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10010050CITY OF CUPERTINO BUILDING PERMIT GE ST CONTRACTOR: LOEWEN & FRECH INC BUILDING ADDRESS: 22931 STONEBRID 245M MT HERMON RD OW NAME: LORA GALLEGOS Lic Co! 4rws PHONE: 4082535719 LICENSED CONTRACTOR'S DECLARATION 2C:l 1 ;nse Class Lic. _ L .,. 1 L�/fesIl k1C. Date Z U l U SCOTTS VALLEY, CA 95066 itractor ereby affirm that I am licensed under th00) of n 3 provisions the Business Chapter Professions mmencing with Isc nsen s ctioOn full force and effect. de and that y Hereby affirm under penalty of perjury one of the following two declarations: ave and will maintain a certificate of consent to self-insure>mpensation, as provided for by Section 3700 of the Labor Code, for the rformance of the work for which this permit is issued. provided for by lave and will maintain Worker's Compensation Ce o the,work for which this action 3700 of the Labor Code, for the p ,rmit is issued. APPLICANT CERTIFICATION ation is certify that I have read this application and state that ivanes and state laws relating orrect. I agree to comply with all city and county o building construction, and hereby authorize representatives seS(We agree to save upon the above mentioned property for inspectionp judgments, ndemnify and keep harmless the City of Cupertaid Cno ity consequence of the ;osts, and expenses which may accrue against said understands and will comply ;ranting of this permit. Additionally, the app with all non -point source regulat s per the Cupertino Municipal Code, Section Date l Sign t✓ I hereby affirm that I am exempt from t e the following two reasons: I, 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) with licensed contractors to I, as owner of the property, am exclusively contracting construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self -insure for Wor the orker's Compensation, as provided for by Section 3700 of the Labor performance of the work for which this permit Insurance, as provided for by I have and will maintain Worker's Comp Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. f the work for which this permit �e Worker's not l�oshall l I certify that in the performance obecome subject not employ any person in any manner so as to bject Compensation laws of California. If, after making this certificae Labor or Codteol must p become subject to the Worker's Compensatn provisions shall bedeemedrevoked. forthwith comply with such provisions or thisp MIT INFO: BLDG UILDING PER PERMIT NO: 10010050 r ISSUED: 01/12/2010 NO: 8313354632 ELECT r— PLUMB I— B g r— RESIDENTIAL MEC COMMERCIAL f JOB DESCRIPTION: SOLAR ELECTRIC WATER HEATER Sq. Ft Floor Area: APN Number: 34213023.00 Valuation: $2000 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Dater-- Issued by: ature RE -ROOFS: All roofs shall be inspected prior to any roofing material being all new materialsed. if a roof for OWNER-BUILDER DECLARATION installed without first obtaining an inspection, I agree to h Contractor's License Law for one of inspection. Signature of Applicant: APPCANT CERTIFICATION LI I certify that I have read this application and state th divanethe s ve and stainfote ation laws relating is correct. I agree to comply with all city and county o to building construction, and hereby authorize representatives oft is cit to saveto er upon the above mentioned property for inspectionpurposes. ud judgments, - unify and keep harmless the City of CupertandoCgainntconsequence of the and expenses which may accrue against s h' grant of this permit. Addition lly, the applicant understandMunicipal Code, s and will Secon comply with all non -point source regul ti ns per the Cupertino 9.18. � �(U _n _ Date — l! Signature Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements undo and 25534.pter 91 of thmaintain California Health & Safety Code, Sections 25505, compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handlh emit hazardous a r e hazardous contaminants as defined by the Bay material. Additionally, should I use equipmentAo ea Air Quality Management District I will maintain compliance ith the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Co , ections 25505, 25533, and 25534. Owne a t i a ,,._ f Date: CONSTRUCTION LENDING AGENCY herebyaffirm that there is a construction lending agency for the performance of work's I for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address. ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional 5 ITEMS OF 10 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 34213023.00 DATE ISSUED.......: 01/12/2010 RECEIPT #.........: BS000009538 REFERENCE ID # ...: 10010050 SITE ADDRESS .....: 22931 STONEBRIDGE ST SUBDIVISION ....... CITY CUPERTINO IMPACT AREA ....... OPERATOR: patg COPY # : 1 OWNER ............: LORA GALLEGOS ADDRESS ..........: 22931 STONEBRIDGE ST CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-5640 RECEIVED FROM ....: LOEWEN & FRECH CONTRACTOR .......: LOEWEN, DEBRA LIC # 21212 COMPANY ..........: LOEWEN & FRECH INC ADDRESS ..........: 245M MT HERMON RD CITY/STATE/ZIP ...: SCOTTS VALLEY, CA 95066 TELEPHONE ........: 8313354632 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW -------------------- BAL ---------- 1BCBSC ------------- VALUATION ---------- 21000.00 -------------------- 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 21000.00 0.50 0.00 0.50 0.00 1PPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1PRWHEATR UNITS 1.00 25.00 0.00 25.00 0.00 1TRAVDOC FLAT RATE 1.00 42.00 0.00 42.00 ---------- ---------- 0.00 TOTAL PERMIT ---------- ---------- 110.50 0.00 110.50 0.00 VOICE ID DESCRIPTION VOICE ID -------- ---------------------------- DESCRIPTION -------- ---------------------------- 518 WATER HEATER N / �ST'9ss CITY OF CUPERTINO WATER HEATER PERMIT APPLICATION FORM Building Address: z Z- q 5� 1 15qi1WF4%R6 Owner's Name: [OFA 6At-Lf60-S Contractor: �Otw f�j 4 fe", INC Cupertino Business License #: ZI ZIP Contact: rp a.'16W Building Permit Info: Residential D Strapped Elect Date: . c TA Nt 1`0Z (0 Phone #: yoB 2s3- s��9 Phone #: 63 z Fax #: Contractor State License #: 3 ------------- Phone #:931 536--L16-)3Z � Fax #• (,�J1 !!235-U 5�2 ISL--- Plumb [�--�� Mech 0"" Commercial ❑ Solar ❑ If solar, number of kilowatts: On Platform Bonded New Location LJ Replacement Valuation (cost of project): , �0 Ci 7n• FYrnrPc� l,✓1 Standard ❑ Large ❑ Major portion of the Green Building Checklist &attach it to Green Building: Please complete relevant the application or if applicable, include in plan set &the sheet index. Green Building Points achieved: Revised 08/20/09 CITY OF CUPERTINO WATER HEATER PERMIT APPLICATION FORM Quantity Fee ID Fee Description IpCWHEATR Commercial Water Heater/Vent 1BCBSC Cal Bldg Standards Commission Fee 1BSEISMICOM Seismic Commercial Fee Permit Type Grou B pCWHEATR B ALL PERMIT TYPES B 1PRWHEATR Residential Water B pRWHEATR Heater/Vent ALL PERMIT TEES B 1BCBSC Cal Bldg Standards Commission Fee 1BSEISMICRE Seismic Residential B p 1ppERMITFEE Plumbing Permit P ffRAVDOC Travel & B Documentation -L 1BUSLIC Business License B Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building D e art ent • an subcontractors: - Lle-- -- Lo- Date I am not using y Signature • ors and complete lete the f ollowin information: Please check applicable subcontract E BUSINESS LICENSE # SUBCONTRA CTOR BUSINESS NAM 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