02090167Ir
CITY
I BUILD NG DIVOF ISION O CONTRACTOR INFORMATION:
PERMIT
BUILDING ADDRESS: PERMIT NO,
22343 MC CLELLAN RD WATER QUALITY PLUMBING 02090177EE67
i�� 19tATE MNGMT SERVICES 1860 ALMADEN RD
APPLICATION SUB
PHONE: SANITARY NO. CONTROL NO.
(408)267-9330
Z ARCHITECT(ENGINEER: BUILDING PERMIT INFO
O
FILEDJ ELI_ PLUMB MI ECH
i LICENSED CONTRACTOR'S DECLARATION
sofChat Job Description
Ihcrcbv eRrm Oatlnm licensed under provisions of Chapter 9lrommcming COPPER REPIPE
o with Section 700o)of Division 3ofthe Businessand Profession Code. and my license
in full farce en c
a Li.,a m Contra
FINALE®
D Dme - Commc N /
g A CHITECT'S DECLARAD0 V
I understand my plans shall W used as public records
o Licensed Profe..innal OCT --1'5 2002
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
a " following reason. (Section 7031.5. Business and Professions Code: Any city or county ��' �a.a C Q�Q
O which requires a permit ro conswa. he, improve, demolish, or rcpmr my structure u��
m print t sotarceatm q th applicant fur such perms fl gne!statement - c --- --- - -- ---
- "ache licensed Inundatoro theprovisions of the ContnmofsL se Law (Chapter 9 f 3'S`1`?l,�a (O W'YOr(}Ayea t p/ Valuation
(comma ting, with Section](gWi of Division 3 of the BusneY and P(fessons Code) .,f,af1 - is x. hl. 1, 1i1a'^✓Si lti �JA IO..\+ t
or that he is caempt thcrefrotsrand the basis fnr the alleged exemption, Any violation 1
-"ofSection 7031.5 by any ii,licumfar. permit mbjecta the applicanllea civil pmWry- ARN P Occupancy Type
Iof not more than five hundred dogar:(S5om. 202 I�ID(MLFLOOR PL BI•NG" P Y YP
❑1.asowner ofine propenr,mmyemployee.swith wages astheir sole compensation, 301 - ROUGH PLiU.iMBTIN
-.111 do she'work'end' the structure is not !.(ended or offered for sale (sac 7064; .. 502 - FINAL PLgy i;�{ry gym t'•Ty�Y !.!1 !,.\ '
Busmlas and Pmfesslons Cade: The Conlr¢mr's License law does not apply tom
owner of progeny Who Wilds m improves Nermn, and who does such work himself 507 - FINAL PLUMBING
or through his own cmpmyecs. provided that such improvements are nm intended or
�oBmed farrr'sale-lfhowcver. the buildingt;ssold'withidona .._f.
m improvement Ywr n
completion, the owner builder will have the burden of proving that he did not build or
improve for puryose of sale.).
_.--__-__..-._.__—.___.__.,__..___.._.._.ensedc_____.._._..__..__..-__-_______..__.__-._-____..-___.
0.1 ti owner pRbe progeny a , B.,inev, and
with licensed comYtors to ..... �.. ;1 - • 1 I:"` `)
_ License
the does
project (Sec. ]O6 a, Business and eoy who
Cade:) The Contractor's ,li_ ,,,, ^.--,- , I • \;;1 „-,
- Licenc Low docs nut apply to an owner of it contY won builds or improv. thereon,
. and.who.cammcu foasuch.projmu_with.0.conracmrtsl licensed.Punmm ..the. _.. _._..__.._._._._.._______..._..__._-____....._.___-.____._......_._...._____.._......_.-___
Convenors, License See , ,, ..
.i ❑lomcscmpt uno.dea 5a �, ,,,,,,•--•,• \B& -,"Nis notion
-
Oan ,r. 'Dole*,, ...... u,. t.. : .
'
'WORKER'S COMPENSATION DECLARATION
thereby aRrm urtdtt.nnn4y of perjury, one of the following declaration:
❑ 1 have and will'maimxin a Ccnificaie of Consent 'm .self -insure for Worker's
Compensation, as -provided far by Section 3]00 of the later Code, for the
performance of the work far which Nis permit is issued. I.
h slanted will redound n Mm iusev conipegsiiiod insumrrce, m haunted by Secdan
of the'Labor'Cade. for the Performance of the work 'for 'which thii permit is
. tY TIC pc 1 n Insurance cart er d Pot y b< _ -- _ _ ...,,
.sued MyW 1, r`
Crime I FERE
F CATION FSATION INS FROM, RKERS �,` - ^0 1 \. 1 A _ 4, t - .. n...
COMPENSATION INSURANCE '- vas
'�u't f`I`:' r'¢al tr all3d .1' it FC
"(TMs xediun'necd not W cnmple¢d'ff the Permit is for one hundred dollars ;
I rt f lh t o Ne rt mt of th ork f h ch sec ren ti t s ed' I i r r tv.. .
"hall no, employ any Pr ran any ma to becomesubject to the Wdkirs ♦.l �'I;; t I j i '- tl +
Comps i Yaws of California Date.,
:APPI cam. - :.. .:'.. .' .. .. :.. _. _...... _._ ....___... _._ . _..... .' .._---------_ ...... __ ....
'NOTICE TO APPLICANT IL after trading thisCenficam of Exemption. you should ":II `:\ '•:'"
I Wcome subject she Workefs Compensation provisions of the Labor Code, you must'
fonh the ly with cb ns or this -. .,l ,. _I . ..... ....... .. .._. ...._ ....-.... _... __. .. _. _ ... .
p i p� permit hall W dee ed rt ked.
/] s CONSTRUCTION LENDING AGENCY
Ihereby3(Enn that sheen soconnWfunn lending agency for lAc performance
� 'of the work for which the pcnnit is issmd (Se<(3(19], Civ: C.1 - ' _ __ - -__"
L'eHder'1"Aeaicsa JI
1 e. n'fy th t I h a read N s applic t d state shot the aha <. of rmetion rs'
cbrtect. I agree to,rolpplY,with oil city And county ardinon¢e end rote laws e, upon
ro building conswaion: and hereby Suthorile rep¢senulivabf this eery to m¢r upon
the uhove-mentioned progeny mr inspersion puriwms.
y Wc)5gne to save: mJemnify and kee ha mles the Ciiy of Cup nino against
ai
A liabilities, ju�gmetns, costs and eapenses wh mayin eny,way acerae againss said Q
City in consequence of ifie:grunling of Nis nit.'„”", 't. .' '
p jAP JCANT.UNDERST \ '.!II I i OSIPLY WITH �oN:PoINT
' Issued bADate
UR ER):GG ATI N '• :'i: , .,� Ya
pnV RUOUS :MATERIALS DISCCOSURE'd' ]:.1Da�� Re -roofs
. ,:.der mley.th<pplicam mfuture Wlthng Occupy tae a hurdle naawgn tnale,,a Type of Roof - -__..... _ . .- -- .._ - _-..-. �..�.::
Chapeau. Mumnpal Cade Chapter 9 12, and the Health and Sakry -., A t t •' s -• • , • ( �s' I .' I
Cdde Section 25532(). \ f h l a f... a: `' a .. A 1�' 1 Y . k 11r A, I I ivV
oY. "'' ' , r i ' " All roofs,.shal]-be.inspected prior_ to..any.roofing.material.being installed.....
wtRth, pprc �a�rmorebuldi g p sero pmem da which If a roof is intstalled without first obtaining an inspection, I'agree`to'remove
emrl hazed - a cam moot defined by he ByArcaA QualityMostaganem
Divides?all _new materials for inspection. Applicant understands and will comply. with
Urea •' No., ', --all non -point source regulations. -
Califom'u Hcollh'&tSafet Cade. Sections 25505.25533 and 25536. 1 understand d the
' us ma¢nak rtquircmrntrt rode Chapter 6.9
Safety land thnl
neibilit to nodi the.
�if,the Wilding does not currently haves len. lh 't is en rcspo y y
occupmu of the rcquireavros which muni be m or to ispumce of a Cehire.. of
1°pefore'.
- "OFFICE
' " -- 2
�raf
Signature of Applicant Date
- "
All roof coverings to be Class `B'a or better.
cot li 'Oast..
ulhonled,
Ir
CITY
I BUILD NG DIVOF ISION O CONTRACTOR INFORMATION:
PERMIT
BUILDING ADDRESS: PERMIT NO,
22343 MC CLELLAN RD WATER QUALITY PLUMBING 02090177EE67
i�� 19tATE MNGMT SERVICES 1860 ALMADEN RD
APPLICATION SUB
PHONE: SANITARY NO. CONTROL NO.
(408)267-9330
Z ARCHITECT(ENGINEER: BUILDING PERMIT INFO
O
FILEDJ ELI_ PLUMB MI ECH
i LICENSED CONTRACTOR'S DECLARATION
sofChat Job Description
Ihcrcbv eRrm Oatlnm licensed under provisions of Chapter 9lrommcming COPPER REPIPE
o with Section 700o)of Division 3ofthe Businessand Profession Code. and my license
in full farce en c
a Li.,a m Contra
FINALE®
D Dme - Commc N /
g A CHITECT'S DECLARAD0 V
I understand my plans shall W used as public records
o Licensed Profe..innal OCT --1'5 2002
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
a " following reason. (Section 7031.5. Business and Professions Code: Any city or county ��' �a.a C Q�Q
O which requires a permit ro conswa. he, improve, demolish, or rcpmr my structure u��
m print t sotarceatm q th applicant fur such perms fl gne!statement - c --- --- - -- ---
- "ache licensed Inundatoro theprovisions of the ContnmofsL se Law (Chapter 9 f 3'S`1`?l,�a (O W'YOr(}Ayea t p/ Valuation
(comma ting, with Section](gWi of Division 3 of the BusneY and P(fessons Code) .,f,af1 - is x. hl. 1, 1i1a'^✓Si lti �JA IO..\+ t
or that he is caempt thcrefrotsrand the basis fnr the alleged exemption, Any violation 1
-"ofSection 7031.5 by any ii,licumfar. permit mbjecta the applicanllea civil pmWry- ARN P Occupancy Type
Iof not more than five hundred dogar:(S5om. 202 I�ID(MLFLOOR PL BI•NG" P Y YP
❑1.asowner ofine propenr,mmyemployee.swith wages astheir sole compensation, 301 - ROUGH PLiU.iMBTIN
-.111 do she'work'end' the structure is not !.(ended or offered for sale (sac 7064; .. 502 - FINAL PLgy i;�{ry gym t'•Ty�Y !.!1 !,.\ '
Busmlas and Pmfesslons Cade: The Conlr¢mr's License law does not apply tom
owner of progeny Who Wilds m improves Nermn, and who does such work himself 507 - FINAL PLUMBING
or through his own cmpmyecs. provided that such improvements are nm intended or
�oBmed farrr'sale-lfhowcver. the buildingt;ssold'withidona .._f.
m improvement Ywr n
completion, the owner builder will have the burden of proving that he did not build or
improve for puryose of sale.).
_.--__-__..-._.__—.___.__.,__..___.._.._.ensedc_____.._._..__..__..-__-_______..__.__-._-____..-___.
0.1 ti owner pRbe progeny a , B.,inev, and
with licensed comYtors to ..... �.. ;1 - • 1 I:"` `)
_ License
the does
project (Sec. ]O6 a, Business and eoy who
Cade:) The Contractor's ,li_ ,,,, ^.--,- , I • \;;1 „-,
- Licenc Low docs nut apply to an owner of it contY won builds or improv. thereon,
. and.who.cammcu foasuch.projmu_with.0.conracmrtsl licensed.Punmm ..the. _.. _._..__.._._._._.._______..._..__._-____....._.___-.____._......_._...._____.._......_.-___
Convenors, License See , ,, ..
.i ❑lomcscmpt uno.dea 5a �, ,,,,,,•--•,• \B& -,"Nis notion
-
Oan ,r. 'Dole*,, ...... u,. t.. : .
'
'WORKER'S COMPENSATION DECLARATION
thereby aRrm urtdtt.nnn4y of perjury, one of the following declaration:
❑ 1 have and will'maimxin a Ccnificaie of Consent 'm .self -insure for Worker's
Compensation, as -provided far by Section 3]00 of the later Code, for the
performance of the work far which Nis permit is issued. I.
h slanted will redound n Mm iusev conipegsiiiod insumrrce, m haunted by Secdan
of the'Labor'Cade. for the Performance of the work 'for 'which thii permit is
. tY TIC pc 1 n Insurance cart er d Pot y b< _ -- _ _ ...,,
.sued MyW 1, r`
Crime I FERE
F CATION FSATION INS FROM, RKERS �,` - ^0 1 \. 1 A _ 4, t - .. n...
COMPENSATION INSURANCE '- vas
'�u't f`I`:' r'¢al tr all3d .1' it FC
"(TMs xediun'necd not W cnmple¢d'ff the Permit is for one hundred dollars ;
I rt f lh t o Ne rt mt of th ork f h ch sec ren ti t s ed' I i r r tv.. .
"hall no, employ any Pr ran any ma to becomesubject to the Wdkirs ♦.l �'I;; t I j i '- tl +
Comps i Yaws of California Date.,
:APPI cam. - :.. .:'.. .' .. .. :.. _. _...... _._ ....___... _._ . _..... .' .._---------_ ...... __ ....
'NOTICE TO APPLICANT IL after trading thisCenficam of Exemption. you should ":II `:\ '•:'"
I Wcome subject she Workefs Compensation provisions of the Labor Code, you must'
fonh the ly with cb ns or this -. .,l ,. _I . ..... ....... .. .._. ...._ ....-.... _... __. .. _. _ ... .
p i p� permit hall W dee ed rt ked.
/] s CONSTRUCTION LENDING AGENCY
Ihereby3(Enn that sheen soconnWfunn lending agency for lAc performance
� 'of the work for which the pcnnit is issmd (Se<(3(19], Civ: C.1 - ' _ __ - -__"
L'eHder'1"Aeaicsa JI
1 e. n'fy th t I h a read N s applic t d state shot the aha <. of rmetion rs'
cbrtect. I agree to,rolpplY,with oil city And county ardinon¢e end rote laws e, upon
ro building conswaion: and hereby Suthorile rep¢senulivabf this eery to m¢r upon
the uhove-mentioned progeny mr inspersion puriwms.
y Wc)5gne to save: mJemnify and kee ha mles the Ciiy of Cup nino against
ai
A liabilities, ju�gmetns, costs and eapenses wh mayin eny,way acerae againss said Q
City in consequence of ifie:grunling of Nis nit.'„”", 't. .' '
p jAP JCANT.UNDERST \ '.!II I i OSIPLY WITH �oN:PoINT
' Issued bADate
UR ER):GG ATI N '• :'i: , .,� Ya
pnV RUOUS :MATERIALS DISCCOSURE'd' ]:.1Da�� Re -roofs
. ,:.der mley.th<pplicam mfuture Wlthng Occupy tae a hurdle naawgn tnale,,a Type of Roof - -__..... _ . .- -- .._ - _-..-. �..�.::
Chapeau. Mumnpal Cade Chapter 9 12, and the Health and Sakry -., A t t •' s -• • , • ( �s' I .' I
Cdde Section 25532(). \ f h l a f... a: `' a .. A 1�' 1 Y . k 11r A, I I ivV
oY. "'' ' , r i ' " All roofs,.shal]-be.inspected prior_ to..any.roofing.material.being installed.....
wtRth, pprc �a�rmorebuldi g p sero pmem da which If a roof is intstalled without first obtaining an inspection, I'agree`to'remove
emrl hazed - a cam moot defined by he ByArcaA QualityMostaganem
Divides?all _new materials for inspection. Applicant understands and will comply. with
Urea •' No., ', --all non -point source regulations. -
Califom'u Hcollh'&tSafet Cade. Sections 25505.25533 and 25536. 1 understand d the
' us ma¢nak rtquircmrntrt rode Chapter 6.9
Safety land thnl
neibilit to nodi the.
�if,the Wilding does not currently haves len. lh 't is en rcspo y y
occupmu of the rcquireavros which muni be m or to ispumce of a Cehire.. of
1°pefore'.
- "OFFICE