05040119 CITY OF CUPERTINO %a- A
BUILDING DIVISION PERMIT CLINTRACTnR INFORMATION
a BUILDING ADDRESS: WATER SYSTEMS PLUMBING PERMITNC05040119
.19735 AUB RN
W NER'S NAME: PERMIT ISSUE DATE
ALBERT SCHERER 3844 HEPPNER LN 04/20/200c;
10 ONE SANITARY NO. CONTROL NO.
(408) 266-8222
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'SDECLARATION Job Description
C 1 7 ffirm athat I am reamed under ivmu of Chapter 9(mmmcno
cing
U with Section
on]IXIU)of Division 3of�hcBminesa enndd Pm@ssinnsC dmyliccnm is
. oN L eneCllesndeffeCl.s` Lic If 680 —7 r REPIPE/MAIN LINE
Z License chis GG�� I
Dam Contractor
J2E ARCHITEC1`5 DECLARATION (k1
K I undersand in,plans shall be..it as Public records v
'u.
nu
3 0 Licc )Pmfcssionel
OWNER-exempt R DECLARATION 0
.C 0 1 hereby.(Erre that 1 1. exempt from the Contractors License Law for the
C o following masa.. emit t 703 1.5,Business and improve,
de tins Calc:Any city.,County
which rtyuiroa n permit to tines Lhe alma improsu demolish, file
repair any macent
PdOr
H Z a that he its i en e d c.also pursuant to the the Applicantor forthe Contrach ctor's
lLuca=Law hapocrm
(commas Tuna)pursuanttoh)of Division
ivionn3 of t Comoumrind Professions
Law(Chapmr9 Sq. F[. Floor Area Valuation
w. (commas examithhomfon7000)thebasis for tftheeged Business and Pro Any violde)ation
of
y�� Nat be u exempt Ibere(rom and Ibe buts far the illsgrA exemption.Any violation a(
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penally ofCi0 0 Occupancy Type
not m..Nm
an e hundred dollars P Y YP
El 1.ass owner of Jia pmperty,or my employees with wages ss their sole compensation,
will do the work and the swcwre is not intended or offered forsile(Sec.7(Y14.Business
and Professions Code:The Contractor's License law does not apply to an owmr of Required Inspections
property who builds m imyrows thereon,and who does such work himself or through his
own employers,provided that such improvements art not inmrbed moRemd forsak.if,
however.the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that M did not build or improve for purywu of
sal.).
❑1,as Owner of the property.am erzlusively contracting with licensed contractors to
emutrvcl Nc project(Sec.7W.Business and Professions Cal:)The Comism st's Li .
cents law does not apply to an Owner of property who Wilds or improves Ncreon,and
who convaea for such projects with a eomnemKs)licensed pursuant o the Convectors
License Law.
I am exempt under Sec. B&P C for this mason
13071Date
WORKER'S COMPENSATION DECLARATION
1 hereby afro under penalty of perjury One of the following declarations:
I have and will maintain a CeruBale of C...i to ul6inu,for WorkersC.N.-
W
on,us provided for by Section 3700 of the Labor Code,for the performance of the
k err which this permit is issued.
1 have and will maintain Workers Compensation Insurance,es mi,ired by Section
of Ne labor Code,for Ne performance or Ne work for which Nis permit is issued.
Worker':C.[LpP�pensation lmm�na saris,and Paiq numWra'.r[ae:1� s
Grticrf FrrC Policy No.:137.; 0 1 —.2OID
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the Permit is Intone hundred dollars($113()
or less.)
1 anify that in the performance of the work for which this permit is house,I shill net
employ any parson in any manner SO o to become subject o the WorkersCompawuon
Laws of California.Dem
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
Wxrome subject to Ne Workers Compcwtion previsions of the lecher Coder,you most
.,z forthwith comply with such provisions or this Permit shall be accrued rmmked.
'Z'O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency rot the ptrformance of
(Y the work for which thu permit a issued(Sec.H197,Civ.C.)
tr]Q Lender's Name
= z Iemdera Md.
U Q 1 cenify that 1 have read this application and sato that the above information is
U, F" Carmel.I agree to comply with all city and county ordinances and state laws relating to
C) building construction.tied hereby authodre representatives of this city to enter upon the
r Qabovcmentioned property for inspection p oposea
(—' 9L. (We)ogre to ow,indemnify and keep huml.the City of Cupertino against
y Iiabiliuca.judgmena,costs and expenses which may in any way accrue against said City
(„) z in consequence of the graining of this ,mil.
'—' APPLICANT UNDERSTANDS WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R �LkA�TI.D�NS.
Signature of pplimnVConuamor Dare Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fmua building Occupant store or handle havardous material
dcGncd Cupeprtino Municipal Codc.Chapter 9.12,and the Health and Safety
dc.Sccdonbythe 25532(aAll roofs shall be inspected nor to an roofing material bei.
❑Yea �i. P P Y g g installed.
Will the applicant or mtnm building occupant use equipment or dcvias whim If a roof is installed without first obtaining an inspection,I agree to remove
M
it havadous air contaminants az dcrined by dm Bay Area Air Quality Management all new materials for inspection.
DialricQ
❑Ycs KNu
I have mail Ne hvardrms materials requimonsma under Chapter 6.95 of the Calif.,
Iia Health&Safety Coda,Sccumts 25N15.25533 and 25534.1 and.nand thd if Ne Wilding
Jties not autmnlly have a tenant,that it is my responsibility m nouly the cmupam of the
req mcnItt whim e gpostaleme,prior to issuance of a cenmaam of a�cuyM% Signature of Applicant Date
y��o
Owneror authon7od agent Dam All roof coverings to be Class "B" or better
Community Development
aa
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT #
H735 Avtburn -Dr,
OWNER'S NAME: AL t S u PHONE # 214 - 812-t
GENERAL CONTRACTOR i see, �,,,. FAX #
I am not using any subcontractors: q-,2 0 ^D-T-
Signature
Signature Date
Please check applicable subcontractors and complete the following information:
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
Owner/Contractor Signature Date
CITY OF CUPERTINO
' REPIPE/SEWERS/MAIN SERVICE /
CUPECTINO PERMIT APPLICATION FORM
APN # Date:
3 o y- 20- or
Building Address: g 7 3 sb
u �sl Qf.
Owner's Name: ff Phone #: �7
o h I �` z51 ' �117
Contractor: Phone: License#:
wale244 - 2.222, 68o -7X I
Contact Phone: Cupertino Business License#:
M, k k,O r itt 8 Z --oq6
Building Permit Into:
Bldg ❑ Elect ❑ Plumb
Job Desc iption:
f.w VK0.m k.nG
Residential Commercial ❑
Cost of Project:
Qty. if
Al5plicable Fee ID Fee Description Fee Group
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
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