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05020166 CITY OF CUPERTINO BUILDING DIVISION PERMITCON-TkkCTORANFORMATI,ON - BUILDING ADDRESS: JAMES C. SEAY PERMIT 5[05020166 WNEr-S NAME: PERMIT ISSUE DATE JAMES' ONE: SANITARY Ni CONTROL NO. ARCHITECfIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LOO LICENSED CONTRACTOR'S DECLARATION O O O O WU U1 hereby affirm tin I am licensed under previsions of Cliapler 9(commencing Job Description it Section 7Q7B)of Division 3 order Business and Professions Code,and my license is Lie.mmCi rid erdos Liccnse - REPLACE ELECT. SUBPANEL/ADD CIRCUIT p ? mc Class 4;:0 Dam Contmc er Ery ARCHITECTS DECLARATION �i z< I understand my plans shall M used u public records D31 yU 0� Liccn cd Professional 3 OWNER-BUILDER DECLARATION <i 1 hereby apron tat 1 am exempt from to Conmscto's License Law for the 00 following moon.[Section 75131.5,Business and Pmfr'aim Cone:Any city or county a$ which mquire,a permit to construct,alter,improve,demolish,or repair any swemm prior to Rx issuance,also requires to applicant for such permit to rile a signed statement Ecothat Im is located pursuant to ffic provisions Of to Contractor's Uccrom Law(Clunsf 9 Sq.Ft. Floor Area Valuation at (commencing wit Section 7000)of Division 3 of the Business and Profrssm.Code)M tat he u exempt therefrom and to basis for to alleged exemption.Any violation of Section 7031.5 by arty applicant for a permit subjects to applianuo a civil penalty of 3 4f$1 MI914aei0 0 Occupancy not comm tan five hundred dollen(5x001. P Y Type O 1,Is owner of the prepery,or my employees with wages u dicer sole compensation, will do to work,and to shoots,is not intended or offered for aide(See.701,1.Business and Professions Code:The Conmemes License Law does not apply to an owner of ..acquire spections progeny who builds or improves tenon,and who dues such wink hinulf or trough his own employees,provided Na such impmvemens,are not intended oroffemd formic.IL however.to building or impmvemenr is cold whin one yeti ofowner,n,to owner, builder will have Om burden of proving Nat he did not build or improve for purpose of V mRJ. 1,as owner of she property,am exclusively concocting wit licensed conhacmrs to cumtmet do project(Sec.7044,Business and Professions Code:)The Canuactri Li corse Law does not apply to in owner of propeny who builds or improve domain,and, who mnmets for such projects wit a conmemgs)licensed pursumt to to Conhactore License law. ❑1 am exempt Motor Sec. ,B At P C for tis moon wrier Date WORKER'S COMPENSATION DECLARATION 1 hereby aRrs,under penalty of perjury one of the fallowing declarations: I have and will maintain a Coriff W4 ofComent to se8-insum for Workeri CrmlMn- sation,as provided for by Section 3700 of de labor Cam.for to performance of the work for which this permit is lamed. ❑1 have and will maintain Workers Compomatm Insurance,u acquired by Section 37M of do labor Code,for to performance of to work for which this permit is issued My Worker's Compensation Insumuce carrier and Policy number am: Canicr: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not he completed if to permit is fmomc hundred dollars(5100) unless.) 1 Unify tat in to permrmanm of she work for which tis permit is issued.I shall mol employ any person in any man ny nttJI� }obi etm she Wmkcri Compinvuhm Laws of CalRom' Dam /1 Ot Applicant _ NOTIC LICANr:If, fm rtlakmg rrtlakmg r cnf of t Exemption,oq you should bttom uE i m tc Workch Compcnmtion preiFitns mf to IaM1nr Code,you muss .,.� fortes amply with such provisions or to permit shall he dttmcd nvokcd. zO CONSTRUCTION LENDING AGENCY 'r+ 1 hereby affirm tat dem is a construction lending agency for the performance of lY to work for which Oka permit is issued(Sec.3W7,Civ.C.) W A Lenders Name =z Undcrs Address U Q I canify tat 1 have read Nis application and stain tat the amen information'¢ ly fir cart I agree to comply with all city and county ordinances and suite laws relating to ' p U building construction.and hereby amhpfim mprearrusti s of this city to came upon do r G above-menunned property for impoctien purposes. (We)agree to save,indemnify and keep humless the City of Cupcnino a,imt r h liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of to granting of des permit ^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 21/ Die SOURCER ULATIONS. </ 2 ? Re-roofs Si re pplieanvcnnmaor D.m HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will she applicant or future building Occupant scare or handle hamrdous material as derined by to Cupertino Municipal Code.Chapter 9.12.and to Heald and Safety See....seetizssun(aAll roofs shall be inspected nor to an roofing material beim ❑Yea ONn P P Y g g installed. Will the applicant or future building occupant use equipment or deice which If a roof is installed without first obtaining an inspection,I agree to remove mit hanrdoe air contaminants as dcrined by to Bay Area Air Quality Management all new materials for inspection. District? 0W WN. 1 have mad de hexardaus materials requirements,under Chapmr6.95 of to Califm- nia Health&Safety Code,Seetioe 25515.25533 and 25534.1 understand dztifte building don not currently hoc a mnanL tat it is my respomihiloy to notify to Occupant of the rcquircm hicb mumMand pnonoissuancc ofa CcniOcate of Occu i Signature of Applicant Date Owner mhori'red agent am roof coverings All f in s to be Class "B" or better rx Community Development 10300 Torre Avenue J Cupertino CA 95014 Telephone(408) 777-3228 � CITY OF Fax(408)777-3333 UPEkTINO Building De artment JOB ADDRESS: `PERMIT # OWNER'S NAME: Tq�,rr r per �J PHONE GENERAL CONTRACTOR: ,Lio FAX # I am not using any subcontractors: i /Signature Date Date PIease 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 OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent, spouse or child) will perform: A. V All the work authorized by this permit B. A portion of the work C. _ None of the work If B or C is checked,complete 2 or 3-below, 2. A state licensed contractor will be hired to do: A. _ All of the work B. A portion of the work (complete section below) Contractor Address/City Phone # State License # Type of work to be performed 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer(see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. - Persor/Firm Address/City Phone Number Type of work to be erformed ..................................................................................................................................................................................... I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder513 Ejov e). Property Owner's Date: I Job Address: Permit# Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. j.: City of Cupertino Building Department CITY OF 10300 Torre Avenu C O P E kT I NO Phone: (408)777-3 Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as owner-builder you are the responsible party of record on such a permit Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself, you may protect yourself from possible liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the city or county. They are also required by law to put their license number on all permits for which they apply. If you plan to do your own work,with the exception of various trades that you plan to subcontract,you should be aware of the following information for your benefit and protection: If you employ or otherwise engage any persons other than your immediate family, and the work (including materials and other costs) is$200 or more for the entire project, and such persons are not licensed as contractors or subcontractors, then you may be an employer. If you are an employer,you must register with the state and federal government as an employer and you are subject to several obligations including state and federal income tax withholding,federal social security taxes,workers' compensation insurance,disability insurance costs,and unemployment compensation contributions. -- There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with respect to workers' compensation insurance. For more specific information about your obligations under federal law,contact the Internal Revenue Service (and,if you wish,the U.S.Small Business Administration). For more specific information about your obligations under state law,contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale,property owners who are not licensed contractors are allowed to perform their work personally or through their own employees,without a licensed contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder building permit,erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing their own work personally. Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your community or at 1020 N Street,Sacramento,California 95814. Please complete and return the enclosed owner-builder verification form so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. Very truly yours, Building Department, n City of Cupertino Printed on Recycled Paper -( - CITY OF CUPERTINO ` CITY OF PERMIT APPLICATION FORM 0 , � Z CUPEkTINO N # 3 yc� y,J�— �a ` © d Date: I a 1 I Building Address: Mailing Address (if different from building address): I Q Q 7 w� Owner's Name: Phone#: s Contractor: License : Contact: Phone: Cupertino Business License#: �0. Fax: Building Permit Info: Bldg ❑ Elect 14 Plumb ❑ Mech ❑ Job Description: n 6A&Residential-M b c9 ���c�r� • Sv� An k 99 Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy Group: Type of Construction: , / ,� / Please check this box if the project is a V V second-story addition: ❑ ro'ect Size: Standar Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> IOOK to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILERS Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax—Resi/Mobile BUILDING BELEC1000 Elec 600V <= IOOOA ELECTRICAL BELEC1001 Elec 600V> 1000A ELECTRICAL BELEC200 Elec Svcs 600V <=200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING � 707 1of3 i ( 1 CITY OF CUPERTINO CUP TOF YO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Cbeck Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Fumace MECHANICAL BREMFURNOV Relo Furnace > l OK btu . MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2of3 3 CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Ternp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERNUTFEE Elec Permit Issuance ELECTRICAL MPERAIFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3