDING ADDRESS:
I EM A 17
JUST WATER HEATERS INC
PERMIT N0.04020120
NER'S NAME:
PERMIT ISSUE DATE
ONE:
SANITARY O OL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
ij LICENSED CONTRACTOR'S DECLARATION
Description
F 1 hcuby affirm he, 1 and licensed under provisions of Chapter 9 (commencing
.Job
with Section7(XXE.f Division 3 at On Busineaaand Professimu Code,ud my license is
w
K4
in
z Kcleasndefrect Llc.x
REPLACE WATER HEATER FINALEO
Dem Contractor
(4 0 GAL GAS)
ARCHITECTS DECLARATION
I understand my shell be used as recor&
MAR 0 4 2004
plus public
Licensed Professional
DECLARATION
Oat
I am BUILDER
1 .(Sero I License Law for me
from the Gonion
BUILDING
I.S.exempt
Ca
O following mnson. (Bordon 813 LBusiness and Profession Cade: Any tiny Of County
maxo on
I which requires a to improve, de nte
Sber. impmw, demolish, ri mash any awment
issuance. aim d res dwt
mquime tiro applicant for Coh pormin micense rile a Law (Chapter
�, pdonn its enseppursuant nfthe aLirense law(C
Othat is
pSectiottOthe
Sq. Ft. Floor Area
Valuatia
ecmmod
mmM)ofDiviou
Code)
Division of me Busincu and Professions Curio) or
the Business
$ Out he is exempt Section TOM) the
That he if exempt therefrom antl the buts for the alleged esemption. Any violation of
975
APN Number
Occupancy �'Pe
Section 70315 by any applicant for a permR subjects the applicant to a civil penalty of
.at mora than five hundred dollars ($500).
P Y
❑ p peeconemycmntended with wages as uncomic
1, as w,ner ofth, property,
32615019.00
will 044,Bu0on,
forsalt(Sec.]614, BnerOf
sheibitions
work, ands:
Required Inspections
Prohdo
4w dose not apply lf owner of
oCmiunotintendedarawit
and Professions Cade: The Contractor's License,and
property who who does such work rt his
Ids or ed
OawaNucor,endwho
Own met such improwmuts tie orofffedIlwugh
s. or offered
however, me building ane you or completion, theowner
.a year f c me anvmoL
builder me building or den
did
builder will have the burden of proving thm he did non Wild or Improve for purpose of
of proving that
utoJ.
❑ 1, as Owner of the prope ty, am exclusively contracting with licensed commerce; to
construct due project (Sec. 7014, Business and Pretnsiam Code:) The Comawtor's U.
cone Law don not apply in an owner of property who builds or improves thereon, and
who contracU for such projoem wish a contractor(s) licensed pursuant to me Contracbra
License Law.
Iamexemptunder Sew .Bk PCfarthismuon
nor Data
WORKER'S COMPENSATION DECLARATION
I hereby a m under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate Of Consent t0 self -minus for Workers Compere
cation, ss provided for by Section 3]00 of the labor Code, fm to per(otmeuc of the
work for which this permit is issued.
❑ 1 have arta will maintain Worker's Compensation Insurance, u required by Section
3100 of the labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance camim and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section reed no Wwroputcd if the Pcrmin Is formic hundred dollsn ($100)
or less.)
I cenlfy that in the perfermucc of the work for which this Permit is issued. l shall not
employ any person in any meamerso as to become subject o the Workers' Compensation
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If, after making this Conilicate of Exemption. you should
become subject M the Workers CamPeesanion provisions of she Leber Cow. you must
forthwith comply with uch provisions or this Permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
1 herbyhi that mere is a construction leading agency fm me performance of
me work cur which Nis permit is issued (Soc. 7091,Giv. Cd
nder'. Nam e
U
� Lender's Address
D 1 certify that I have read this application and form that the shove Information is
confect. l agree no comply with all city and county ordinances and sate bws misting to
building conswction. and hemhy authmix, mp esurnmocs of rots city to enter upon the
U shovomentimed property for inspection proposes.
y (We, agree to save, indemnify and keep harmless On City of Cupertino against
O liabilities, judgments. casts and expenses which may In any way scene against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
Signuum of ApplieaHA2A DO Dow
HAZARDOUSMATERIALS
tsumaDISCLOSURE
Will the applicant or future building occupant stare or handle h motorial
eallous
Muni
defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and safety
rode, Section 25532(a)?
All roofs shall be inspected to any roofing material being installed.
❑sen r] No
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
.not ha'rardmo air conmminanuf u deemed by me Bay Area Air Quality Management
all new materials for inspection.
Dishier?
❑Yes [I No
I have mad me hauNnus materials requirements under Chapter 6,95 ofthe Califor-
niaHulmhSafcnyCodc,Sccdow25505,25533ud25534.lundcrsundmuif0m building
docs not cunently how a annual. man It is my respmasibility to notify Use, occupant of the,
mquiremcnor whim must Ina met prior or issuance ora Cmtincatc or Occupancy.
Signature Of Applicant Date
All roof coverings to be Class "B" or better
Owner or authorized agent Dam
•
4
City of Cupertino Building Permit Application
E -Mail
oc /l2/061
Jobsite Address: 22392 Salem Ave. #3 Date: Z= -
Owner's Name: ---Bacon Jay
Phone No.(408)996-1555
APN#: 326-15-019 Project Valuation: $ 975.00
Building Permit Info: Bldg _--------- Elect----------- Plumb ------>L---- Mech -----------
Job Description
Replace 40 gal gas water heater
Contractor Information
Company: just Water Heaters Inc.
Contact Name: Dulce
Address: 1764 National Ave.
City, State and Zip: Hayward, CA. 94545
Phone: (510)293-2012
Fax: (510)293-2022
E-mail: permits@justwaterheaters.net
State Contractor's License # 591 329
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 Z
Name on Card: just Water Heaters Inc.
Expiration Date: 9/05 l�
Visa ❑
MasterCard X
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