05040053 y CITY OF CUPERTINO fz
BUILDING DIVISION PERMIT 11CONTRACTOR INFORMATION
BUILDING ADDRESS: PERMIT NO.
EUSTACIO BELTRANO 05040053
GAR99NA DR.
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY OL NO.
ARCHITEC 41NGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
too LICENSED CONTRACTOR'S DECLARATION - 1
C I hereby affirm Thal I am licensed uA&,provisions of Chapter 9(commencing lob Description, ,t
b wiln 5ccsian lOfXl)of Division3of NCBusineuand PwfcWti Co .andmyficc=is J
^ n• 'n full force and effca
'q?
in
class Lic.g REPLACE WATER LINE ('METER gr,7�O HOUSE)
^r
Dow Contretor �C^/'v 2G G5
¢¢ ARCHITECT'S DECLARATION V ll
Di 2 1 understand my plans shall W used az public records
Drs U
3 C Licensed professional
5 OWNER-BUILDER DECLARATION
Contractor's
t
1 hereby affirm art 1 L exempt from the Contractor's e:Any c Law for the / .. L
O C following mason.(Schon 103 pont. Business and w.de oli Code:Any city or county
m which requires n permit m construct,aline improve,h formsh,rt repair any immmm
poor m its issuance.also require IW aision ao foe such permi0o f le a signed summent
(comm is licensedpursuant tothe provisionsorthe Comsineas LkcneLaw sCode)(Chapter 9 Sq. Ft. Floor Area 'Valua[io
QFC that he h ing exempt
han And the
Division J Of the alleged
errs and Professon.Any vi Code)of
that he u exempt therefrom and Um base for One alleged cemption.Any violation of
Section 1031.5 by any applicant far a permit suhire.the,applicant to a civil penalty of 32Vtt1LRtqr00 Occupancy Type
not more than five hundred dollars($580).
❑Lasownerof property, e.with wageuNei(sole compenetion,
will dothe work.andrad ustructure
m is isnutintended License Law
dos nale(Sec.7044,Business
And Profeviom Cade:The Convacmri License Law doe not apply N an owner of Required Inspections
property who buildsor improves demon,andwho dexssuch work hineselfur through his
ownemployces,provided Nal such improvements oe not intended oraRered forsuce.It,
however,the building or improvement is sold within one year of eemplcuon.the owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
❑I, a owner of the propeny,am exclusively contracting with licensed Contractors to
construct the project(Sec.7014,Business and Professions Code:)The Cimmucmr's Li.
arse Law does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects with a contrecu r(a)licensed pumuanfto the Contractors
Lima.Law.
am xe
empttoder Seca B&P C for Nis oxhms,
ORK
Owner !IW0
ER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following dech(adonst
1 have and will maintain a Certificate ofCom of to elf-insure for Worker's Comfort-
.her,as provided for by Section 3700 of the Labor Code,for Ne perf notme.of de
1037W
rk for which Nis q(mit is issued.
1 hast and will maintain Worker's Compensation Insurance,u inquired by Section
ofthe Labor Code,for Nermit e performance of the work far which this pis issued.
y Workers Compensation Insurance carrier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ibis section need not bo completed if dm permit 0 foranc hundred dollars(SIM) r
or less.)
1 certify Na in the performance of the work for which this permit b issued,1 shell net
employ any person in any man ssmbcf9'JlF subject to thin Workers'Compensation
Lawa of Califur • !/ n
NOTICE TO APPLICAh?f:IL after making this Cenifcam of Exemption,you should
bttome subject to thc Worker's Compensation previsions of Nc Labor Code,you most
�Z foMwith Comply with such pnoiraans or Nil permit shall W deemed revoked.
ZO CONSTRUCTION LENDING AGENCY
[-. I hereby Affirm that there is a construction lending agency for dm performance of
(Yi 7 the work for which this Permit is issued(Sec.3097.Civ.C.)
6W.Q Lcnumes None
=Z Lenderi Address
U C) I certify that 1 haw rad this application and sum that Nc above information is
U. Correa.1 agree to comply with all city and county onfinances and auto laws relating to
U building convection.and hereby authorin repraenutives of Nis city to enter upon the
abovomcmioned property for inspection purposes.
LL (We)agree to save,indemnify and keep harmless the City or Cupertino against
(n liabilities,judgmcns,costs and expenses which may in any way see=against MidCity
U Z in consequence or the granting of this permit.
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU RE LATIONS.
p ��-�✓ Re-roofs
Signature of Appimat/Contretor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Nc applies.,or(even building acupant some or handle havardWa material
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code.Section 25532(a)?
(3 Yea 4. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or device;which If a roof is installed without first obtaining an inspection,I agree to remove
it ha mous air conteminames As defined by the Bay Area Air Quality Management all new materials for inspection.
twist?
❑Yves Oki.
I have read the hxrardous materials roquiroments under Chapmr6.95 of the CalifoF
ria FNa1N&SafctyCodc,S Sections 25537 am125534.1 undcrswW NazifIM Wilding
nes At c lly haw a tenant Nu it u my responsibility b notify the acupant or Or
quit" vers uuheMCI priorm �a�✓ar.CerdficamafaepPamey. Signature of Applicant Date
/-,//-a; All roof coverings to be Class "B" or better
Owner ser a.,h.H sd agent Date
. ! - Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building Department
JOB ADDRESS: PERMrr# / l
2iiO3 617xV,;5;U4
OWNER'S NAME: ��s0-C�f PHONE # 6 7zr 12
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:, //�—� y`�✓ ��' y�� �S!
Signature Date
Please check applicable subcontractors and complete the following ' 0 tionc
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
Owner/Contractor Signature Date
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform:
A. 1All 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
VG GSt13222tGi1
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
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 Signature: / /-�Y/ Date: y- i-vJ(/
Job Address: Permit# O
Any changes 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 Avenu
C V P E[?T I N O Phone: (408)777-322
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 compensatiore
contnbutions.
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 (arid,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
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE 65��
CUPEkTINO PERMIT APPLICATION FORM
APN # -Z�6 O�O Date:
Building Address: ,Z1103
Owner's Name: Phone#:
Contractor: Phone: 7�ad X2.9 License#:
Contact: Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description: ✓�
Residential Z Commercial ❑
Cost of Project:
Qty. if
Applic4ble Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWS VCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
2-� ? �
7. 37