02090171 CITYBUILDING DIIVIIISIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT N0.
22831 STONEBRIDGE ST LOEWEN & FRECH INC 020901771
SUB
G6'M'" A LEE PMB #242 APPuc09/25/2002
(ppOPHONE. 8313354632 SANITARY NO. CONTROL NO.
O O ARCHITECT/ENGINEER: # BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
F LImme
CENSED CONTRACTOR'S DECLARATION Description
Z O n Z 1 hereby Xro that I am licensed under provisions of Chapter (commencing REPLACE
b
Fit withS.du7000)ofDNh;hn3of@eBusinessendPrafessionsCade,andmy,iicense REPLACE WATER HEQATER
illmm�r° eanaerce 38 (LEANING 80 GALLON SOLAR ELECT)
Ou Lae. lass _ Lic.%
a�3 a Dote n— S DECw r
A Chan k use DECLARATION
=�,y 1 understand my plans snail be used as public records
sp Licensed Professional
OWNER-BUILDER DECLARATION
titR I hereby.Rath that 11. exempt from the Connvemros bionic Law fan the
m
Z
N
C follawin rt n. Section]031.5 Business and Rofessioi Cade:An cityor count
aw
D which try nes n Permit re construct.aalter,pplicant
improve demolish or repair any structure
3$ thetavissuance.edplsorcgo the neyisionoffan such
ect.Lfiensete a igned Law,(Chapter
- _._.-
ththeSlebnsithSecou,71 p Division3otheBusinsLtoemelawonsCoe) , ,Sq.Ft. F1oor:Area ,-y f., Valuation
or cuteI,awith Secuoo70003of Division3oftheege ass and all.Any vi Code] '{ 4J.ti 1l , tt O}? n,\,• x3{,;',SrLa 311.'
of Nat he ma 31.5 b thertfroYn and the basis for the alleged ekempdon.Any violation
-of Section om than
v any hundred
odt for a pcmdrsubjais Ne applicant ro e civil penalty
of not more man fi.e Wnarta aogars(ssoB). APN Number !el:.c1 V. Occupancy Type
01,as owner of the property,ormy employees win wages as their sol.mrapeneation, 502 FINAL PLUMBIN ENERGY
-will-chi the work;-ud the sWcturc is out intended a,ciffercdfor'sale'(Sec:7041,' 506 - GAS TESTRequired Inspections'
Business and Professions Code:T
he Contractor's License law does wt apply to w
owmr of property Who Wilds or improves thereon,and who does such work himself 507 - FINAL PLUMBING
or through his own employees pro ided that such improvements m intended _ _ ._,_ --------
completion.
__
offered for sale:If.however the bmld'ng or nnim mens sold-within e y o f - - - - - - -
c mpletin the owner budder will have the burden of proving that he did not Wild or
improve for purpose of wl<)
i El Las".m.fdm emecluw 1 t to nl' and ntricroram
of
who
s or
mve.s
I:. _end contract f r spy projects the tha conuuctor(a)LcensMmpuraum ro the. --
construct the project(Sm.7044 Business y d Professions Cade:)The Convector's
License Lo does not 1 to an
Ca clot's License Le
? lame t er Ba:P/C forth.moron
- 0 ER'S COMPEN N ARATI N
1 hereby affirm under penalty of perjury one of the following declarations:-
=( ❑ 1 hive an!will mainuio'a Cntifiel.of Consem`m selbinsum for Worker's
Compensation, as,provided for by Section 37W of the labor Code, for the
- _ performance of the work far which this permit is issued.
_- ❑1 have and will miintuin Worker's Camputaidoti Insurance,as required by Section
3700 of the LeWr"Coic,for the performance of the work for which this permit is
issued,My Workers Compensation Insurance carrier endP61icy number a.rt: _
Pal cy No . ...... ,... . - ,-t, t" i �Y p e:;tl
.6, (CERTIFICATION OF EXEMPTION FROM WORKERS., 'E,)�s t 1, as J 3�
t�s,.. -.•., -.COMPENSATION INSURANCE-
readout
NSURANCE need not W completed if the permit is for one hundred dollars
:�(51o01 or lessl , .
'� YI nfylthufln the pertrm: c of thew rk fnrwh ch th.pc ' tis issued,l
;bail n or employ inyr p/apn man runner X31 tnB&a@ bjwpthe W rk s
Co.
ni'lluon L oftvagf a. to % C�,J V tom`
APPiawt
NOTICE TOO AP/ NP If.ofter mukmg this Certificate of Exemption,you ahoT
old
Z tied me subject mon Workle Compensation provisions of the labor Code.you mu t
O 0 fort Id ply with uch provisions mons r this permit shell W deemed mvokcd
CONSTRUCfIONLENDINGAGENCY " >`
fBrtn Out the t cansimcuon Iendlne rugeoey fm the per(ommnm
wpt.Q sof the work for which this mit ii seised(SaJ09] Crv.C7
D,Z Lender s Address t
U• ,I 1 c mfy net I h...read this application end nam that the aW a information is
fir+ cdtrtct 1 ague 1.comply dry h all c and county omdinan aid rate laws relating
�: to building construction.and hereby audiarize reprclemasivesofnis city to enrr upon
W theubqva-meminned property for inspection proposes.,, _•-
Oa (Wej agree io sive. indemnify and keep harmlessihe City of Cupertino against
(A liabilities,judgments,costs and expenses which may in any way accme against said
U:4 City in'consequehce of the granting of this permit. -
APPLICAM1T UNDERSTANDS'AND WILL COMPLY WITH ALL NON -POINT Issuedb Date
SOURCE REGULATIONS.: •• y
Sign lure of Applicnnt/Comractnn' '' -' j Date '. Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
""'the
applicant a future Wfill amuWt.orc m haMk hvvd°us m.enal Type of ROOF
Municipal.,
uncipal a Chapter eMtlm?HWthwdSa/aY p prior
t .; y
as defused!by ill Cupenmw l
Code Secy n255J21aj p
°Y"' All.roofs shall•be,ins acted rior.to.an roofing material being installed__
W'llthcapPi t fuwrehuddng occupantuse equipment ordevices which If a roof is installed without first obtaining an'itispecnon 'I'agfe&tti'remove
emit h rarA us air comenimarts as dein by the Bay Arca A Quality Management
District] I all new materials for inspection.,Applicant understands_and will comply with _
.. ovea ° } - - -
-all non-point source regulations;,,_
1 hale aid the hruzadous mmenels requiremema under Chapter 6.95 of the.
California Health At Safety Code,Sections 25505,25533 and 25534.1 understand that
If ill Iolding time not pis ly have a tenont that is my responsibility to notify the
t mcupe of ted rcgwrcm u hteh most be me prior to since of a Certificate of
Omuponc
All roof coverings to be Class `B" or b
Signature of Applicant Date
atter
Owner or unauditedgen , Date g '
,l, I
4- OFFICE '