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03120061jp0 NM i� 3��FF U CITY OF CUPERTINO ,`L ti Q z 0 iTa ftp *`""�`�^x•'�" �"` BUILDING DIVISION PERMIT �ifQNI CTO IN%'Ok'MA Q, ' BUILDINQ ADDRESS: REED JAMES W AND KAREN B PERMIT NO.03120061 22 OWNER'S NAME: PB rr MSUEDAM REED JAMES W AND KAREN 13 NE: SANITARY OL N0. ARCHITECTIENGINEER: BUILDING PERMIT INFO B O ELECT PLO O LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that l am licensed under previsions of Chapter 9 (commencing wish Sedan 70u0 of Division 3 of Ne Boa.aW prefesaiom Cade, and my license Is in rren NEW GAS LINE TO FIREPLACE Lkauo Class Lk. g iceneClass Dau CO-rs ' ARCHITECTS DECLARATION I understand my plans lull k used u public mmrds Licensed Prefcuiaml OWNER -BUILDER DECLARATION I hereby Stull that I am emmpl from acv Contractors License Lou far Ike (allowing mason. (Section 1031.5, Business and Pmf"siom Code: Any city of county which requires a Permit m construct, slut improve. demolish, or repair my etrmure Prior m its Issuance, alm requires the applicant for such Permit u file a Signed mtement law(CMput9 Sq. Ft. Floor Area Valuatio Nat he is licensed pursuant u Ne prevision of the Contrmuri License (wmmeneing with Section 70100) of Division 3 of the Business and Profession Code) of Nat he Is emmpt thertfamm and the basis fa the alleged exemption. Any violalfon of Section 7031.5 by any applicant for a permit Subjects the applicant m • civil penalty of 3 5 V1tW*ero 0 Occupancy Type not more Nan five hundred dalks ($5001 0 Lsa. rte propmyncM'empuy. with wgesuUebmle eompeanton. willdo lhework, and the Wuctum isnmlmendlulmoQared forsau(Sec. 70a4,Bummu Required Inspections 9 p and Pmreuions Code The Conummrs License Law dues Out apply u an Owner of Wlld; or hu himmcaul damprevemmuarenmrounded owpmywk fireugh providmpmvealhimpecondwkdma,mhwal ownemployees•provided Nue, maDeaedhr uk. if. builder, Ne gar improvement is halt within aro )vara improvefar builder will kve to bunters of proving tut k did mol kilt m Improve !or purymt of haveth all..). 0 1, m Owner of the Property. am emluaively contracting with licensed mnlranurt u mmtmm to project (Sec. 7044. Ballow and Preraudom Code:) The Comnnors Li - ✓(� came law dean am apply m an weer of property who builds as improve demon, and. who contracts for Such pmjem with a conlambr(s) twined personal m the Contractor, nee law. lmm..maapplanim SCec �Jq/ B&PC for this mason .. 0. /` � \ C 7/MPE.C� DaOW . COMPENSATION�rSij.ARAT10 I hereby affmm under penalty Or perjury of the following deck adore: have end will mdnuin a Ctntesu of Consent msel6iam for Wor4era Compen. , u provided for by Section 37M of the labor Cade, res the penarmame of to IMyWORKERS for which this Permit is issued. ban and will maintain Workers Compensation Immanuel. u requited by Smton of the Vbur Cade, far the performance or the work for which this permit is Island. Workers Compensation Insuruue emirs and Policy number art: Cmer, Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (ITU section need nut W completed RIke permit is foram hundred doll=($100) or Tru) I calory that in the performance of the work for which this Permit a island, l shall not employ any person in any manncrm u u WIMS, tyle, u IRe�ark�rtLompemetlon S WS` (( Tawe of Call- !"�A , A I I NOfIC APPLICANT: If, abut making Nu CeAOule of Exemption, you should Warren, jmt u the Worker's CompemWon provisional often lakr Code, you mut foMwitb comply wish rah provisiam or Nis Permit shall be deemed revoked. CONSfRUCDONt.ENDINGAGENCY I herby eRmm aper Nem is • connotation lending agency fm the performance of the work (" which Nu permit u issued (Sec. TIM. Civ. C.) Lenders Name ' Lendefa Address 1 cnmify, that I have mad tide application and ,tau that the be. InfmmWun is colts" I agree m comply With WI city and cOmty Otdinalltte and state laws MIAling m Wilding construction. and hereby auNodm mptesraudves of NU city to enter upon Ne, shove- (W do gm property (m inspectionnificer, blameless the City of Caperton against (We,) agree to eve, indemnify and hick hay In M y mng and expenses which may In any way accmc Against said City / Aconsequence U Ne granting or this perms inconsequence of APPLICANT UNDERSTANDS AND WI1 COMPLY WITH ALL NON -POINT Issued by: Date SOR R ULATONS. �'� Re -roofs Type of Roof rue of ApplicmtConuactor HAZARDOUS MATERIALS DISCLOSURE WilltoappiimniorfuturebLalding"cupuLa morhuhuhanrdommamrial defimd by the Cupenino Municipal Cade, Chapter 9.12. and the Health and Safety ede, Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed. 4 Oyu ..PINS 0.1, ' If a roof is Installed without first obtaining an inspection, I agree to remove Will the applicant or future building Occupant use equipmmt or devices Which haurdnus air canumimenu u defined by the Bay Area Air Quality Management all new materials for inspection. DiRri 57 El Yen .819u I have mW the hasallous materials requilcments underCkptar 6.95 of the Califor. nia Hearth&Sa(etyCode.Seem=25505.15533 and 2553/. l understand and if me Wilding Jana nor currency how a anent Net It ism "Pomibillty u notify Ne, occupant of Ne 11 11 4mi menuwhicchhmustk mm.f.0c fe.y Orompm .`v Signature of Applicant Date / Z roof coverings to be Class "B" or better own m mNomed egem DataAll OWNER -BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent, spouse or child) will perform: A x 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. Person/Firm Address/City Phone Number Type of work to be performed I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner -Builder Information (reverse side). Property Owners Signature: /� 4 o 0� Date: 12 - I I -03 Job Address: :2 CY E JZ4A � Permit # 2'd OP 1. ^� Department. Dear Property Owner. City of Cupertino Building Department 10300 Torre Avenu Phone: (406 777-3 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 US. 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 ow;t 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, City of Cupertino Printed on Recycled Paper a0F CUPEkTINO (9312aaX) CITY OF CUPERTINO PERMIT APPLICATION FORM 1 of 3 # _ T Date: 1 Building Addr 7N O wner's Nafie: Pone #: ontractor: License #: S Contac(, J° ��Gt 1� e Cupertino Business License#: Building Permit Info: Bld Elect ❑ Plun*'t Mech ❑ Job Description: Residential ❑ 1 1�� r/ „ice to er al e Sq.Ft. Floor Area: $/Sq. t.: Cost of Project: (� Occupancy Group: 2, Type of Construction: Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILER1 Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > I OOK to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 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 <= 1000A ELECTRICAL BELEC1001 Elec 600V > IOOOA ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING _ BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING 1 of 3 4 L a7r o CUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BMITIGATR . Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi -Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BNUSFD New Single Family Res BUILDING 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 Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Repipe 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 cfrn MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREM 3USWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREVE URN Relocation of Furnace 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 2 of 3 CITY o CUPERTINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Grou BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/After Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 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 13UILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECUL Special Inspection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 3 of 3 J