03110103 CITY OF CUPERTINO
BUILDING DIVISION PERMPI' ,CQ NTRAGTQR INFQRMATION.
BUILDING ADDRESS: JUST WATER HEATERS INC PERMIT N103110103
OWNER'S NAME: PERMIT ISSUE DATE
CY GRANZELLA 1764 NATIONAL AVE 11/20/2003
NE: SANITARY NO, CONTROL NO.
(510) 293-9901
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLOG ELECT PLUMB MECH
I= Q � 0
100 LICENSED CONTRACTOR'S DECLARATION
u❑ I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
F�W inellf.mn]N cffe,.ivHionlof the Busincsa and Professions Cade.mdmYlicense is
in mummeanderrea. REPLACE WATER HEATER
i 5= thea Lm.e (50 GALLON GAS) '
DDalem Contractor
;H0 ty
ARCHITECTS Wuse DECLARATION
)�U 1 understand my plana shall be used as public records
u
s o Licensed Professional
q 3 OWNER BUILDER DECLARATION
2 C i I hereby..1firmseci Nnt 1 em exempt from the Cnntractm's License Law for the
O 4 which
re remna Permit
t IDM,Business and Professions Code:Any city or county
5$� which rcyuirca a pertnil m construct,alter,imprnw.JcmalksA,or repair any mmctum
prior to its issuance,also requires theepplieant for such permit to Ole a signed statement
F� that he is licensed pursuant the provisions of the Connector's License Law(Chapter 9 Sq. Ft. Floor Area ValUatl 814
Eq $ (commencing with Section 70t of Division 3 of the Business and Professions Code)or
that M is attempt thcref e.and the Iwo for the alleged exmpdon.Any violation of
Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more Nan IT.hundred dollars($500). 36947018 . 00
❑I,as owner of the property.or my employee with wages as their salecompensation,
will do the work.and the structure is not intended or offered for sale(Sec. Business Required Inspections
and Pmfcssions Code:The Connector's Littnx ns Law data not apply to an owner of q P
properly who Wilds or improve Merton,and who doessuch work himself or Nmugh his
own employees,provided Nat such improvements are not intended oroffered for ole.If.
however,the building or improvement is sold within one year of completion.Ne owner.
builder will have On burden of proving Our he did not Wild or Improve for purpose of
sale.l.
❑1,as owner or Ne property,am exclusively contracting with licensed c0mamares to ������®
construct the project(See.ID44,Business and Professions CodeO Li
The Contractor's
cave law does not apply to an owner of property who Wilds or improves thereon.and
who contracts for such projects with a coronations)licensed pursuant o the Contracmh DEC rev a9 rgLoo3
License Law.
❑I un exempt cantle Sec. .E k P C for this tenon
Owner Data BUILDING
UIi�. „tt LNG '
WORKER'S COMPENSATION DECLARATION sa�Yl ,N!■M_t
I hereby affirm under penally of perjury one of the following declarations:
lyf Thaw had will for byneCeni37M of ConsentLabor xude,for the Worker's Compere
scion, r provided far by Section 3]00 of the labor Code.for the performance of the
work for which This permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,u required by Section
371W of be labor Code,for Ease performance of the work far which this permit is issued.
My Worker's Compensation Insurance carier and Policy number are-
Cut
rt:
Curticr. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed If the permit Is for one hundred dollars($1(50
,a less.)
1«nary that in the performance of the work for which this Permit is issued.I shall not
employ any Person in any manner so as be become subject to the Workeri Compeneatlon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this CcniBcue of Exam prion,you should
become subject to the Worker's Compensation provisions of the Labor Cnde,you must
',Z forthwith comply with such provisions or Nis Permit hall W deemed revoked.
ti O CONSTRUCTION LENDING AGENCY
I hereby affirm that Nero is a construction lending agency for Be performance of (Y
'Sr, rk ermi
fur which this permit is issued(Sec.709],Civ.C.)
'JALe wo
4 Lc
A Lender's Name
z nder'sAddrcu
U Q I certify Out I have read this application and tart that the ahovt,information is '
Uy F cored.I Agree to Comply with all city and county ordinances and state laws mlaiing to
�U building construction.and hereby aunhoriar representatives of this city to enter upon Oc
{Ll above-memiored properly for inspection purposes
(We)agree to saw,indemnify and kap harmless Be City of Cupertino against
rvFi l4A liabilities,judgments,casts and ex Pensca which may in any way scram against mid City
U z APPeNTUNDERSTANDS AND cof ffic onsrant!ng of equence
Permit.
LICAWILL COMPLY WITH ALL NOWPOINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaDate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Na applicant or future building occupant store or handle hararduus material
ss dented by the CupeAn.Municipal Cade.Chapter 9.12.and Be,Health and Safety
ale,scaler zssu(°7 All roofs shall be inspected prior to an roofing material beim Installed.
r-1 Yet ON. P P Y g P,
Will the applicant or mtore building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it havamous air contaminants as deGnN by,Be Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yea ON. -
1 have mad Ne Wmrdous materials requirements under Chapter 6.95 or the Califon. .
nis Health K Safety Code,Seen=255(15.25533 and 25534.1 understand than if On Wilding
Jou not currently haw a rehear,Out it u my responsibility an purifythe axupant of Ne
requirements which must be met prior to issuancea a Cenlficateof occupancy. Signature Of Applicant Date
Owner or authorirnd agent DateAll roof coverings to be Class "B" Or better
0-3
City of Cupertino Building Permit Application
E-Mail
jobsite Address: 20298 Pinntage Parkway Date: 11-18-03
Owner's Name:---Granzella, Nancy
Phone No.(408)996-8575 '
APN#: 369-47-018 Project Valuation: $ 814.00
Building Permit Info: Bldg----------- Elect----------- Plumb------X----- Mech-----------
Job Description
Replace 50 gallon 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: 3/31/04
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. Z30
Expiration Date: 9/056 G /
Visa MasterCard ® /
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