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10010051 UPERTINO BUILDING PERMIT o51 CITY OF PERMIT NO:10010 CONTRACTOR:LOEWEN&FRECH INC SUED:01/12/2010 BUILDING ADDRESS: 22890 STONEBRIDGE ST 245M MT HERMON RD DATE IS OWNER'S NAME: RAJ SHINGAL&JENNIFER CHAN SCOTTS VALLEY,CA 95066 PHONE NO:8313354632 NER'S PHONE: 4089967690 � ECT PLUMB� BUILDING PERMIT INFO: BLDG EL LICENSED CONTRACTOR'S DECLARATION COMMERCIAL � 4z&.5&L___� MECH RESIDENTIAL Lic.# License Class I�097--1 r� ( Contractor 1,60"1,60" JJOB DESCRIPTION:SOLAR ELECTRIC WATER HEATER REPLACEMENT I herebyaffirm that I am licensed under the provisions of Chapter 9 commencing with Section 7000)of Division 3 oeC�a Business&Professions Code and that my ( license is in full force and effect. I hereby affirm under penalty of perjury one of the following worker's rations: I have and will maintain a certificate°ion 3700 of the Labor Code,for the f consent to self-insure forValuation:$2000 Compensation,as provided for by Sect is issued. Sq.Ft Floor Area: performance of the work for which this pensation Insurance,as provided for by I have and will maintain Workers Com pe Occupancy Type: Section 3700 of the Labor Code,for the performance of the work for which this APN Number:34213031.00 permit is issued. APPLICANT CERTIFICATION SIF WORK IS NOT STARTED that I have read this application and state that the above information is PENT EXPIRE CE OR I certify with all city and county ordinances and state laws relating IT ISSUANCE correct.I agree to comply WITHIN 180 DAYS OF PERM INSPECTION. building construction,and hereby authorize representatives (We)this a to aver CALLED to g for inspection purposes. LAST C upon the above mentioned property 180 DAYS FROM of Cupertino against liabilities,judgments, indemnify and keep harmless the City in consequence of the accrue against said City� �� f-��".�? Date: costs,and expenses which may applicant understands and will comply __.._� of this permit. Additionally,the app Issued b�._" granting per the Cupertino Municipal Code,Section with all non-point source regulati 9.18. Date Signature RE-ROOFS: TION All roofs shall be inspected prior to any roofing material being installed.If a roof is RAemove all new materials without first obtaining an inspection,I agree to ror � OWNER-BUILDER DECLA installed inspection. hereby affirm that I am exempt from the Contractor's License Law for one o Date: I he y licant: the following two reasons: Signature of es as their sole compensation, App I,as owner of the property,or my employees with wag will do the work,and the structure is not intended or offered for sale(Sec.704 , COVERINGS TO BE CLASS"A"OR BETTER Business&Professions Codes exclusively contracting with licensed contractors to ALL ROOF I,as owner of the property, HAZARDOUS MATERIALS DISCLOSURE .95 of the construct the project(Sec-7044,Business&Professions Code). under Chapter 6 under penalty of perjury one of the following three affirm u p I have read the hazardous Code,ls 25505 requirements25533,and 25534. I will maintain I hereby affi Code, declarations: ertino Municipal Code,Chapter 9.12 and the Health Certificate of Consent to self-insure for Worker's Calif 1 ance�v�'�th the C Pty handle hazardous material. I have and will maintain a Cert comp should I store or provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a) Compensation,as p issued. Additionally,should I use equipment or devices which emit hazardous air the Bay Area Air Quality Management District I will performance of the work for which this permit is rovided for by contaminants as defined by Chapter 9.12 and the Dance with the Cupertino Municipal Code, I have and will maintain Worker's Compensation rformance of Insuas rance, for which this maintain comp' 25505,25533,and 25534. Section 3700 of the Labor Code,for the p Health&Safety Code, tions permit is issued. nt: at in the performance of the work for which this permit 1 e issued, Owner or r' d 1 certify that me subject to the Date: not employ any person in any manner so as to become J Compensation laws of California. If,after making this certificate ofexemption, Code, must LENDING AGENCY it shall be deemed revoked. CONSTRUCTION LEND erformance of work's become subject to the Worker's Compensation provisions isions of the agency for the p forthwith comply with such provisions or this pe I hereby affirm that there is a construction lending g for which this permit is issued(Sec.3097,Civ C.) APPLICANT CERTIFICATION thLender's Name that I have read this application and state at the above information is I certify l city and county ordinances and state laws relating correct.I agree to comply with all d hereby authorize representatives of this city to enter Lender's Address------------------ to d ressto building construction,any purposes.(We)agree to s unon the above mentioned property for inspection pure ARCHITECT'S DECLARATION harmless the City of Cupertino against liabilities,judgments, nnify and keep in consequence of the fans shall be used as public records. accrue against said City 1 I understand my p ;,and expenses which may applicant understands and will comp y granting of this permit.Additionally,the app Licensed Professional 11 non-point source regu 'ons per the Cupertino Municipal Code,Section with a P 9.18. Date Signature CITY OF CUPERTINO PERMIT RECEIPT OPERATOR: patg COPY # � 1 5 ITEMS OF 10 Sec: Twp: Rng: Sub: Blk: Lot: APN 34213031.00 DATE ISSUED. • • • • " 01/12/2010BS000009538 RECEIPT # . " 10010051 REFERENCE ID # • • • SITE ADDRESS 22890 STONEBRIDGE ST SUBDIVISION : : : : ; : : CUPERTINO CITY . . • IMPACT AREA . : RAJ SHINGAL & JENNIFER CHAN OWNER . _ • — 22890 22890 STONEBRIDGE ST ADDRESS • • • • • . . . . . CUPERTINO CA, CA 95014-5644 CITY/STATE/ZIP . • • RECEIVED FROM . . . . : LOEWEN & FRECH LIC # 21212 CONTRACTOR . . . . . . . : LOEWEN, DEBRA pANY . . . . . . . . . . : LOEWEN & FREOC COM : 245M MT HERMN RD ADDRESS • • • • • . . . • SCOTTS VA TELEPHONE • LLEY, CA 95066 CITY/STATE/ZIP : : : : 8313354632 THIS REC NEW BAL PD-TO-DT __ y AMOUNT ____ -- EE ID UNIT QUANTITY ____------ ---------- -- 1.00 ----0 . 00 F - 0 .00 ---------- ---- -------- 21000 .00 1. 00 0 .50 0 . 00 BCBSC VALUATION 0 . 50 0 .00 0 .00 1 2, 000 . 00 0 .00 42 . 00 1BSEISMICR VALUATION 1 . 00 42 . 00 25 . 00 0 .00 1PPERMITFE FLAT RATE 25 . 00 0 .00 0 , 00 1 .00 0 .00 42 . 00 1PRWHEATR UNITS 1.00 42 . 00 ___----- ---------- 1TRAVDOC FLAT RATE ---------- ------ 110 . 50 0 . 00 110 .50 0 .00 TOTAL PERMIT AMOUNT- MOUNT REFERENCE NUMBER METHOD OF PAYMENT ---______ _____- _ ----------------- ------- --221.00 #1030 CHECK _______________ 221. 00 TOTAL RECEIPT VOICE ID DESCRIPTION _______----- VOICE ID DESCRIPTION__------- -------- ---------------- 518 WATER HEATER CITY OF CUPERTINO WATER HEATER pEgM17' APPLICATION FORM CUPERTINO Date: APN # I Z 10 Building Address: 22gCi0 s,-o I\J eP::;2tn61:�7 Phone #: Owner's Name: ��0� (�� (� AT c�HIM�� Soyivi1�e� CN�� Phone #: �3Contractor: 5 INC.-I�G Fax 31 =��2�� 2 5; Contractor State License #: Cupertino Business License#: 1�, 4 E,62,v Q� 12 12, Phone#� Contact: Fax /v Building Permit Info: OCJk✓Z- ��- c�J�Gt✓t- I�EasPvt- Bld ❑ Elect Plumb P' Mech❑ Commercial ❑ Solar E] If solar, number of kilowatts: Residential _— On Platform Bonded New Location Replacement Strapped Valuation (cost of project): COO� 'r, Project Size: Express Standard Large Major Green Building: Please complete relevant portion of the Green Building t & the sheet ind&attach it to the application or if applicable, include in p Green Building Points achieved: Revised 08/20/09 CITY OF CUPERTINO WATER HEATER pERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Permit Type Grou 1PCWHEATR Commercial Water B pCWHEATR Heater/Vent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICOM Seismic Commercial B --------------- 1PRWHEATR Residential Water B pRWHEATR HeaterNent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICRE Seismic Residential B 1PPERMITFEE Plumbing Permit P ------------ 1TRAVDOC Travel & B Documentation ----------------- 1BUSLIC Business License B Community Development 10300 Torre Avenue ,- Cupertino CA 95028 3 Telephone(408)777 ' E Fax(408)777-3333 �:. CITY OF ,XpETINO ln e artme. D nt uid 1 F _ PERMIT # OB ADDRESS: C v JOB a 10 nQ b ?c fl G� PHONE R'S NAME: f N FAX OVVNE GENERAL CONTRACTOR: 2,t I am subcontractors:not using any Signature co lete the followin information: Date Please check applicable subcontractors and BUSINESS LICENSE # BUSINESS NAME SUBCONTRACTOR 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 t Date Owner/Contractor Signature