04090269 : CITY OF CUPERTINO -, 7 '
BUILDING DIVISION PERMIT. CUlVTt2A�bRMT
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT"°04090269
• OWNER'S NAME: MRIMITLSSUEDATE
JOHN SKI
ONE: SANITARY N0. CONTROL NO.
(510) 293-9901
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
ELECT PLUMB MECH
t�
p p LICENSED CONTRACTOR'S DECLARATION
2 I hereby affirmIC that I am ONTRA ander S DECLARATION
of Chapter 9(commencing lob Description
< with Section RMB)of Division 3 of the Business and Professum,Code,and my license is
rt�<„ imm�fmommiarr REPLACE WATER HEATER NOV f7�.
,t E? License Class LM.M
t-9 Oam con DEC (4 0 GAL GAS) Bak 'C004
�MQ AR bell W Mind.,DECLARATION `/V
< I undersand my plana bell M wed ns puhlic records
3u. Licensed Pmfcuionel �w
� OWNER-BUILDER I am exempt force DECe Contractor's
ontr ON
0 1 hereby.(Sere Net 1 1. exempt the Cantracta Code:
Lieu Law for the (v`
O O following mason.(Section 71131.5,Business and Improve,
demolish,
Code:Any city.county -
y$ which requires a permit re uirewa alta Improve,demolish, file
mash any acromin :
FZa prior to its issuance.aim requires the applicant Car such permit in filcasigned suremem
that he is licensed pursuant in the prevision of the Connector's License Law(Chapter 9 Sq.FL Floor Area Valuatio,�998
$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
.. that he Is exempt therefrom and the bssis for the alleged emulator.Any violation of
Section 7031.5 by any applicant for a permit subjects due applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500).
❑1,as owner of the property,or my employees with wages as their sole compensation, 37538050 . 00
will do the work,and the structure is not intended w9Bem l for3ale(Sec.7B4a,Business
and Professions Code:The Conuacurs Limese raw does not apply as an owns,of - Required Inspections
property who buil ds or i mprovm thereon,end whit does such work himsel f or through his
own employ.,,provided Met such improvements are not intended orml emd foredo.If,
however.the building or improvement is sold within one year of completion,the owner
builder will have 0s,burden of proving that he did not build or improve for purpose of
.in.).
❑1,as owner of Ne property,am exclusively contracting with licensed convectors be
construct the project(See.7044,Business and Professions Cade:)The Contractor's Li.
comae Law does not apply to an owner of property,who Wilds or improve Noreen,and
who contracts for such projects with a antmcoons)licensed pursuant to the Convmura
License La-
0'.......p
aw.Olamexemp ,moo Sec. ,B&PCfm M1,nmsim
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penally of perjury,one of the following declarations:
1 haw and will maintain a Certificate of Consent to ulr--inaum for Warier'a Compen.
ian,m provided for by Section 3700 of the Ube,Cade,for the performance of the
73700
rk for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
lo
of the be,Code.for the performance of Ne work for which this permit is issued.
y Workers Compensation Insurance carrier and Policy number are:
rtier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu sectimt need not hecomphocal if the Permit is rumehuodred dollars(SIM)
M leas.)
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 m become subject in the Worked Compensation
Laws of California.Date
APPlicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
became subject to the Worker's Corepcnu ion provisions of the labor Code,you must _
�Q forthwith comply with such provisions or this permit shall be d .wa
deemed nked. /
z 0CONSTRUCTION LENDING AGENCY
[r4 1 herebyaliirm that there isa.®Imctinn lendin,agency rmtheperf.hromocuf
Rai the work fur which this permit is issued(Sec.3097,Civ.C.)
MW Q
Umbers Name
z Lcmiar's Address
V Q I certify that 1 have mad this application and noun that the above Information is
R. cancel.1 agree to comply with all city and county ordimnces and soon laws relating to
V Wilding convection.and hereby autitorim mpnsenotiws of this city to enter upon Ne
W above-mentioned property for inspection purposes
gy (We)agree to new,indemnify and keep harmless the City of Cupertino against
fn liabilities.judgments,cents end espcnce which may in any way same against mid City
t.j 7 in conse<ryence of Ne granting of this Permit.
�7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
Signature of AppliaDere
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant ser forum building occupant store 9.1 or handle Health a material
as de.Section
io the Cupertino Municipal Code,Chapter 9.13,and the Haiti and Sandy
Cattle.Sorties 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yc, ❑Na
/ 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
/V its hal dims air conumimnts as,defined by the Be,Arca Air Quality Management all new materials for inspection.
'� District?
❑Yes ON.
1 have mad the hvardousmarcrials requirements under Chapvr6.95 of the Califon 71�
nit Hcalth&Safety Code,Sections 15505.25533 and 25534.1 understand thardthe Wilding
does not currently hove a tenant that it is my responsibility to notify the occupant of tic
requirements which must be met prior to tuuvlce of a Ccmficam of Occupancy. Signature of Applicant !Date
Owner or auohorimd agent Date All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
/ Cupertino CA 95014
Telephone(408)777-3228
ICITY OF Fax(408)777-3333
CUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
939 S. Tantau Ave. ° / 0 Z G
OWNER'S NAME: Skinner,John PHONE # 408-446-5451
GENERAL CONTRACTOR: Just Water Heaters FAX # 510-783-6360
I am not using any subcontractors: O�'� ^^-� 9/27/04
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
• (T'i'lle 1 I,.J`� CQ- �v`-�' 9/27/04
Owner/Contractor Signature Date
10/28/03
p¢p o Z C7
l /
City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 939 S.Tantau Ave. Date: 9-27-04
Owner's Name:---Skinner,John
Phone No.(408)446-5451
APN#: 375-38-050 Project Valuation: $ 998.00
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: 1764 National Ave. E-mail: permlts®Justwaterheaters.net
City,State and Zip: Hayward,CA. 94545
State Contractor's license# 591 329 Exp. Date: 3/31/06
Worker's Comp#: 1626288-04 Carrier:State Compensation Insurance Fund Exp. Date: 4/l/05
Credit Card Information
Credit Card #: 5474-6390-0026-5679
Name on Card: Just Water Heaters Inc.
Expiration Date: 9/05 C) 2
Visa MasterCard X
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