04100149 CITY OF CUPr WFINO
BUILDING DIVISION PERMITCONTRACI,OR INFORMATION s'
9�,
BUILDING ADDRESS: PARRY MARTIN H AND JENNIFET P11AMITNf)4100149
697 GALWAY D
OWNER'S NAME' PERMIT ISSUE DATE
PARRY MARTIN H AND JENNIFER A 10/21/2004
ONE:
SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MFGH
Zinc, LICENSED CONTRACTOR'SDECLARATION Job Description
WU F 1 herchy affirm Nn 1 am licensed under provisions of Chapter 9(Commencing
no wish Scnion 7000)of Division S of Nc Business and Professions Code.and my license is
infull eClass erred MAIN WATER LIN p �
prs�? License Class Licp ' [
ire Date Contractor REACTIVATION 0 1 M T #03060190)
,,�tj ARCHITECTS DECLARATION
41a 1 undersmnd my plans shall he used u public recmds
3 o H Licensed Pinfcssional NOV Y / 2004
5 OWNER BUILDER DECLARATION ,1
S 1 hereby affirm Ihat I am exempt from the Contractor's License Law for the
no following recon.(Section 7031.5,Business and Professions Cade:Any City Of county
If m which requires a permit to construct,alter,improve,demolish.or repair any etructum
w—'^ prima)its issuance.also requires he applicant for such permit to rile a signed statement
< pursuant ns
that he is licensed pursuano the p.,isioof the Contractor's[.a..lLaw(Chapter 9 Sq. Ft. Flo Valuatior$50
Of a (commmming with Section 7")(if Division 3 of the B usiness and Professions Code)or
Cc Nat he is exempt Ncmfmm and Bar basis for Ne alleged exemption.Any violmoft of
Section 7831.5 by any applicant for a Permit ubjects Ne applicant to a civil penalty of APN Number Occupancy Type
not mom duan five hundred dollars(SSW). 36624030 . 00
❑ L m owner of the pumilany,or my employees with wages az Ncirnole compensation.
will do Nc work,and Ne strucmm is not intended in offered for sale(See 71044,Business
and Proressiona Code:The Contractor:License Law Was not apply to an owner or Required Inspections
Minicoy who builds or improves Ncomm,and who docs such work himself or through his
Own employees,provided that such improvements arc nut intended or offered for sale.If.
howesea Ne building or improvement is sold within one year of completion.Ne owner
builder will have Ne burden of proving Nat he did not build or impose,for purpose of
sale.).
Ej I,as owner of Ne property,am exclusively contracting with licensed contractors to
consumer the project(Sec.71144.Business and I4ofessions Code:)The Contractor's Li.
ceme law does not apply to an owner of property who builds or Improves themon,and
contracts lot prujects with a contractor(s)licensed pundin or the Cantractmx
w cens=SKI
la B&PC Zihi�rguOwn1 "^kkyyJJ,,,,�.�wsER'S COMPENSATION DI:CLA
I hereby affirm under penalty of perjury one of the fol g declarations:
1 have and will maintain a Certificate of Consent m self-houre for Worker s Compeer
ration.az provided for by Section 37th of Ne labor Code.far One peformonee of the
work for which Nis permit is issued.
❑1 bays and will maintain Worker's Compensation Insurana,as required by Section
77110 0(Ne labor Code.foe the peRormanee of Ne work for which Nis pCtmil is issued.
My Workers Compensation Insurance artier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is form=hundred dollen(glib)
or less.)
I certify then' tn`hc py�lmmance of the work fyr i`'p r perms i9T.I shall nut
cmpiny any n m�annermaz/u cPmc tdc ) h o c omprocumn
Laws of Calif J,Ig-9afd! L� ll�
A 111' f.YI r:/
NO 0 A :IL after making Nis Certificate of Exemption,you should
h suhjcct to the Worker's Compcnswum provisions of the labor Code,you must
�z forthwith comply with such provisions or ibis farm it shall the decomdrevoked.
Z O CONSTRUCTION LENDING AGENCY
1 hereby affirms that there is a eommiction lending agency for the performance of
W'
On,work for which this peorno is issued(Sec.3057,Civ.C.)
W O lcnticis Wmc
G Lender's Address
V C 1 certify that 1 have read Nis application and sum thin Bac above iofo m orm is
(y P Correct.I agree 10 comply with all city and county ordinances and sere laws relating In /
(]U buildingConstruction.r and hereby w.indemnify and representatives Of Nis city to enter upon lM
>'14 shove-mentioned property for inspceumi purposes.
4. (We,)agree to sass,indemnify and kith hay in an the City of Cupertino against
Ffq in'Miticquent of
costsandof this expenses which may in any wayaeeme against said City yL
V z inconsoqucncc of Ne RSTA granting of this permit. V
APPLICA U ERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 6, Dale
SOUR TI N 62
10
�' Re-roofs
Cit of ApplicanuComra r Dau
IIAZA OUS MATERIALS DISCLOSURE Type of Roof
Will One applicant or future building Occupant sore or handle hanrduus material
as defined by the Curcrono Municipal Code.Chapter 9.12,and the acidic and Safety
Code.Section 255320: All roofs shall be inspected prior to any roofing material being installed.
0Yes Nu
Will Nc applicant or uwrc building acupaof use cyvin enfor devices which If a roof is installed without first obtaining an inspection,1 agree to remove
mir naaantous air crnlamm.ts az dewed by the my Area Air Quality Management all new materials for inspection.
DiWricl?
Vcs
I have read Ne baaaNnu.materials reyvimments under ChapkrbJS of the Cnlifoo-
ria HcalNhSafctyCc4,Sccli 255(15.25533 and25534.1 undusstand Nsifthelaolding
dt not cuncndy have a mnanL that it is my responsibility In nnGly the tkc up t of Nc
ich mos be mm pool mssmancc ofa mf,\ of aaney Signature of Applic ant Date
2X4 alit
All roof coverings to be Class "B" or better
0 u rho v.cdagcn Das
Community Development
' a 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
I
UPERTINO
Building Department
JOB AD S : PERMIT #
04 too 14-
OWNER'S M PH $ 144 S$
GENERAL CONTRACTOR. FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
_ W .2
ctor Signature Date
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)
Contractor Address/City, Phone # State License # Type of work to
cmc ua viuscu
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 Addres VCity 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 (rev se side). / /
Property Owner's Signature:� .—T—
Date: �C�I 2 t 1 O
g
job Address:16 ( 1. w Permit# b
Any chances to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
City of Cupertino Building Department
CITY OF 10300 Torre Avenue
C 1 I P E kT I N O Phone: (408)777-34
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
obligatiorts 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 an Racycled Paper
SIM
CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO 17
APN# Date:
Building Address: Mailing Address (if different from building address):
16f?, �rgtwq
Owner's Name: Phone#:
/k v?-n N 44dxesitvIr&2 f} Pigru2 4o4z 9qb �S8
Contractor: License#:
�toME—oWNErL
Contact: Phone: Cupertino Business License#:
Fax:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential jepaW
CC4 WOL 4& Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
So -
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Pro'ect Size: Standard EW Large ❑ 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 IM 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> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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CITY OF CUPERTINO
OT OF PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
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
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 .
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
BRENIAMIAN 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
BREMNRt1PP 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
BREMREPALT Repair/Alter Heatin MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
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a�jix CITY OF CUPERTINO
PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
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
BS WIM 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 Issue PLUMBING
PPLBG Plumbing Fee sR foot PLUMBING
ZADDCHG Address Chane BUILDING
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