06090159 CITY OF CUPERTINO
BUILDING DIVISION PE MIT
BUILDING ADDRESS: ALL VALLEY PLUMBING PERMIT NO.06090159
21740 LOMITA AVE
OWNER'S NAME: FERMrrr I SUHDATE
STEVE ELLSWORTH 3345 SELDON CT 09/20/2006
ygE. SANITARY NO. CONTROL N0.
(510) 376-4816
ARCHITEC (ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
!oo LICENSED CONTRACTOR'S DECLARATION JOb Description!I"J I hereby affirm tat 1 am licensed under prevision of Caper 9(commencing
zj wilhsccdan7OOB)ofDivisian3of&BusirmssandProfcssiomCode.Wmylimmis WATER HEATER REPLACEMENT
e p Dale
an, 7rSDECLARATION RATION
IuncsunJ my piens Mail housed
As public rtcwm
c Licensed Professional
1y� OWNER-BUILDER mDECLARATION
i
COO
I hereby affirm on I em exempt fruit Om Cssions o IJecoR law for the
apo following masa n.Permit
t ]1131.5,Business and Profession Cotte:Any Amy s county $482
$ which its ism a prem m consnck alms Improv,mmnitsh,me,sig any atrteorm
-Zf~^ thiorbiuivueoce,alw rt 10 Led dmaWons o for mchpemi'b OmuLaw(Mutemenl
££mmom (commenkcnedpursuant 7")ofDialonaofbee,Buidess xmnRlaW(Capmr9 Sq.Ft. Floor Area Valuation
aF (commencing with Scdi.n]OW)of Division 3 o NeBmimuand Profession Cade)or
y $ that M is Attempt IMaefmm and the bub for be alleged eaempdam Any violad,on of
Station 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of r Occupancy Type
out mart than five hundred dollars(3500).
0 1,As ower of the property,or my employ..with wages u Neth sob compewdon,
will do the work end the sucwhe is niummaded or offered rankle($".7014.Barn. Required Inspections
Add Pre diction Cade:The Conuecmes Licewe Lew does not apply b an owner of q P
pmpnywhobuildscrlmprewabemon.andwhodaeasuchwwkhlmsalfor Woughhie
own employees,pmvided bnl such Improvements Are nosh mnded oroRered for sale.If.
however,be building or Improvement is sold within one year of completion,the mmcr.
builder will have the burden of proving bet he did not build ar Improve for purywe of
sale.).
0 1,as Owner of the property,am exclusively contracting with licensed con nscbm b
construct be project(Sec.70".Business and Prefeui.w Code:)The Cnuusoes U.
cane law does not apply An an owner of property who builds orimpws thumn,and,
whoconuacLL for such pmjects with a con amr(s)licensed pursuant b the Comnemes
License law.
0 l Am exempt under Sea .B&P C for this won
Owner Dam
WORKERS COMPENSATION DECLARATION
1 hereby LBIm under penalty of perjury an of be following deelanormnd
1 have end will maintain.CutViiumaf Co..[to salt-inure for WarkePaCompen-
.don,As provided f.,by Section 3700 of the labor Code.far W performance Of the
wah for whish this permit is bsudd.
0 1 base and will maintain Worker's Compensation u mquimd by Section
3700.f Me Mbar Code.far be pe fomanceof Oe work for which this permit is issued
My Worker's Compensation htsuratme canduW policy number art: aq
Cartier. IMC ZBNriH Policy NA,;C-065501401
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis mire need not becomplucd if the permit is farone hundedd.11an(3100)
or Ica)
1 anify that in be perfwmancc of the work,for which bis permit is issued I Mall not
employ any person in any mrd cr ao As in become subj"t in be Waders'Gampnation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this CcniOnm of Emmption,you Mould
become subject to the Wo&ets Compdwtion provisions of the labor Cede,you muss
'J Z forthwith comply with such provision or this permit shall be deemed Rveked.
O CONSTRUCTION LENDING AGENCY
1areby afnrm that there lex eounctinn lending agency for the pAformameof
the wort for which this permit b issued(Sec.3M.Ci,C.)
W Q Lender's Nurse
Lendee.Address,
V Q I canify dust I have mad this Application And sum tun the shove informadun Is
U, COMM l agree to comply With all city and county ordinencesand Mme laws misting to
0 U building convection,and hereby auborim mpresemmivcs of this city b enter upon the
W above-mentioned property for inspection fugmus.
4 (WA)agree to save,indemnify and keep harmless be City of CupaftinO against
vE"y fq
liabilities judgments.costs and eapemas which may In any wry accord against mid City
U 7 in cuuequance of be{noting of this permit,
v7 APPLICANT UNDERSTANDS AIJD WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RENULATIn,5&k � Cl�ZD/D�
l>>t JJs Re-roofs C7
Signature of ApplicuruCanusactor Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the APP1ICAALCupertino
or lMuni building e.Chant store or addle Heardon material
As mRmtl by the CupeninO Munidpal Code.Chapter 9.11,and tM Hulth and Safety
Cam.section 15532(a)? J.JJJJ All roofs shall be inspected prior to any roofing material being installed.
OY. Na
Will the applicant or I tuR building ocntp m use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hmardow alai commommis As dorms by the Bay Arta Air Quality Management all new materials for inspection.
District?
OYw Nu
I have Rut the losommw materials mquimmew under Caper 6.95 of the Califw.
Ala Heath&Safety Cam,Sccdwu 25305.15533 and 15534.1 understand that if the Wilding
dor ret currently hew a tenant.bat it b my mMponbility in miry Oe occupant of due
mqui n13 which ones! tpnwgOiuu is Certificate of Occupancy. Date
Z _LJLy✓�wl� �l`1.0�0� Signature of Applicant
ow.erw audumocd.Zen( oam All roof coverings to be Class"B"or better
CITY OF CUPERTINO
•m 2 of 2 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35718002 . 00
DATE ISSUED. . . . . . . : 09/20/2006
RECEIPT # . . . . . . . . . : 36129
REFERENCE ID # . . . : 06090159
SITE ADDRESS . . . . . : 21740 LOMITA AVE
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : STEVE ELLSWORTH
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . :
RECEIVED FROM . . . . : ALL VALLEY PLUMBING
CONTRACTOR . . . . . . . : MARY SANDBRINK LIC # 23015
COMPANY . . . . . . . . . . : ALL VALLEY PLUMBING
ADDRESS . . . . . . . . . . : 3345 SELDON CT
CITY/STATE/ZIP . . . : FREMONT, CA 94539
TELEPHONE . . . . . . . . : (510) 376-4816
�EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BENERGY PERMIT FEE 1 . 00 34 . 86 0 . 00 34 . 86 0 . 00
BPWHEATER PER HEATER 1 . 00 10 . 79 0 . 00 10 . 79 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
---------- ---------- ---- ------ ----------
TOTAL PERMIT 84 . 02 0 . 00 84 . 02 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
--- -- ----- -- ----- ----- ------- ------------------
CHECK 168 . 04 7481
TOTAL RECEIPT 168 . 04
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
----------------------------
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
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Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
car Fax(408)777-3333
4JUPEI�TINO
Building De artment
JOB ADDRESS: PERMIT#
OWNER'S NAME: I/ I-f- PHONE # .fD - 9,P
GENERAL CONTRACTOR: FAX #
I am not using any subcontractor o—oC
Signature Date
Please check applicable subcontra rs and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
AM 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 wogc(ep
WATER HEATER
:CUPEkTINO PERMIT APPLICATION FORM
APN # I Q „ Date: / D/
Build* Address:
2 d C mid (cL . q561
Owner's Name: n Phone#:
Conc)r: /ql/e d �i7 D/ L�9 e#�1��
Contact: M one• Cupertino Busines License#:
Building PermitInfo: /
Bldg ❑ Elect Plumb Its Mech
Job Description: GLS`
Residential Commercial ❑
Cost of Project: 1*".
Strapped On Platform Bonded
New Location ElReplacement @/
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEA'I'ER Water Heater/ Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
/ BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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