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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 • 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 •