04080226 (2) ct Bubo c DIVISION
PERMIT PERMIT CONTRACT®R INF.ORMATIO„kN
BU ILDING ADDRESS: JUST WATER HEATERS INC PE ""04080226
OWNER'S NAME: PERMIT nUE DATE
T
ONE:
SANITARY 0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELER PLUMB MECH
0 0 0 0
=ore LICENSEDCONTRACTOR'S DECLARATION Job Description
y C 1 M1cmby alErm Nal 1 am licensed under previsions of Chapmr Y(commencing
'U. with gemian]OW)of Division Sof Inc Business and Profrssium Code.and myli<cnx is
r.„_ inrouoreeand err t' REPLACE WATER HEATER
t"�— Daten¢Clau Contractor
” g ARCHITECT'S DECLARATION (8 0 GAL GAS)
z 1 undersand my plans&hall M1c used u public records
JyU
u. Licensed Pmfcuional
OWNER-BUILDER DECLARATION
p5 hereby affirm Not 1 rem exempt fmm me Conuamao e:Any c Law for the
O follwhich re mast..perm(Sectit
t 7031.5.e.afttess and Proeve,do of Code:Any city sir county
m which ris, a permit m construct.iloa Impmvc,dcstch ermits m e pair and avudute
i< primtoslicc adpursantto nc the aishos o(om Contractors
ontrarmiuomas Law(COcd apoe,9
thatheit pursuant to Inc of Divisionf d¢Canuines and Professions
(C Code)or Sq.Ft. Floor Area ValuatdOk1800
(commencing t Section IDnd basisofrnfthccgeincuamd Professi vi Cmk)of 4U
Wt k u exempt therefrom and Ik basis for the ilkgcd eumpuon.Any violation of
Section 7031.5 by any applicant for a permit sobjccu me applicant o a civil penalty of APN Number Occupancy Type
not mom man five hundred delta.($500).
031626096 . 00
1,ss owner of the pmpeny,or my employe&with wags u their sole campcnadon,
will do the work and the avuaum is notineendedor offered for sale(Sec.7044,Business
and Pmfessiom Code:rhe Comment'Liceve Law does not apply m an owner of Required Inspections
property who builds or improwes thereon,and who does such work himself or through his
own employees.provided that such improvements art not intended morremel for We.IL
hawevm.the building or impmvemcnt is sold within one year of complcu..me&toter.
builder will have the burden of proving that he did not build or improve for purpose of Ak
sale.).
Q I,as owner of the property,am exclusively contracting with licensed convectors to /
construct the project(Sea 70.q Business and Professions Code:)The Contractor's U.
mme Taw docs not apply to an owner of property who builds or improves memo,too /
who contracts for such projecac with a contractor(s)licensed pursuant m me Convactori
Li 1Law.
❑lam exempt now gee .B&PC for this reawn
Owner Date O( /
WORKERS COMPENSATION DECLARATION 7
1 hereby anion under penalty of perjury one of the following declarations:
I haw and will maintain a CenOTam of conaem to seH.insum for Wtrimes Cumpem
cation,az provided for by Section 37M of the labor Code.for ft performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,m required by Section
377 of the labor Code,for the pcRormance of the work for which this permit is issued.
My Warkcfs Compensadon Insurance amu and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sectio need not hecomplaed if the permit is for one hundred dollars($10(t)
or less.)
1 certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any maencrso as to become subject to the Wmkcri Compensation
LawsCalifornia.Date
Applicant
NOTICE TO APPLICANT:IL atom making this Certificate of Exemption,d,y should
become subject w it Worker's Compensation this previsions or me deemed
Code,you mus
., Z forthwith comply with such provisions or this Permit be deemed rtmkcJ.
ZO CONSTRUCTION LENDING AGENCY
�-. I hereby affirm mat there is a construction lending aprey for the performance of
Q: the work(sir which this permit is issued ISec.3091,Ci¢Cl
dLender's Namc
= Z lenders Address
U O I certify that I have mad this application and sure that the above information is
LL f^ correct.I agree to comply with all city and county ordinances and sate laws relating to
0 building construction.and hereby summon,mpmunatint of this city to enter upon the
move'memioned rummy for iruPcnion purposes.
(We)agree to save,indemnify and keep hm rdess the City of Cupertino against
F” 1n liabilities,judgments.costs and expenses which may in any way accrue against saidCity
U Z in conuqucncc of the granting of this permit. -
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
HAZARDOUS
gignamrc of ADDlicaHDam
lTAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Inc applicant or future building occupant store or handle hvardous maadil
Cdcrned by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
C.
dc,Sccdon Dyes 25532(.) 0 N
? All roofs shall be inspected prior to any roofing material being installed.
10,
Win the applicant or future building Occupant use equipment or&vice&which If a roof is installed without first obtaining an inspection,I agree to remove
it havaNnus air contaminants u derned by the Bay Area Air Quality Management all new materials for inspection.
istrict?
❑Yes ❑Nu
I hove mad the h.vadn.sOrom ials mqulmmenaunderChapor6.95o(the Cahfm-
ia Health&SafetyCodc,sections 25505.25533 and 25534.1 undersand that ifthe buildingoes not currently bac a imam,thm it is my respomibility to notify the occupant of the
quiremenawhichmuateemetpoortoissuanceofaCen;rcamofoccupancy. Signature of Applicant Date
wner or amhmirN agent Date All roof coverings to be Class"B" or better
Community Development
10300 Torre Avenue
a� O
Cupertino CA 95014
Telephone(408)777-3228
F Fax(408)777-3333
SCUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
10110 N. De Anza Blvd. o o,o Z Z.�
OWNER'S NAME: St. Jose hes of Cupertino PHONE # 408-252-7653
GENERAL CONTRACTOR: Just Water Heaters FAX # 510-783-6360
I am not using any subcontractors: 0.0� �4 8/25/04
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
Tile
440"+019-X� 8/25/04
Owner/Contractor Signature Date
10/28/03
0 o ? o 22,
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 10110 N. De Anza Blvd. Date: 8-2S-04
Owner's Name:---St.josephes Of Cupertino
Phone No.(408)252-7653
APN#: 316-26-096 Project Valuation: S 3,800.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----- Mech-----------
Job Description
Replace 80 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# 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. Z
Expiration Date: 9/05 o�
Visa MasterCard
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