09120128 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22911 STONEBRIDGE CONTRACTOR:LOEWEN&FRECH INC PERMIT NO:09120128
OWNER'S NAME: JANES LINDA B 245M MT HERMON RD DATE ISSUED: 12/21/2009
`YNER'S PHONE: 6509964314 SCOTTS VALLEY,CA 95066 PHONE NO:8313354632
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class Lic.# �� 3;11U/ REMOVE AND REPLACE EXISTING 80 GALLON SOLAR/
ELECTRICAL WATER HEATER
Contractor Date IZ-Z'I
709
1 hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$2000
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:34213051.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City Cupertino against liabilities,judgments,
costs,and expenses which may accru a Inst said City in consequence of the -� ,
granting of this permit. Additionally th applicant understands and will comply Issued bye, `d-- Date:
with all non-point s cc ul ions the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date GV All roofs shall be inspected prior to any roofing material being installed.If a roof is
_ installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
1 hereby affirm that I am exempt from the Contractor's License Law for one o
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipLrdevices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay AreManagement Districtperformance of the work for which this permit is issued. will maintain compliance with the upertiode,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Secti , 34.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: Date:
permit is issued. '
1 certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING_AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I mus I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec 3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address_
1 certify that I have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating;
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned pro y for inspection purposes.(We)agree to save
+emnify and keep harmless e City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
and expenses which m y accrue against said City in consequence of the I understand my plans shall be used as public records.
.1anting of this ermit.Addi onally,the applicant understands and will comply
with all non-po t sour reg lati ns per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature _._Date f��� /
CITY OF C UPERTINO
WATER HEATER
PERMIT APPL]_CATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Permit Type
Group
1PCWHEATR Commercial NVater B PCWHEATR
Heater/Vent
1BCBSC Cal Bldg Stan lards B ALL PERMIT TYPES
Commission Fee
1 BSEISMICOM Seismic Commercial B
1 PRWHEATR Residential Water B PRWHEATR
Heater/Vent
1BCBSC Cal Bldg Standards B ALL PERMIT TYPES
Commission Fee
1BSEISMICRE Seismic Residential B
1PPERMITFEE Plumbing Pennit P
1 TRAVDOC Travel & B
Documentation
1 BUSLIC Business Lice::ise B
Community Development
., 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF
-;UPEI�TINO Fax(408)777-3333
Building Department
JOB ADDRESS: PERMIT #
'22-g -,D n Ce,Y2-ine,—e: q -2 ore<f'--
OWNER'S NAME: Lt&/PA JDAN E�, PHONE # (SU q96 - q3
GENERAL CONTRACTOR: ( r Cradj,t<<. FAX # / - O Ste!
I am not using any subcontractors: Q1212
Signature Date
Please check applicable subcontractors and com Clete 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
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER
PERMIT APPLICATION FORM
CUPERTINO
()ql 2-o 2k'
APN # Date:
3y 2 13 0 51 - oC) Dec Z 1 09
Building Address:
2,2°I 11 S�
Owner's Name: Phone #:
L.i1Api!�, Ives C&s--))
Contractor: Phone #(82,I)2,pS_�l�32
Lo v\ q Fw--ec-o 1 wc.
Fax #: c ( ?j3S—O Sq--L
Cupertino Business License #: Contractor State License #:
2 1212. qz�
Contact: FD S Phone #(53,0
Fax #: $2 �
Building Permit Info: �i;mope �Qp � c`j(t�►ir 69,?,C(cK So1^t1gleavaL &Afept
Bldg ❑ Elect Plumb Er" Mech ❑
Residential le Commercial ❑ Solar ❑ If solar, number of kilowatts:
Strapped On Platform Eg,'Bonded New Location ❑ Replacement
Valuation (cost of project):
Project Size: Express ❑ Standard :Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to
the application or if applicable, include in plan set & the sheet index.
Green Building Points achieved:
Revised 08/20/09