04020127 CITY OF CUPERTINO 'k +- �' "N3 `"' "° `•' r
BUILDING DIVISION PERMIT "CdC 'nR,,
BUILDING ADDRESS: JUST WATER HEATERS INC PERMITND04020127
OWNER'S NAME: PERMIT ISSUE DA'Z'E
ONE: SANITARY NO. CON7ROLN0.
ARCHITELTIENGINEER: BUIIDINO PERMIT INFO
BLDGEt.P-Cr PLUMB MECH
p 0 0
+fop LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisiau of chapmr 9(commencing lob Description
Ith Seedon 71)(10)a(Dlvialon 3 of me Busircs,mot I'meaion Code,and my Menne is 'y
in full fora and effect.
'z License Class see.« REPLACF� WATER. HEATER
�' Da Contractor (4 0 G AS)
4$t�
ARCHITECTS DECORATION
I understand my plan shall bo used as public rtrnNa
06" u
5 Licensed Professional
OWNER-BUILDER DECLARATION
f I hereby affirm that 1 am exempt from the Contractors License Law for the
00 following mama.(Session 7031.5.Business and Professions Cade:My city or aunty
$ which requlros a Permit in cAWAM,alter.Wpm".demolish,m repair my muctum
H S° prior in its Issuance.also mqutres the applicant for such permit to rile asigned moment
�< Net he is llccmed pursuant to the provisions of Ne Contractor's License Law(Chapter 9 Sq.FLFloor Area \ Valuati OF1750
G (commencing with Section 7001))of Division 3 of the Business and Profession Code)or -� \ 4
$ that he Is exempt memfrom and the bub for the alleged co mp ton.Any violation of t
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number O cupancy Type
not more Nan five hundred dollen($500).
❑I.as owner of the property,or my employees with w{es as their sets exmpsnation, 36939026 . 00
will do mo work,and du structure Is not Intended or offered for safe(Sec.7044,Budneu
and Profestiaa Code Tha CantrmmM1 License Law dace nes apply m m owner of Required Inspections
propeny who buildsm imlwnvemereon.and wbodoessnch work Mention Waugh his
new employees.provided that such Improvemmu an,not Intended moffered for sate.IL
however.the building or Improvement ismid within one year of compkdon,the owm-
builder Ull ban the burden of ponder,that he did nm Wild As improve for puryose of
cele.).
1,as owner of the pmpeny,are exclusively contracting with licensed contra sees an
construct the project(Sec.7044,Business and Professions Code:)The Contractors U. '
cease law don not apply m an owner of progeny who builds or improve Murton.and
who contracts for such projects with a contractor(s)licensed pursuant in this Conmcmes
Llcerrm law.
0 Iamesemptumer See ,BAPCfndd3.
owner Date
WORKER'S COMPPNSA71ON DECLARATION
I hereby afOm under penalty of perjury one of the following declanRon:
I have and will maintain a Certificate of Cement m self-luum fer Workless ComPen-
737M
ies.u povided for by Section 3700 of tise Labor Code.for the perfamame of the
ok for which this permit is Issued.
1 haw and will maintain Worker's Compensation Laurance,u mquirtd by Section
of the Labor Code,for me performance of ties work for which this pemil is issued.
y Workeri Compensation Insurance carrier and Policy number are:
rtier. Polley Na:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
fnds section sound Act becompleud trthe Permit is two=hundreddollars($100)
or less.)
1 anify that in the Performance of who work for which this permit is land,I shall net
employ any Peron in my mmnerm as to become subject m who Workai Cempens Don
laws of catifamla.Dau
Applicant
NOTICE TO APPLICANT.If,after making Ibis Certificate of Exemption.you should
become subject an the Workers Compensation provision of me Labor Code,you muse
.OzfoMwith comply with such provision orthis Permit mill hadeemed mvoked.
O x
z CONSfRUC ION LENDING AGENCY
1-v I hereby a Rim that mem is a connection lending agency for the perfumsnce of
Ir> the work for which this permit Is issued(See.3097,Civ.C.)
W QLanders None
{Y Landers Addrese
Mz
U 0 1 certify that I ban mid this application and rete that the show InformNon is
U.P corer 1 agms m comply with all city and county on irwres and sum law mlsdng to
0 U building construction,and hereby aumodm representatives of this city a ether open the
W above-menWned Property for Inspection purposes.
tl (We)agree saw.indemnify and kap harmless the City of Cupertino a taint
py
liabilities.judgments,cats and expenses which may in my Wayaamu against said City
U 7 In conagance of the grueling of this permit.
r7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REQULATIONS.
Re-roofs
Signature ofAppllcaHAZAR non Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the apCtmer or foam building occupant r 9th or handle Heallon acaudal
a derined by me Cupertino Municipal Code.Chanter 9.11.and the Health and Safety
Idoes
che.sectron 25533()7 All roofs shall be inspected nor to an roofing material beim Installed.
❑Yea ❑No P P Y g g
Will the applicant or future building occupant use equlpment u devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hamdous air conuminmts u dcfad by the Bay Arse Air Quality Mangemcm all new materials for inspection.
suiclT
❑Yes ❑No
I haw mad W haurdrns materials nquimmenu under Chapter 6.93 ofthe Califor.
Health k SafctyCode,Section 25505,35533 and 25334.1 understand that if me building
not cumntiy haw a MAUL Nat It b my responWlity m notify me occupant of the
uiremcnu which most W:met prior u issuance aft ecrGBcae of Occupancy. Signature Of Applicant Date
nerar.amadudagpn, ry,te All roof coverings to be Class"B"or better
D/ 2-7
• City of Cupertino Building Permit Application
E-Mail
Jobsite Address: 10526 Whitney Way Date: 1-3,04'
Owner's Name:---Orton Sheldon
Phone No.(408)446-3407
APN#: 369-39-026 Project Valuation: S 750.00
Building Permit Info: Bldg—----_— Elect—____— Plumb------1L—__ 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(Pjustwaterheaters.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
Name on Card: just Water Heaters Inc. �,�, Z
Expiration Date: 9/05b �(
Visa MasterCard
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