03070149 (2) CITY OF CUPERTINO ^'�^ saCzdsa -. ,?
BUILDING DIVISION PERMIT CONTRACTOR INFOTtMATION
n :LDINGADDRESS: WATER SYSTEMS PLUMBING PERMITNO03070149
711711A r)RANGE TREE IA.
OWNER'S NAME: 3844 HEPPNER LN PERMITISSUEDATE
ONE: SANITARY NO. CONTROL NO.
(408) 266-8222
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
Y00 LICENSED CONTRACTOR'S DECLARATION tion (�
C 1 heR (f
hy affirm that 1 am licensed under proviuJobDescriP
on5 of Chapter 9(commencing �9 N tJ�n�A P.tt�
U withsm 70fM1)nf Division3of Ne in.and Pmessino Code.and my license is
Lell fn erten. L 6 g( REPIPE/REPLACE WATER LINE 8 2003
g
Lice Cress Lin.. J U L 2
n't$
Dow mr Yr
K"I A CHITS CLARATION
a dcrstanJ my phos shell Jns Public records ��I�D���
O�u
;o Licensed Pntfcaxinnal
OWNER-BUILDER DECLARATION
x1 hereby al'Erm that 1 am exempt from the Contractor's License Law for the
02 following meson.(Section 710 1.5,Business and Professions Cole:Any lily Or county
$ which m9uires a permit to convect,.Iter,improve,demolish,or repairr-any lu uc-re
prior m its i-uanro.Hou require the applicant for such permit to life signed statement
that he is licensed puruam to the provisionsnf,he Central Unnse Law(Chapter 9 'Sq.Ft.Floor Area Valuation
N $ (commencing with Section 7MEof Division 3 nl the Business and Profession&Code)or
_
that he la exempt therehom and the bash for the alleged exemption.Any vinlulon or 31634016 . 00
Section 7031.5 by any applicant for a permit objects She applicant oacivil penalty of APN Number Occupancy Type
not mom than Eve hundred dollen(5500).
❑1,as owner of the property,or my employee with wages as their aide compensation,
will do the work,and the Structurt is not intended or offered fonale(Sec.7004,Business — ] gg ..bons
and Professions Coeses e:The Contexture,Liaee Law ane.not apply to an Owner or 2 0 2 - UNDERFLOOR PL B I s
progeny who builds or improthereon,end whodues such work terminator through his
Own employees.provided Nat such improvements me not intended inclined for Sale.If. 301 — ROUGH PLUMBING
however,the building or improvement is old within one year of completion,the Owner.
builder will hear the burden or proving that he did not Wild or improve for purpose of 302 - TUB & OR SHOWER
sale.).
❑hruowner ofthe ctprogeny,am excessively confession&with;)nno Colum contractors to
502 - FINAL PLUMBING ENERGY
centore does project apply
in
owner
of and l y who i Code;)no Conusnon U. 506 — GAS TEST
root law does not apply e ts owner or proper(who Wates orlmproves Corton,and 507 — FINAL PLUMBING
who seLacta for such PmJccts with acamnnor(q licensed pursuer.10 the,Contractor's
Lions ext
❑1 em exempt under Sec. .B @ P C for this meson
Oe
wner De
WORKER'S COMPENSATION DECLARATION
I hereby of red under peolty of perjury one of She following decimations:
I have and will maintain.Certificate nu
of Consent self-inre for Workees Camper.
-tion,as provided for by Section 3700 Of the Inter Code,for the perfo lomce of the
work for which this permit is issued.
❑I hove and will maintain Worker's Compere-tion Insurance,as required by Section
3700 or the labor Code,for the petformanro of the wok for which this permit is issued.
M WorkCe,Cn Natio ejartier an Po'ynurnk,em: y
r,.S TY n Vhd Po' CMWORKERS- 2
CERTIFIC OMPE SATION'1 N AN WORKERS'
COMPENSATIONINSURANCE ,
(IDIS section need not he completed If the permit is for one hundnddollan(SIM)
or leve)
1 ecnify Nat in the performance of the work for which this Permit is lamed.I shall not
employ any peron in my manner an IS an become subject o the Worker'Comarrea on
Law,of California.Date '
Applicant
NOTICE TO APPLICANT:IL after making Cis Cer ifcate of Exemption,you should
become object to the Worker's Corepen-tion provisions of the I.hor Coca,you must
.JO forthwith comply wi0..In provisionm this permit&hall he deemed revoked.
z '� CONSTRUCTION LENDING AGENCY
_�
IhemM1y tRum Net there is a construction lending agency lir the Performance or
04 de work for which this permit is issued(Sec.3097,Civ.C.)
{&1 UnitNahe
1<ndera Address
U 0
O Q 1 ranee Cat I have reed this application and stem that the muve ws ociminn is
Dr U bonen.I agree to comply with all city otl county ordinances and eat t laws relating la
L7 V building conswction,and hembyiccu nurpoescmetivcs of this city to enter upon the
0. above-mentioned progeny forimpccdrn purposes. 1
(We)agree m um,in mnify and keep hatmle-the City of Cupertino against
U fq liabilities,Judgmenta,c B OfL i may In any way ace-e against-id City
U Z in bits cncc m n&ref Ci r t.
AP (CANT R AND ILL COMPLY WITH ALL NON-POINT Issued by: Date
S RC S.
Re-roofs
Signamrtof ApplieanUComncmr i` Date -
HAZARDOU ALS DISCLOSURE Type of Roof
Will the applicant or futumbuildin cupmt Store or handle hexudous material
u mimed by the Cupertino Municipal C de.Chapter 9.12,and the Horth and Safety
Code,Section 25532O? All roofs shall be inspected rior to an roofing material being
❑Yea (N No P P Y g g installed.
wBl the appuem Or future building occupant use equipment or devices which, If a roof is installed without first obtaining an inspection,I agree to remove
hha-rGousmrenntammanr-dcrncdbytheBayAreaABQuablyManagement all new materials for inspection.
um7
❑Yes No
I have read the a.N sooerials mcnsundcrChipwr6.95oftheCalifor-
d&H-I0hiSalety 1 .25 Sand 25334.1 understand that if the Wilding
dna not a ow nant, t' my re a nihi'ry unto tify the accupant Ce
ecyul c e' m oh- odflicur.rixetipan ignature of Applicant Date
Dw ra thomcdearn, Date All roof coverings to be Class "B" or better
CITY OF CUPERTINO
0c, REPIPE/SEWERS/MAIN SERVICE 3 7
• CUPERTINO PERMIT APPLICATION FORM
APN# — yq Date:
Building Address:
Owner's Name: Q i Phone#:
F v
/'!� 7 �-
Contractor.- Phon : License#:
66 `92-22 �g67g
Contact: Phone: Cupertino Business License #:
�2f orh� 0266 $z22
Bu' mg nut Info:
]d i Elect ❑ Plumb
bescri on:
Residential ff _ (' Comm rcial ❑
Cost of Pro' ct: o
ODD _
Qty. if
Fee ID Fee Description Fee Group
PPERMPTFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
i''-..BPERMFEE Bldg. Permit Fees BUILDING
e BPFIXTURE Pbl . Fixture / PLUMBING
BPWSVCS Main Water Service PLUMBING
- BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING