03120055 CITY OF CUPERTINO 'cs
BUILDING DIVISION PERMIT �CONTlkAT-,,O-RxINFORMATIO
BUILDING ADDRESS: PERMIT NO.
JEFFREY D SCHULKEN 03120055
S PERMIT ISSUE DATE
F
W 'RE�Pn
SANITARY OL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
mo, LICENSED CONTRACTOR'S DECLARATION Job Des
pppp
in
C I hc.bY affirm that
I am licensed under previsions of Chapter 9(commencing
<U with 5eetum7=)),fD. soon 3 ofthe Business and Professions Code.and my license is
m in fun force and offer
5�: Leemeclasr Lw.g ADD 90 SQ. FT.
—o Dat Contractor FEB 1 8 2004
�sy ARCHITECTS DECLARATION
< I understand my pias.hall hPubl
e used as ic records
Ddu
ig,wt; Licensed Professional �a11 N II�t�ea�0
OWNER-BUILDER DECLARATION abs' utl1}�
+� 1 Wmhy alfirm than I am exempt fru.Oe Cmumemrs License Law for be
x
5.'00 fallowing resson.(Section 703 1.5,Business and Pmfestias Code:Any city or county
$ which paquims•permit to coruuucL ohm,imps•dcmnlish,or repair any swnure
prior or its issuance,also mquims Ne applicant for such PI 1.file s signed sate omit
shat he is licensed pursuant the previsions of the Contractor's Licenti Law(Chapter 9 Sq.Ft. Floor Area Val❑ IOn
hie (commencing with Section VOW)of Division 3 of the Business and Professions Code)or
w. $ that he is exempt therefrom and the basis for the alkgcd exempdm.Any violation of
Section 7031.3 by any applicant for a permit subjects the applicant to a civil parr lY of 3 7AMNI30e10 0 Occupancy Type
not mom than five hundred dollars(3500).
❑1,u owner of she ryoprny,ar mY employes with wegm as tiair sole compenssuon,
will dothework-end the he Contunot,Licensm awdofor rode(Sts.]oan Owner of
and edywhos Code:The Conmmors Luse taw does ret apply to an ough is Required Inspections
Own employees.
who Wilds or improvesch improvements
and who daeaauch work himself offered
his
ownemployes,provided Oat suchimprovementsarerat intendedoricumi.for owner-
however,the Wilding hu improwmc in is old within one year of improve
the owmr-
builder will have tho WAan of owing that W tlitl trot Wild m improv for pugoti of
ole.).
❑1,as owner of the pmpomy,am eaclmirely ca.raeting with licensed contractors to
comtmct the pmject(Sec.7061,Business and Professions Cade:)The Comnemn ti-
ewe taw dom mt apply man owner of property who Wilds or improv thereon,and,
who contracts for such projects with a mnuaetnr(s)licensed pursuant M use Contractors
License taw.
q'I am c.c.-P,Uder Sc 7 .B k P C for this moan
e %' Data (Z_lv-03
lWORKERIBIMPENSATION DECLARATION
1 hereby dorm under pendty of perjury ore of Ne following Hechrados:
I have and will maintain.CcrtiOm c of Continuo self-insure for Worker bCompen-
'numn,as provided for by Section 37M of the IOW,Code,for On perfmormce of the
work for which Nis Permit is issued.
❑1 have and will mdnldn Worker's Compensation I...as required by Section
3]00 of be labor Code,for the performsoce of the work for which this Permit is issued.
My Workces Compensation insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EKEMPION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not W completed if the Permit is forone hundred dollars($100)
or less.)
I certify that in the Performance of the work for which this permit is issued.I shall nm
employ anypc,an. ymanncir _in o2 Itothe Workers Compasadon
Laws of CdifotarL7��=.a —
ApPli f
NOTI TO A�p e :IL eller making Nu Genion of of Exception,Cod you abuse=
subjecttothe Workers Compensation this provisions of the Itsedr Code.you muse
�Q foMwish comply with such provisions or this Permit shell W deemed revnkctl.
z CONSTRUCTION LENDING AGENCY
F" I Wrebyaliirm Nat there I,.. firm wndingagercy,for the orfamumxser
pa.> the work for which this permit is issued(Sec.301 Civ.C.)
W n Lender's Name
�+ lenders Address
U C) I certify that I have read this application and some Nu the abow information is
LL f. mnect.1 agree to comply with all city and county ordinances and sate laws palating to
0U building consomme ,and hereby amhorin repromenutiv of this city to enter upon thc
}W above mentioned property for impaction pugwcs.
(WO)agRe m
to save,indemnify and keep harmleas the City of Cupertino against
F' ti limilium,judgrecou,costs and expenses which may in my way accrue against aid City
U z in eonseguenec of the granting of this Permit.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR�REGULA NSA_ ,e_
4 / !1-/0-03 Re-roofs
Signa
7'ar4pliciiiNcontonnor I Da r
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant mom or bandit our maarid
u deft ad by the Cupertino Municipal Code.Chapar 9.12,and the Health and Sac y
Algjkde.semen zssu(a>7 All roofs shall be inspected prior to an roofing material being installed.
❑vex o� P P Y g g
Will the applicant or future Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haiardous air communities as defined by the Bay Area Air Quality Management all new materials for inspection.
District? �wr
Yes
I haw read the hmadnus mmertals mquirements under Chapter 6.95 of the Califor-
IiaHWI"Softly Co@.Sccumu25M5.25533.d25534.1undc.landthmiflW Wilding
Jars not currently hoc a avant,that it is my rmponsihility to nnuly the Occupant or We
myuirtmcnu whch mumWmss pdorwi Lunceon cwrreaa of Ocea�ay. Signature of Applicant Date r /�
2` a^O
oume arize agent Daa All roof coverings to be Class"B"or better
0t
Z
0
U
CITY OF CUPERTINO
BUILDING DIVISION PERY
0 .... . .. ..
BUILDING ADDRESS:
10415 CALVERT R.
JEFFREY D SCHULKEN
PERMIT NO. 03120055
—n
OWNERS NAME:
PERMIT ISSUE DATE
JEFFREY
"tbWRoL
PHONE.
SANITARY A& NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRAC'T'ORS DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
License Class Lic. #
ADD 90 SQ.FT.
Date Contractor
ARCHITECTS DECLARATION
i I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 703 1.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
License Law 9
Sq. Ft. Floor Area Valu il On
that he is licensed pursuant to the provisions of the Contractor's (Chapter
(commencing with Section 7000) of Division 3 of the Business and Professions C a or
that he is exempt therefrom and the basis for the alleged exemption. Any li-1.7-a' Of
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of
3 7AMNIIJ09110 0 Occupancy Type
not more than five hundred dollars (M).
0 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered forindo (Sec. 7044, Business
Required Inspections
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds orimproves thereon, and who doessuch work himself or through his
own employees, provided that such improvements we not intended or offered for sale. It,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
0 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's U.
cerise Law does not apply to an owner of property who builds or improves thereon, and ,
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
am ex t der Sec B & PC for this reason
am, Ile
�emu
Own
a
O'KE94&,COMPENSATION I ECLA ATION
I hereby affirm under penalty of perjury one of the fallowirt; larationse
0 1 have and will maintain aCerfificate of Consent to self -insure forWorker'sCompen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued,
My Worker's Compensation Insurance carrier and Policy number we:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
tint
employ any pet . r:lr to be Workers' Compensation
marine
�"5-, C
,Wny -
), a ..
Laws Of a
Appli a.
N N Orl To AOFOCANT* If, after making this Certificate of Exemption, you should
be, a subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued (See. 3097, Civ. C.)
zUndoes Name
Lender's Address
D I certify that I have read this application and state that the above information is
r� correct. I agree to comply with all city and county ordinances and state laws muting to
building construction, and hereby authod?z representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harnilm the City of Cupertino against
;#2 liabilities, judgments. costs and expenses which may in any way accrue against said City
Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date
SOURCE REGULATI NS
5 M "2-ra-03
Re -roofs
ractor " Dia
SlfmaVdAfPIic4FHftA/C-.1ZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant store or handle hVj ousmaucrial
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0 Yes OINO—
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
0 Yes
Ihave read the hazardous materials requirements undcrChaptor 6.95 of the Califor-
nia Health& SafrtyCodc,Sccdons25505,25533 and 25534. 1 understand that ifthc building
does not currently have a tenant, that it is my responsibility to notify the occupant Of the Date
Occupancy.
to
requirements which must be met prior to Wumcc of a Certificate of
0,
-Z 5 Signature of Applicant
"/.-,
All roof coverings to be Class T" or better
Ownc -a rize agent Date
0 "NER-BUILDER VERIFICA.T'IN
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. _ r None of the work
If B or C is checked, comm
2. A state licensed contractor will be hired to do:
A. All of the work
B. A portion of the work (cor
E. », TR
r State License #
3. _ 1 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
erformed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner -Builder information (revers side).
Property Owner's Signa t Date: 2-�� r
job Address: l� Permit #
V
Any changes to the information provided on this form shall be submitted to the gV of Cupertino Build
Department.
City of Cupertino Building Department
CITY OF 10800 Torre Avenue
C U P E` o I i'11 O Phone: {408} 777-3728
Dear PropertyOwner:
Buildingbuil g permit has been submitted in your name listing yourself as the builder of
the property improvemet4'specifie&
For your protection You should beaware that as owner -builder you are the responsible party of record
on such a permit
permits are not required to be signed by property owners unless they are
personalli performing their own work. If your work is being performed by someone other than yourself, you
mav vrotect vourself from possible liability if that person applies for the proper p in his or her name.
ermlt
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 #apply.
if you plan to s• your own work,exception of • trades# plan to subcontract,you
followingshould be aware of the information for your benefit and protection:
(includingif you employ or otherwise engage any persons other than your immediate family, and the work
materials and other costs)$�.0 or morefor R. project,•suchpersonsnotlicensed
as
contractors or subcontractors, then you may be an employer.
If you are an employer, you must register with the state and federal goverrunent as an employer and
you are subject to several obligations including state and federal income tax withholding, federal social
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 lirnited 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 workpersonally.
information about licensed contractors may be obtained by contacting the Contractors' State License
Board in your conununity or at 1020 N Street, Sacramento, California 95814.
Please complete and return the enclosed owne ' r -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,
i • r # .. ■#
City of Cupertino
Printed on Recycled Paper
Ll
CITY OF CUPERTINO
PERMITAPPLICATION FORM
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3 of 3