04060161 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,C 0NTRA0T0Rj1NFORMAn
BUILDINGADDRESS: EDWARD PUCCINELLI PEBMITNO04060161
10128 DENISON AV
OWNER'S NAME: PERMIT WUE DATE
EDWARD PUCCINELLI
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 0 0 0
you LICENSED CONTRACTOR'S DECLARATION JbDescription
>; C I hereby affum Um I am liceo
nsed undar pmvisioes of Chapter 9(commencing
b wilLSection7")of Division 3 offt Busins and Professions Code.and my license is
�z„ inrmlroreeatidercect. INSTALL BRANCH CIRCUIT FOR MICROWAVE
Ovv{? License Class Lic.N f� �1�vCI n
ARCHITECTS DECLARATION u At m sJ
'2 I understand my plans shall W used a public records
;LL Licensed ProfeaSlanal
Din OWNER-BUILDER DECLARATION JUL 19' 2004
<I 1 hereby affirm that I am exempt from the Contractor's License Law for the
O O following mann.(Section 703 1.5,Business and Professions Code:Any city or ounty ��
K m� es which requires a permit to construct.aloe demolish,or delish,or repair any structure
'ter^ prior m its issuance.also requires the applicant for such permit to file a signed statement
F2 Nat he is licensed pursuant to the Provisions of ths,Combustor's License Law(chapter 9 Sq. Ft. Floor Area Valuation
ale 1-$ (commencing with Section?BOD)of Division 3 of the Business and Professions Code)Or
— this W is exempt tM.refrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any appliaa for A permit subj.M the applicant m A civil penalty of a Occupancy Type
not mom than fixe hundred dollars(2500).
❑1.as owner of the property,u my employees with wages as their sole compensation,
will do the work end the Andean,is not intended or offered image(Sec.7044,Business
and Professions Code:The Comment's License Law saes not apply to an owner of Required Inspections
property who builds or improves Neuron,and who doessuch work himsel(or through his
own employees,provided that such improvements are not intended oroffertA rosier.If.
however,Ne building or improvement is sold within one year of compledon,the owner.
builder will have the burden of proving that he did not Wild or improve far purpose of
sale.).
❑h as owner of the pmknty,am exclusively contracting with licensed c0nVaelaa]to
construct the project(See.7044,Bainas and Ped estians Code:)The Convector's U.
were law does not apply in an owner of property who Wilds or unprom thereon,and
who contracts for such projects with a convactorud licensed pursuant in the Contractors
memo law.
'I am eae��m��ppJJ�aytJJ��der Sec. ,B&PC for this reason
Owner zl— Date d 1`
WORKER'S COMPENSATION DECLARATION
/1 hereby affirm under penalty of perjury one of the fellowhngydcclantions:
I have and will maintain a Certificate ofConsem to self-insure for Workci a Compcm
EL
ion,As provided for by Section 3700 of the labor Codc,for the performance of the
work for which this permit is issued.
1 have and will maintain Workers Communique Imuran¢,as required by Section
00 of the labor Cock,for the performance of the work for which this permit is isvued. -
My Workers Compemation Insurance artier and Policy number M:
Cartier. Policy No.: '+
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not becompleted If the permit is(erotic hundred dollars($100)
or less.)
I coni fy that in the performance of the work for which this permit is taued,1 shall not
employ any person in any manner an as in become subject to the Workers'Compensation
Laws of California.Dere
Applicant
NOTICE TO APPLICANT:IL after making Nis Ccnifica¢of Exemption,you should
become subject to the Workers Compensation previsions of the labor Code.you mat
�z forthwith comply with such provisions or this permit mall Wdecmcdrewland.
ZO CONSTRUCTION LENDING AGENCY
F' p 1 Wholly 4MM that there is a cansuuction lending agency for the performance of
<>: > the work ser which this permit is Wood(sec.3097.Civ.C.)
W Lenders Name
z Lenders Address �-
U Q 1 comfy that I have read this application and state that the above information 1A
Iz. F coned.l agree to comply with all city and county ordinances and state laws rotating 10
[) C.) building construction,and hereby authorise representatives of this city to enter upon the
W anove-mcntionetl property for inspection purposes. /J
(We)agree to save,indemnify and keep harmless the City of Cupcnino against /`f/V/ -
H N an
Iimilides.judgmenu,costs and expenses which may in y way accrue against said City
U z in consequence of the graining of this permit.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
/(
SOURCEREGU ONS.
b D Re-roofs
Si aturc of ApplicaHAZARDO f Oak
HAZARDOUS MATERIALS DISCLOSUREy� Type of Roof
Will the applicant or future Wilding Occupant store or handle haardous mamdal
a defined by the Cupenino Municipal Code.Chapter 9.13,and the Health and Safety
otic.Section 35532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes )16 No
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hit.ndous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
0Yes No
I have read the hoarddmis`matcrials requirements under Crap cr6S5 of IM Califor.
nia Health&SafeyCodc,Secdom35505,35533 and 35534.1 undersand thaidthe Wilding
dins ria currently have A tenant.Nat it is in,respomihiBry to notify the aeupam o(dw
raquiremcnts 'chmuute Ipriormissuaoceor.Contrav:of cupancy.
Signature ofApplicant Dale
All roof coverings to be Class "B"or better
O urauthorivcd agent Dam
OWNER-BUILDER VERIFICATION
1. (Check one) I or my ithmediate 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)
Contractor Address/City, Phone # State License # J Type of work to
® 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.
PersonVFirm 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 (reverse side). _
Property Owner's Signatur e� tete: 6�18��
Job Address: /0/ 2 8- ve - Permit,#
by06 0161
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
a
I3 1
City of Cupertino Building Department
CITY OF 10300 Torre Avenu�
C U P E IST I N O 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 vourself 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,
City of Cupertino
Printed on Recycled Paper
7
Sin- CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
qpkPN#3,K 2U 0 Date:
Building Address: _ Mailing Address (if different from building address):
/0/ 2 � J7cnr rrn
Ownerr's N / Phone#:
EP VCG Ine/f! 11f0E- - 2T7 - 3540
Contractor: 7r License
411 TA LCA'
Contact: Phone-.-P �9 9-73 Cupertino Business License#:
Cb qn Pr• Fax:
Buildipng�ermit Info:
Bldg rp Elect Plumb ❑ Mech ❑
Job Description: 4XP,'M e �
Residential El Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Y &V OZ7 Occupancy Gr up
Type of Construction: Please check ths-box—iftfie project is a
second-sto addition: ❑
Project Size: Standard ❑ Laze ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
13130ILER5 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> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
* 2� -� (�6
1 of — /? / 63
k s
CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group
op 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
BOVERTM E 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 Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler/Backflo 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 cfin MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfin MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN 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
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
Ah BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res App liance ELECTRICAL
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a(�tmm CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM '
CUPERTINO
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmdl Sips Add Branch ELECTRICAL
BREMSIGNS Remodel Sips, 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 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
MPER 4FEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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