03110010 CITY OF CUPE101NO a' ' ' s ?n?' —:m aw 2 a-^3 wb
BUILDING DIVISION PERMIT � 0 T—RDACTnR INFORMATION.'`•°r .
BUILDING ADDRESS: FRANKIE & JOHN SMILLIE PERMIT No 03110010
O NF,R'S NAME: PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO.
ARCHITEC11INGINEER: BUILDING PERMIT IN
BLDG ELECT PLUMB MECH
Too LICENSED CONTRACTOR'S DECLARATION O O O O
U I hereby affirm thus I am licensed am ,provisions of Chapter 9(commencing Job Description
with Section 701)(P of Divi.sm 3 of the Ousincss and Prufcssinns Cod..and my license is
s in full force and eff.ct.
;q= License Class Lie,. SKYLIGHT, A/C, FURNACE @ATT 1�AfiskiLE®
F n Date Contractor
'E'3' ARCHITECTS DECLARATION
eau Iunderstandmyplan.shallWusedaspublicmeet& DEC
°off Licensed Professional O 2�U3 ,
g OWNER-BUILDER DECLARATION �y
ry
<$ I hereby affirm that 1 am exempt from the Contractors License Law for the BUILDING a�
. ®®p 0 following mason.(Section]131.5,Business and Professions Code:Any city or county
e m L which mquires a permit to consumer,altar,improve,demolish,or repair any structure 000
�ai prior to to issuince.alsu squires the applicant forsuch permit to rile aligned statement
< that he is licensed pursuant othe previsions(if the Contractor's License Law(Chapter 9 I Sq.Ft. Floor Area Valuation
Ifo (commencing wi in Serum,7")of Division 3 of the Business and Professions Cods)of
Nat W is exempt rherelfom and Ne baso for the alleged exemption.Any violation or 35928031 . 00
Section 7031.5 by any applicant for a Permit subjects the applicanuo a civil Penalty of APN Number Occupancy Type
not more than live handled dollars(SSW).
P Y YP
❑ Lssowncr work,the pmscny, remyempiny.ns with wage sae tale(Se .compensation,
will do rhe sunkand the he Creo isnot intended or offered far sale(Sec.to an
Business
and ertywhob.code:The improves taeton.License Law does not apply lf an owner or Required Inspections
propertywho buildsorimpmvsuchimrove who adoes mnutchworkhimselfe tEmugh his
Own employees.provided that suchmiLiss sold
Wit arenotintendedor mpleetedforvie.lr-
however,Nc building or improvement is sold within one year of Completion.Ne owner-
builder will have the burden of proving Nm he tlitl not Mriltl or improve for purpose of
sale.).
❑I,as owner or rhe property,am exclusively contracting with licensed conttacmrs to
consumer the project(Sec.71)1q,Business and Professions Code:)The Contractors Li- .
ttse law does nor apply 10 as..net of propery who builds or improves thcmon.and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's -
License La
❑ lam ca pt outlet Sec. .B&PCT this moan
I..,k
LWORKER'S COMPENSA NDECLARAT1 hereby afrm under penalty of perjury one of the following declarations:
have and will maintain a Cenificme or Consent to self insum for worker's Cumpen-
n,or provided for by Section 37M of the labor Code,for the performance of the
Tor which Ibis permit is issued.
have and will maintain Workers Compensation Insurance.u required bySection
of the Labor Cole.for rte performance of the work for which this permit is issued.
orker's Compensation Insurance carrier and Policy number aa:
Canso, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This wscion need not M completed lithe permit is for one hundred dollars(SlIX1I
of leaQ
1 certify that in Be performance of the work for which this permit is issued,I shall not
employ any prefer in any manner an a as bcesmc subject o the Workers''Compensation
Laws of California.Date
Applicant _
NOTICE TO APPLICANT:IL after making this Ccnifcam of Exemption.you should
become subject to the Workers Compensation previsions of the labor Code,you must
z forthwith comply with such provisions or this Permit shall M deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat there is a construction lending agency Ice the Perl'ormare,of
Yr the work for which this permit is issued(Sec.3090,Civ.C.)
t1 lender's Namc
z Under's Add.
Q 1 cenify that 1 have read this application and state that the above information is
i collect.1 agree to comply with all city and county ordinances and sum laws relating to
DU building Construction,and hereby substrim representatives of this city to come open Be
ahovcmentimod property for inspection purpose.
y esjuagreeto sass,indemnifyandhich harmildiss;roan Ne CityolCupcnst sagainst
y liabiliti(W)greeto cum and mnify aswhich mayinanyle Way City f Cupertino said City
j zince yucnc.of rhe granting of this permit
'—' APP IC ANT UNDERSTAN S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
5 CE REGU TIO
I Re-roofs
ntumoTApplinnt/Contt for Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant score or handle haardous material
az defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety
Code.lotion 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
Yu
will dlc apps"i nr !.ta Wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it b.nedooe air contaminan.as defined by the Bay Arca Air Quality Mangan n, all new materials for inspection.
istrict? ,,,���/// r
❑Yes gnu
Ihave leaf thehma ruse 25505.25533
41 toCh,aind t95 ofthe Calif.,
RO.O111,
Sol yCodc.Smnou 25N)5.255JJand 255}q,lundcrsmnd thatilthc building
have a tenant 0 it is my responsibility w notify the otopant of the
uwNchmusthe poo of c aCerecricamof upon Signature of Applicant Date
error authorised aFcnr 1 t. Q3s All roof coverings to be Class "B"or better
Cl'CY OF CUPERTINO
BUILDING DIVISION PERM CONTRAGTnR IN;F N
BUIL DING ADDRESS: FRANKIE & JOHN SMILLIE PERMIT NO.03110010
PERMIT ISSUE DATE
OWNER'S NAME:
JE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINELR: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
10LICENSED CONTRACTOR'S DECLARATION
e 0 o Job Description
mB N I hereby affirmthat 1 am under provisions of Chapmr 9n(commencing
zwi@Section]Nk) Ofpvision3oTOO ValsinessaJ Pmfcssinns Cndc.ed my license is
in fall force and effeCt. SKYLIGHT, A/C, FURNACE @ATTIC
e�? License Claim Lic.M
;-0 Dale Camncwr
ARCHITECTS DECLARATION
a< I understand my plans shall W used as public rcemds
tau
o Llocnud Pnnfcstrunal
OWNER-BUILDER DECLARATION
i g 1 hcrcby`R' that I am exempt tram the Contractor's License Law for the
.p o rallawing rcamn.tScctiun]IBI.5,Business and P.E.,,ion,Cod,:Any city nr county
f$ which te9uires a permit b,construct,alta,imprnvc,demolish,or repair any structure - 1
ate"' priono it ivsuanc..also requires[he applicant forsuch permit m Glc aligned statement
;wthcisrcensr ttnth. smnsnrth,Cnmraetarsuecnwr w(Cha ter9 S Ft. Floor Area Valuation
parsaan pray' p 9
«o (commencing with Section 7")of Division 3 of the Basin=.%and Professions Ch011 or
jr Oat he is exempt therefrom and the basis for rite alleged exemption.Any violation of 35928031 . 00
Section]031.5 by any applicant for a Permit subjects the applicant to a civil penalty Of APN Number Occupancy Type
not more than five hundred dollars(150().
❑1,as owner Of the property,or my employees with wages as their sole compensation,
will do the work,and the SWcture is not intended or offered for sale(Sec.7044,Business Required lHS eCIIODS
and Professions Code:The Contractor's License Law does not apply w m awncf ofP
property whobuilds or improves mercon,and who does such work himselfor through his .
own employees.Provided that such improvements are not intended oroRered formic.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.).
❑1,as ser the f of the Pec.70a am Beside exclusively confessions with Restated Cc imeaebrs m
comwa the project(Sec.o an Business and property
wh ions Code:)The ves premor'a Lid
cense low does not apply je an owner of proPeny who sed p or improves thereon,and
whocontractsLa for such pmjccts with aconaanor(s)liccnud pursuant to h,Contractor's
Licence Lsy
❑1 am exdnpt under Sec.
�
B&PCfthis rc
n
o
pX1 � rWORKERSCOMPENSA �NDECLARATr— Q
r�
1 hereby affirm under penally of perjury,one of the following declarations:
1 nave and will for by
a Ccni37W of the Lab r Cadc.fore for Worker's Cumpcm ✓\
salon, r provided for mi Secrnh 3]00 Of the labor Cade.for rhe performance of me J
work for which Nis Permit is izsuct.
I have and will maintain Worker's Compensation Insurance,m required by Section
3700 of the labor Code,for Ne performance of rhe work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EKEM Pr10N FROM WORKERS'
COMPENSATION INSURANCE l
(This section need not becompleted if the permil is!Brant hundred dollars($100)
Or less.)
1 certify Nat in the performance of the work for which this Permit is issued.I shat:not t
employ any Person in any manner an as in become subject to the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Cemiriuma of Exemption,you should
become subject to the Worker s Compm eakar provisions of the lobw code,you amt
DZforthwi R comply with such provision or this Permit shal I no deemed revoked.
�O CONSTRUCTION LENDING AGENCY
I hereby aRrm Nal here is a eonstm tion:ending agency Ire the Performance of
Y. > the work for which this Permit is issued(Sec.3097.Civ.C.)
A 0 under's Name
1 Lendch Add¢.. '
� z
1 certify that 1 have mad this application ancounty
and stare ces and above information relatwn is
L f" building 1 agree w comply with all city and county ordinances and curt laws relating to
0l) building construction,end hereby authmiae rcpmscmatives of his city menter upon the
Lk] ahavomchummad propeny for inspection purPmes. ///
fY lWe)egmeto save,indemnifyendkeep hay in any
CityOfCuPcnst id City
fq
list!litics.j)gree to case,iand expenses and keep
maylnanyic City f Cousins Said City /
z in ca gOeO,a of I granting of this permit.
APP [CANT UNDERSTAN S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
5 CE REGU TIO ) I, L -�',
r / Reroofs
i n turcof ApplicanUComr for Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
W ill me applicant or future building Occupant store or handle hasarduus material
az turned by the Cupertino Municipal Cafe.Chapter 9.12,and the Health and Safety
Cade,Section25532(ay] All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the aPPliemt err awn,btdltlmg ocoapant ase.yaipmenl or aemaa which If a roof is installed without first obtaining an inspection,I agree to remove
.mil hvzrdata air conmitinano as defined by the Bay Arca Air Quality Management all new materials for inspection.
0 yes
DisrimT
have real the heard"us materials reyvimmcnu under Chapter 6.95 of the Califon
nizli alth&Safety Code,Sectium 25505.25533 and 25534.1 understand that if the building
does of
do .urtcmly nave o'er m do`t ix my responsibility to noddy IM......—nr the
rc mme,
,hwnicnmasthrodwissa a acertm.amorapanry Signature of Applicant Date
raathory dagent
er ol L Dam All roof coverings to be Class"B" or better
e Q- WITY OF CUPERTINOO
CUP TYOF O PERMIT APPLICATION FORM o3ll° ol'o
N# �Q 03 I Date:
Building Address: en I e c? 1 Lci n .12—
Owner's Nam e:�an A 66:- o hr1 Sfn i J /'(LPhone "(00
G I //t // _2 5�"
Contractor: ,�/��' License #: OJ'7``fit((OO J V i
�n �o CM e2
Contact: Cupertino Business License#:
B -Permit Info:
Bldg (Elec Pi Me
Job Detion: L
Residential E] �� �� uH' No rcia E]
Sq.Ft. Floor Area: a/ice $/Sq. t.:
Cost of Project: / r Occupancy Gro : 3
17
rb
Type of Construction:
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
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
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
* i3
1 of 3L( li�.
( - 4VITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPEkTINO
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 Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers_ PLUMBING
RW 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 HeaterNent 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 Furnace MECHANICAL
BREMFURNOV Relo Furnace > l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPPRem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
2 of 3
WITY OF CUPERTINO*
CITY OF PERMIT APPLICATION FORM
CUPERTINO
AAantity Fee ID Fee Description Fee Group
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
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 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 MECHANti'ICAL,
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
•
3 of 3
OWER-BUILDER VERIFICAT16N
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)
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 at the above is true and correct. I have read and understand the
Owner-Builder Information (reve a side). q-03
Property Ow�ne(r�'s Signatu
fte:
Job Address' I,1q 1—a \tA(-"I-/Cz�/a �� Perm# l I 0 O 10
' J
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
•
JIT
_ City of Cupertino Building Department
CITY OF 10300 Torre Aven
C U P E kT 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 yourself from possible liabilitv 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 materiai
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 an Recycled Paper
F—ALLENLLP�-F LANA
�� �_►� . S K y L i Cr N---F v e-L-v I O to
grTICE
'cFz
NOV 0 4 200
BY: n
til
k7
tD �.
.hUL
LL
r 0
3
7 �
C �
i
i
APROVED
5 M ;A POANCE WITH THE CITY 00
0 COD7SVIRDINANCES
'
P1 TL--
C
71 Sl A
W.
TI is set plans nd specifications MUST
j Si M l� b kept the j„b at ail times and it is un
t� �g la vful is rake any changes or alterations
lE� if 1 same vithout vrrtten permission from
C ✓ th, buil g Dept., City of Cupertino.
✓ TI a sta ing of this plan and specifications
;I All I T be held to permit or to be ar.
a{pr04 f the violation cf any provrsiona
If any I r Ordinance or State Law,
&UTTE 2
•