03100052 LCITY OF CUPEWFIIN0 ✓a°-s"'�
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION V..
BUI LDING ADDRESS: EUSTACIO BELTRANO PERMIT N003100052
OWNER'S NAME: PERMIT MUE DATE
011E: SANITARY NO. ri� CONTROL NO,
ARCHITELTIENGINEER: BUILDING PERMIT INFO
RLDGELECT PLUMB MECH
0 t 0 0
iO0 LICENSED CONTRACTOR'S DECLARATION
:m C 1 hereby affirm that am licensed under previsions of Chapter 9(commencing Job Description
rU with Section 7")of Division 3 ofthe Business and Pmfessom,Code.and my license is
Mfull eforce Class and effect. PORCH ADDITION
FINALEO
Date Class Lin.Contractor
1=p Dam TSDECL
As shall use DECLARATION MAR 0 5 2004
i C� 1 understand my plans shall w used as public recordt
tiU
o G Licensed Professional e
OWNER-BUILDER DECLARATIONBUILDING
n o I hereby affirm that 1 1. exempt from Nc Contractor's e:Any c law for the
.p O following reason(Section 8131.5.Business and improve.
dcrnns Code:Any city or county
e S uo which reyuifu n pewit re cnnswn,ppcc impmsu hch Permith, file
repair any nrucma
s�'^ patIrertoitscenedpursunttobs theapplicantfor Contrarminuiense Law(chmmcm
thatwenci.,wit pursuant tw.1 Division
of the Contractor's Proflaw(Cbepmr9 Sq. FL Floor Area Valuation
2FG
that
exemith SectionM)0)of D osis n3 orthc Business and Profession.Any vi Cak)or
$ Nal h<u exempt twrefmm end the buts for the alleged exemption.Any violation of 32608086 . 00
Section 7831.5 by any applicant for a permit subjects the applicant to a civil Penalty of APN Number Occupancy Type
not more than five hundred dollars($500).
I.as owner of the property.or my creploycu with wages u lbch aolc compensation,
will do the work,and thesvuctum is not intended or offered for sale Business iUl —
and Professions Code The C.."el Ys License Law ones not apply m an owner or d Inspections
property who builds or improves dtcocon.and who does such work himself or through his 102 - PIERS
own employers,provided Nat such improvements are not intended or offered for sale.If. 103 — UFER
however,the building or improvement is sold within one year of completion,me Owner-
builder will hove the burden of proving mat he did not wild or improve for purpose of 104 — REBAR
sale')' 105 — ANCHOR BOLTS
CD I.as owner of the property.em emIUSiw)y contacting with licensed contractors to
couswct the project(Sce.]6M,Business and Profusions Code:)The Convacter's Lilt 106 — SEWER & WATER
mase law dues not apply to an owner of property who vends or improves thereon,and. 202 — UNDERFLOOR PLUMBING
who contracts for such projects with a convaeu r(s)licensed pursuant to the Convector's
eAnxLaw. 203 - UNDERFLOOR MECHANICAL
Ion aey�.t�g� see. Bh PC for Nis reason 204 - UNDERFLOOR FRAME
M`iVOR� y ._ ° 205 - UNDERFLOOR INSULATION
ORKE0.'S COMPENSATION DEC A N
I hereby affirm under penalty of perjury one of the olowirg decimations: 301 — ROUGH PLUMBING
. Iban and will maintain aCetificamofConsemtoxB.insure for Worbar'scumpcm 302 — TUB & OR SHOWER
..tion,u provided for by Section 7]00 of the tabor Code,for Nm
e perforance of the 03 — ROUGH MECHANICAL
work for which this permit is issuetl.
1 have and will maintain Worker's Compensation Insurance,as required by Section 3 04 — ROUGH ELECTRICAL
3]00 of Nc labor Code.for the performance of On work for which Nis permit is issued. 3 05 — FRAME
My Worker's Compensation Insurance terrier and Policy number are: 306 — HOLDOWNS
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 — SHEETROCK
(Thist,ion necdma hccurnidmed Rik permitisfmonehundad dollan(SIIX) 309 — EXTERIOR LATH
or less.)
1 ceniry Nat in the perrurmanec of the work for which this permit is issued.I shell not 310 — INTERIOR LATH
employ
ofany N inanymannersontolm es UttotwWmkeriCompcm.p.n 311 — SCRATCH COAT
Appli=,t ' 313 ROOF NAIL
NOT APPLICANIr.If.aftermekingthisCenifcau:ofEacmption,youdor 501 — FINAL ELECTRICAL ENERGY
been ject to the Worker's Compensation provtsmns of the laver Code,you must
�Z form ithComply with Such pmvnmmo1Nisprmitahall wdeemed revoked. 502 — FINAL PLUMBING ENERGY
ZOCONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
I hereby affirm that thea is a conmcdon Icedingagency far the Performance of 504 — FINAL BUILDING ENERGY
M> the work for which this permit is issued(Sce.3U97,Co,C.)
y p
Unite 505 — FINAL ELECTRICAL
z LcnoePSAaercs. 506 — GAS TEST
C I certify that 1 have read this application and sato that he above infominiun is 507 — FINAL PLUMBING
correct.I.,.I. ..Ply with all city and county ordinances and sum laws relating to
�O building convection.and hereby amborirt representatives of his city to cater upon the FIN MEC CAL
4q above-mentioned property for inspection purposes.
(We)agree to save,indcmni fy,and keep harmless the City of Cupertino against 09 F I
r I Liabilities,judgments,costs and expenses which may in any way act..,.trial said City 5 NG
;Jz in consequence of the granting of this permit Date
'—' APPLICANT UNDERSTANDS AND WIL OMPLY WITH ALL NON-POINT Issued by:5 C WORKS
SOU R LATIONS., J 47
Re-roofs
St nature.(ApplicantiComracmr
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum wilding occupant store or handle havarduus mauflal
d by the Ca
as defineperton Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑YNu
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
it haaardnus air contaminants is Opined by the Bay Area Air Quality Management all new materials for inspection.
is ter
Yes -<No
1 have real the w>ndous materials reyuimments rooky Chaptar 6.95 arrive Califor
ma Hca1N is SafetyCwc,Sections 25505,25533 and 25534.1 undcamnd thmif d¢wilding
Jots no imerid have a le...4 Nat it u my exponsihilit,m notify the oceupent of the
rkquir mmt.twmetpno itsuamm.racpnifiealp.racoroner. Signature of Applicant Date
:. � /O ;,g3 All roof coverings to be Class "B"or better
Owner or authoomd agent
CITY OF CUPERTINO
BUILDING DIVISION PERM a CON�.'RAC10R`INFORMA�N cs
BUILDING ADDRESS: EUSTACIO BELTRANO PERMIT NO 03100052
OWNER'S NAME: PERMrT ISSUE DATE
7'12
NE:
SANITARY NO. CONTROLNO.
ARCHITECrIENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
0 0 0 0
lee, LICENSED CONTRACTOR'S DECLARATION Job Description
iU C 1 hereby affirm that 1 am licensed under provision or Chapter 9(commencing C
w wishSccdun]Otyd7ofDivisionJofthe Busincaand ProfcssiunsCode,and myliccnuis P�NAL.ED
mmnmroeand erreet. PORCH ADDITION
q Z License Class Lie.N
p Dam Contractor
IIunderstandmypinsshallls ARCHmiu�:�blcrec°� MAR 0 O 2004
>ad
30 LicensedPr,reaaien.' BUILDING
g OWNER-BUILDER DECLARATION
S I hereby affirm that 1 am exempt Gum the Cnmtarim's License Law far she
00 following reason.(Section7031.5,Business and Pmfessiom Cadr:Any city or county ,
i$� which requiremit m a percnnswcl,alter,impraw,d.inubih,or repair any Isom ane
±2� mmu,i.issua;ce,alsomean.lhcapplicanito,suchpe.!11.fileasignedstatemenn 5 F[. Floor Area Valuation
xx
that M is Beamed pursuant m provisionalnnt
the provisional Or the Concubines Limn¢Law(Chapter 9 Q
7Fm (commencing with Section 1(1(10)of Division 3 of the B usiness and Professions Code)or
$ that he as exempt therefrom and Ne hies for dm alleged exemption.Any violation or 32608086 . 00
Section 7031.5 by any applicant for apermit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more Nan f hundred delta's($500).
1,as owner of the literary,or my employees with wngu u their sale compensation,
will do Bic work.and Neslrvcmm is not intended oroffered rot laic 1044,Brei — d Inspections
and P'ofoation Code:The Conmetors License Law deal not apply to an owner of 102 - PIERS
progeny who builds or improves human,and who deal such work himself or through his
own employ=,provided that such improvermnu are not intended or offered for life.it. 103 — UFER
however,the building or improvement is sold within one year of completion,the owner.
bullae' e will have d, burden of proving chat he did not baud or improv ter purpose or 104 — REBAR
Wl ) 105 — ANCHOR BOLTS
0 L as owner of Ne properly,am exclusively convecting with licensed convectors to 10 6 - SEWER & WATER
construct the project(Sec.7044.Business and Profer essions CodThe Convector's Lt
«reaLawdoesnotapplytoinOwnerofVmpenywhobuildsorimPraauthemon.nd, 202 — UNDERFLOOR PLUMBING
who contracts for such projects with a coamctor(s)licensed pursuant Or the Contractor's
imau Law. 203 — UNDERFLOOR MECHANICAL
lam axe see.
B&P C for this marmn 204 - UNDERFLOOR FRAME
205 - UNDERFLOOR INSULATION
`WORKERS COMPENSATION Veer- pApON
w Ihe¢byeRrmunderpenaltyofperjuryorcofthc olowingdralar.ical: 301 - ROUGH PLUMBING
I haw and will maintain a Ccnihcamof Concent to lelDinsure for Workers Conran. 302 — TUB & OR SHOWER
inion,u provided for by Section 3700 or the Labor Code,far the Performance of the
303 — ROUGH MECHANICAL
walk far whim this Permit is issued' 304 — ROUGH ELECTRICAL
0 1 hast and will maintain Walker's Compensation Iahurance,ss required by Section
3100 crthe Labor Cook.for to performance of the work far which Of,permit is issued 305 — FRAME
My Workeri Compensation lnsunnce.amicnnd Policy number am: 306 — HOLDOWNS
came': Policy No.: 307 — INSULATION
CERTIFICATE-OF EXEMPTION FROM WORK ERS'
COMPENSATION INSURANCE 308 — SHEETROCK
(Thisuetim head noticcompletedirde terminator onchrndrodd.fars(51W) 309 — EXTERIOR LATH
or less.) 310 — INTERIOR LATH
1 modry Nat in Ne performance of the work for which Nis Permit is issued.I shall not
employs, cooln many mummer as az m bac es yen 10 Us,Workers'Compensadon 311 — SCRATCH COAT
Lava of caa
Applicant 313 _ ROOF NAIL
NOT APPLICANT.If..flar making this Cenificam,or Exemption,you should 501 — FINAL ELECTRICAL ENERGY
beeo jet m the Workers Compcmam.proviskmaar did Labor Cone.you must 502 — FINAL PLUMBING ENERGY
Z loon its comply with such provisions testified.or this Permit shall be deemed testified.
ZO CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
I hereby aRrm that there is a comuvetian lending agency for the rarformanecor 504 — FINAL BUILDING ENERGY
Y> the work for rMchNisPermit isissued(Sm.3097,Cr,C.)
-i Q Lemdcra Namc 505 — FINAL ELECTRICAL
Z) LamialsAdders 506 — GAS TEST
0 1 cmiry that 1 have read this application and suit that the above information is 507 — FINAL PLUMBING
.y
coma 1 agrae eo comply with all city and county ordinances and sum laws relating 10
U building Construction,and hereby suborn representatives of this city to court upon done FIN MECHAkW CAL
�G ahovomentioned property ter itupccuin'titimsel. 09 FI
(We)agree to save,adcmni harmless the City of Cupertino against
N liabiliuu,judgments,costs and expenses which may in any way scam.against said City 5 NG
),Z in consequence of the granting of this Permit. Date
^� APPLICANT UNDERSTANDS AND WIL OMPLY WITH ALL NON-POINT Issued by:5 C WORKS
SOU SLATIONS.
Re-roofs
Si nam¢of ApPIm nanConcractor
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will We applicant or forum building uceutrim store or handle hrearbous material
az Mined by the Cupertino Municipal Cecil.Chapter 9.12.and Ne Health and Safety
Coda.Scalien25532f-07 All roofs shall be inspected prior to any roofing material being installed.
0YuNe
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
it hmsrdnus air Camara bents as defined by the Bay Area Air Quality Management all new materials for inspection.
sWml
❑Yes _<No
I have mad the hicurdnusmaterialsmquircmcnts under Chapter 6.95 of the Calirm,
hie Health&Safety Code,Sections 25505.25533 and25534.I understand Nat if the building
docs bat um ad have a tenant Not it is my rcapansiM1illty m notify the a'u'nt of the
Beni n nmastbcmetpria i......faccrdOnte.f0scupn'y' Signature of Applicant Date
XO - All roof coverings to be Class"B" or better
Owneruramhorisdagcnt Date
�R7�i791/1G� �u�LOr�✓G /'�?cif /�0o��7oti
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a c�vID,(/,/r/c THE pCnInlYw.Q�9 T o /p C7° TD SL 99/��
74,
• sc I; s9ecifi '�� NE+/ /�O/ICh v S B
u catons $� —
!�°x a, atl times and it S U
T cnanCes or, alteration,r,
Inc mi riicn Permission
it" L:r. City of Cupertino. f(Afp
Ili".' iYi 1_ ,.�s p-an and specificado
Pe
pofmit or to nq
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) (N
004ER-BUILDER VERIFICATORY
1. (Check one) I or my immediate family (parent, spouse or child) will perform
• A. X 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 that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side).
Property Owner's Signatn/ /Y � �� �� V D> ��DD�
l/03 U/� �2 Permit#0
5/
Job Addres • '���`
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
DeRaatment.
•
City of Cupertino Building Department
I CITY OF 10300 Torre Avenin
C U TpE[?T I NO Phone: (408)777-3228
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 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 compensatioro
contributions.
There may be financial risks for you if you do not cavy 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
p 1kITY OF CUPERTINO*
CUP TYOF O PERMIT APPLICATION FORM
APN # �F Q Date:
V � zJ .
Building Address: Z J/dam
Owner's Name: 4- �ft��� Phone#: yv�/ z z_9yp3
lJSTi9C/D
Contractor: / License#:
Contact: Grp?6t /y cS ?t 7 9y� Cupertino Business License#:
Building Permit Info:
Bldg .r Elect Plumb ❑ Mech ❑
Job Description:
Residential 0 &?Z Y—/ t 6kfhfercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
IC 7
Cost of Project: g�U v Occupancy Group:
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> 1 OOK to 500K Btu MECHANICAL
BB0ILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> IM 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 <= IOOOA ELECTRICAL
BELEC1001 Elec 600V> 1000A 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
1 of 3
O,&� *ITY 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 Repipe Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinklerBackflo PLUMBING
BPSTORM StomVRain 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 cfrn MECHANICAL
BRENLUUTAN 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> I 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
•
2 of 3
d *ITY OF CUPERTINO*
CITY OF PERMIT APPLICATION FORM
CUPEI�TINO
Quantity 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
BSEISNH OM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Insection 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 MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
•
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