04070184CI'CY OF CUPERTINO
DIVISION PERMITr�C011TRACT
OR INFORMATION
BUILDING
ix,0a��"y.k_,
BUIL DING ADDRESS:
WATER QUALITY PLUMBING
PERMIT NO 04070184
161 ELMSFORD DR
OW NER'S NAME:
PERMIT ISSUE DATE
LOUISA DORAN
ONE:
SANITARY NO. CONTROL NO,
(408)267-933C)
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
1 her by affirm lheI I am licensed under provisions of Chapter 9 (commencing
Job Description /s
Pgfim
witn SCcl ]pptfl oroivisim 3 of on, Businrs dPmfcssinne Cok.md my he.. a is
in lull ffc
1
oncea
License CI s Lie. 0
REPIPE/MAIN WATER LINE ��K{>a0
Data o ,.
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AaCHf1EC
—livKH' and my Plato shell M used u publs oras '� ��
1.�
2004
Licensed Prafe nuonal
OWNER BUILDER DECLARATION
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1 hereby short and I am exempt from dm Conlracmr's License Law for the
following nacho. (Section 7031.5, Business and Professions Code: Any city or county
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which requires a permit to ennslroul, alter, improve, demolish, or repair any structure
prior us its issuance, also requites she applicant forsuch permil to rile a signed sutemem
that he is licensed pursuant to the previsions of the contractors License law(Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing wife Section 7") of Division 3 of the Business and Prof.sions Coca) lir
that W u exempt therefrom and the, basis for dr alleged exemption. Any violation of
R$Qw1bcr0 0
Occupancy Type
P Y YP
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
trot more mm five hundred dollen (5500).
❑ I. as owner of the Property. a my c.,toy. with wag. as their sole eompears on.
Required Inspections
will do me work cad the swcma is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Container's Liceve Law does not apply to an owner of
property who builds or improves mcrmn, and who docssuch work himself or through his
own employe., provided farm sucn impmwmens are r ninnnded or offered for We. If.
however, me building or improvement is sold within one year of compledon, the owner.
.
builder will have me burden of proving mat he did not Wild or improve for purpose of
We.I.
❑ 1, as comer of the property, am .elusively mouaclmg ww licensed c.a.. ro
c ndi dr pmKcl (Sec. 71144. Busm.s and Profe emus Code:) The Contractors Li.
.
rase law does not apply in an mvner of property who Wilda or invowts thereon, and.
who contracts for such projects with a contracmr(s) licensed pursuant to the Contractors
License L.
❑ 1 am exempt under Sec. B & P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Pendry of perjury ma of our following declarations:
I have and will maintain a Cerifmm of Covent to Xif-ina m, for WorkcesCumpen-
sstion, as provided for by Section 3700 of the tabor Cade, for me performance of me
weak for which this permit is issued.
I have and will maintain Workers Compensation Insurance, m required by section
37W of the Labor Codc. for me performance of the work for which this Permit is issued.
My Workers Cam ensation Insunnec wrticr and Policy number a II,,
V�-�
Cartier. icy No.:
CERTIFICATEOF EXEMPTION FROM KERS'
COMPENSATION INSURANCE
(Tnixseclion need not W complco d if the Permit is rare= hundred dollars ($100)
or tees.)
1.W fy that in the porfamoonee of me work for which this Permit is issued. l shall not
employ any person in my mmocr. as to become s itpnei o me WorkersCampcnsation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If. after making this Ccnifenne of Euarroma, you should
become Subject to me Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this Permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 nearby aRrm Nmen ie c nn lending ageney for the performmce of
the work for which Nu pee rmit u coined (Sce(Stt. 303]. Civ. C.)
Landers Name
Leaders Agemss
1 I certify that 1 have mad this application and soon met the aWve information is
comply with all city and county and sooe laws elating
coin. I agreeensu
concwnlao, mJ hereby authorrfamcscOf e
c
rposes. utivrs of this city m cmcr upon me
athavcng
aMvc Propene for inspection p
keep hc.
(WCJogee to cast, indemnify andkeep
(We) 9 Cityru Cupcnst
mar
j liabilitiesjudgment, casting expenses which may in my way accrue agdnslsdd City
may red
A consequence of the of this Permit.
UNDERSTANDS
APPLICANT UNDERSTANDS AND WIL COMPLY WITH ALL NON-POINT
Issued by: D e
RCEREGULATION .
\10
Re roofs
Type of Roof
n r 4 11-.C)
sl ireofApIpponamlY p HAZ.R OUS MATER( LS ISCLOSURE arc
Will me applicant lir future building acupan store or handle hanrdous merchant
as derined by fee Cupeninn Municipal Code. Chapter 9.12, and the Health and Safety
CoJc. Section 25512(x)9
All roofs shall be inspected nor to an roofingmaterial bein installed.
❑b n
P P Y g
If a roof is installed without first obtaining an inspection, I agree to remove
will the indicator or future Wilding Occupant otic equipment or devices which
mil nvargnus air Conoominant. defined by tM Bay Ama Air Quality Management
all new materials for inspection.
District
❑Yes -IB Nu
L have mad do na¢areous materials requirement under Chapter 6.95 of the Califor-
has Health &SafctyCodc, Sections25505,23533 and 25534.1 understand mal ifthc Wilding
no
=q dors nal cuay�try how a roam. thin it is in tea mihility n no61, One, acupant of me
egai anwnieromaslWmett rtdimumcoactnintanafeaa CY'
ftN
Signature of Applicant Date
A
All roof coverings to be Class "B" or better
Owner
or authorize ago^ Date
CITY OF
�UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax(408)777-3333
Building Department
JOB ADDRESS:
S Q—
PERMIT
O c1
OWNER'S NAME- LC -),.A
PHONE # . q 33 C)
GENERAL CONTRACTOR:
#
I am not using any subcontractors( 4 42-
-
ature Date
Please check applicable subcontractors and complete the following information
i
Owner ntractor Signa
-27
Date
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
i
Owner ntractor Signa
-27
Date
0
t
a
CITY OF
CUPERTINO
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
PERMIT APPLICATION FORM
APN #
Plumbing Permit Issuance
Date:
Building Address:
Re i e of Fixtures
PLUMBING
Owner's Name:
Bldg. Permit Fees
Phone #:
BPFIXTURE
Pbl . Fixture
07s�-�3-�2
Contractor: Phone:
Main Water Service
License #:
Aa
-S
PLUMBING
Contact: Phone:
Sewage Disposal
Cupertino Business License #:
tx)
-93
BUILDING
Building Per t Info:
Bldg ❑ Elect ❑
Plumb
Job Description:
(P)
Residential -EA- C-ommercial ❑
Cost of Project 24%�Z�
Qty. if
,Applic¢ble 1 Fee ID
Fee Descrintinn
Fee Grolin
PPERMITFEE
Plumbing Permit Issuance
PLUMBING
BPREPIPE
Re i e of Fixtures
PLUMBING
BPERMFEE
Bldg. Permit Fees
BUILDING
BPFIXTURE
Pbl . Fixture
PLUMBING
BPWSVCS
Main Water Service
PLUMBING
BPSEWER
Sewers
PLUMBING
BPSEWAGE
Sewage Disposal
PLUMBING
BUSLIC
Business License
BUILDING