03080111 CITY OF CUPERTINO �
BUILDING DIVISION PERMIT CONT.RA.',,T,OR INFORMATION i
auaowc ADDRESS: MERCER SHERRYL E PERMIT 003080111
i
• OWNER'S NAME: PERMIT 15511E DATE
NE: SANITARY NO. CONIEOL NO.
ARCHITECYENGINEER: BUILDING PERMIT INFO
BLDG BLECr,— LUMB MECH
IO> O O
.0C LICENSED CONTRACTOR'S DECLARATION Job Description
,i F I hereby affirm that I am licensed under provisions of Chapter 9(commencing y�
with Section7M))of Divislon3ofbe Bustncre and Propellant Code,and my license is SEp 20d 2003
i'q<z u«�Is�cl`asand enact. L1C g WATER SERVICE CHANGE JC
F Data Contractor r
ARCHITECTS DECLARATION BUILDING
qg 1 understand my plana shall be used as public records IGA
EW
.e G Licensed Professional
„3 OWNER-BUILDER DECLARATION
<I I hereby affirm that I am exempt from the Contactors License Law for the
❑O following reason.(Section 703 1.5,Business and Professions Code:Any city ar county
`�$ which requires a permtt to construct,alter,improv,demolish,or repair any structure
d-Zin pAnissuance,
an its also requires the applicant for such permit to file a signed statement
< thatWislicensedpunoammNcpmvisionsoftheContractor,LicenseLaw(Chapkr9 Sq. Ft. Floor Area Valuation
go (commencing with Section]DTD)Of Div'uionJ of the Businessand Professions Chalk)or
��� that he is exempt Neafrom and the buil for the alleged exemption.Any violation of 36921033 . 00
Section 7031.5 by any applicant for ap arch subjects the applicant to a civil penalty of APN Number Occupancy Type
not moa than five hundred doll..($500).
❑1,as owner of the property,or my employees with wages u their sole compensation. ��p��7}pprigeCt1005
will do the work.and the sncmm is not intended or offend for sale 704x.BBusiness 106 — R VIre9`t
and Professions Cada:The Connector,Licence Law docs not apply to an owner or
properly who builds or improves thereon,end who doer uch wolchimself or through his 202 — UNDERFLOOR PLUMBING
own employees,provided that such improvemmus sae not intended oroQered for aie.If. 301 — ROUGH PLUMBING
however,the building or Improvement is sold within one year of completion.the owner.
Wilder will bars da burden of proving Nal he did not build or impmw for purpose of 302 — TUB & OR SHOWER
ale.).
I,as owner of the property,am exclusively 502 — FINAL PLUMBING ENERGY
❑ Se P< Y• d contracting with:)no d contractors la
connmct the project(sec.7rN4,Business and Professmu Cade:)TTe Conuacmri Ib 506 — GAS TEST
come law does not apply to an owner of propeny who builds at improves Neeson,and. 507 — FINAL PLUMBING
who connotes for such projects with a conttacor(s)licensed pursuant to are Contractor,
License law.
❑lam exempt under Sec. .B&P C for this ruson
Ow er
'a-
WORKZRS COMPENSATION D RATION
hereby affirm in dm isonalty of ixoduryoro of wing declaatimme
I have and will routines a Cm6ficam of Consent to self-insum for Worker's Camper.
aasun,u provided for by Section 3700 of don labor Code,(or the perfom ince of the
work fns which Nis permit I.issued.
C3I have and will maintain Workaanu
Worker's Compensation Inrce, required by Section
3700 of the labor Code.for the performance of the work for which this permit is issued.
My Warlices Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not be complomd Irthe rcnot isforone hundrod dollus(SiffO
lir less.)
1 cenify that in the performoace of the work for which this permit is issued,I.hall not
employ any person in my manner an as to become subject to the Workers'Compensation
Laws of Califarnis.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of be labor Code,you must
,Z forthwith comply with such provisions or this pube
ermih.11 deemed rewked.
'Z~(ZI.
rCONSTRUCTION LENDING AGENCY
[—� I hereby aRtrm Nat there is a construction lending agency lot the performance or
C the work for which this permit Is issued(Sec.3097.Civ,C.)
C0 tender's Name
= z lender,Address
O Q I cenify Nu I haw read this application and sum that the shove information is
{7. F correct.I agree m comply with all city and county ordinances and suite laws relating to
❑U building construction,and hereby authorise repsesematiws or Nis city to enter upon the
G above-memo ned property for inspection purposes.
(Wc)agreeto an.indemnify and keephumpless,
ayinan they City of Capers.tsid City
.F.r Vy liebilid(We)gre to cans Indexpenses nifynd kie msyinanywytyof aold City
U Z in consequence of the Shunting or this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by: Date
SOURC GULATIONS.
/// Re-roofs
nuua of ApphcanUConsrumr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dm applicant or future building Occupant sort lir hendls havuduus material
as defined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
Cak.Section 25532()7 All roofs shall be inspected prior to any roofing material being installed.
❑Yu �No
Will the applicant lir future building occupant use equipment lir devices which If a roof is installed without first obtaining an inspection,I agree to remove
rit haardnu air canuimim n,as defined by the Bay Area Air Quality Management all new materials for inspection.
Wrier?
❑Ya AN.
1 have rod the hsrdous materials re,iremcnb under Chapmr 6.95 of the Califor.
nix Health A Safety Code,Stations 25X15,25533 and 25574.1 undemmnd that if the building
does not currently haw a amount,Nat it is my sespomibil lty to notify the occupant of the
sty ' mcnmw' muslEemepjiyfwiaa,nceaocemnc nrot�f�a 0 Signature of Applicant Date
Owner m.tithmiredag AI ///mow`✓ oats All roof coverings to be Class "B" or better
' OWNER-BUILDER VERIFICATION
' 1. (Check one) I or my immediate family (parent,spouse or child) will perform:
A. _ 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)
ContractorAddress/City Phone # State License # Type of work to
A391" 1,19 - - S Q4,L i 0Reeve 1,4-7fi, 9 be performed
a a
C(44y" ]RECEIVE.' 'e
Gj Tgr(icc
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 and t the
Owner-Builder Information (reverse side).
Property Owner's Signature: �/ ✓t' }'Y/r � Date: -
Job Address: /0 7 AiUatt Is(L a:,A�,�.i Permit#
Any changes to the infovided on this form shall be submitted to the ' -,�COu erhno ld
• Deyartment.
i
City of Cupertino Building Department
OF 10300 Torre Avenue
C O P E kT I N O Phone: (408)777-3228
Dear Propel 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:than If you employ or otherwise engage any persons other an 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 Irate 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 laboi 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
CITY OF CUPERTINO o ` C
REPIPE/SEWERS/MAIN SERVICE 3
CUPERTINO PERMIT APPLICATION FO
APN#
Building Address:
10 -7 g R2cok—WEi-C. DP, ( VEE
Owner's Name: Phone#:
S M F-ceC E VL 4OV-_
Contractor: J r Phone: License#:
_
Contact: SI�E�tI�zY AA E 4 a& 473 6 Cupertino Business LicenserL—
#:
B ' mg Permit Info:
Elect ❑ Plu
Job joerEription:
Residential Commercial ❑
Cost of Project:
Qty. i
A lic Fee ID Fee Description Fee Group
PPERMTTFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldiz. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BU LIC Business License BUILDING
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