05060065CTry OF CUPEWrINO
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WON, RACT�OR INFORMATIOMIR
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
JEFFREY MASON
PERMRN0.0S06006S
OWNER 'S NAME:
PERMIT ISSUE DATE
JEFFRE
NE:
SANITARYNO. CONTROL NO.
ARCHITEC tENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
p
with Scion IOR) of Division 3 of the Business and Professions Cods. and my license is
full seand
LacramreeClass Lk. M error.
Licen
E=
DEMO (E) POOL/DISCONN-UTILITD
J
Dale COO.,
ARCHITECTS DECLARATION
1 understand my plans shall be used . public mcomb
C7 _
`T
jjff 2005
Licensed Professional
OWNER-BUILDER DECLARATION
I hereby .('firm then 1 exempt Nc Contractor's License Law for the
following mason. 1. Professions Co ostomy
maso 7031.5,Business and
s an Of: Any city
which requires a Permit improve. demolish. s
mash any struma
alar, nt
n Q A (r'-0u {,\ ij /�
forvc, ermittor
a. also va ianswet,
prior wiucensed pursuant toga the t
that ovisiosof for memmenitmfleasLaw(ned haptens
wit pursuant toN)of
Ir,\1' II
Sq. Ft. Floor Area u�
�" 11� �„
� \\\Vialualion
Division 3 of theCock) or
of (heeged.fand Profusions Cads) at
(eommeneingwith Section ] eBusinos and Professions
commecing
b exempt thertfwm and the burs for the eaempnm. Any violation of
that and basis for
-
3MN4,0&ber00
Occupancy Type
mthe
Section by any (subjccuaaiapplicmuoacivilpcnaltystf
..I..7a3L5
.hundredrens(fo($50Q.
not mon Nan five hundred dollar, (5500).
1, se owner of the property, or my employees with wages u their rule comper cation,
Required Inspections
will do the work and the nmcmai is not intended of offered for sate (Sec. ]044, Business
and Prates, ons Code: The Comsmmr's License Law doe, not apply m in owner of
property who builds orimproves thereon, and whodoessuch work himself or through his
Own employees, provided that such Improvements aR not intended Oraffered for sale. If.
however. the building or improvement is writ within one year of completion. the owner.
bWilder will have the burden of proving that he did not build or improve for purpose or
sale.(.
El 1, as owner of the property, am exclusively contracting with licensed cmatme ors to
construct the project (Sec. 7W, Business and Professions Code:) The Conaacmr's Li
cense Law does not apply lO m owner ofprapent, who builds or improv. Merton. and .
ha contracts for me projects with acontracmr(s) licensed pursuant to the Contractor's
VILi
Cmr Scc. . B k P C far this reu90
Date
+hem�jmrn
ORKER'S OMPENSATION DECLARATION
I under penalty of perjury one of the following dcclantions:
f1h,
sve, and will maintain a Ceniacate of Contend to self-insusc for Worker's Compcm
sa(ion, as provided for by Section 37W of the tabor Code, for the performance of the
work for which this permit is issued.
0 1 ban and will maintain Worker's Compensation Inwrmcc, as required by Section
3700 of the labor Cade. for the performance or Ne work for which this permit is issued.
My Worker's COMNMatian Inwsance carrier and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not ttecampleted Run, permit is intone hundred dollars (Sip))
or less.)
1 certify Nat in the P< mce of the walk for which this permit u issued, 1 shall nut
employ any person in ymmnerwas bens wbjet Ir Workeri Compchuaton
Lawn of California.
Applicant
NOTICE TO APP LI A : Ir. after making this Ceniaeate of Esemption, you should
hecome subjcn m Worker's Compcnuton provision, or the Latin Cade, you muse
Mman provisions or this permit shall m deemed revalued.
fowi(h eomPlY I
CONSTRUCTION LENDING AGENCY
1 hemby affirm that then is a conawction lending agency for the performance of
the walk fur which this permit is issued (Sas 3097, CO. C.)
tarda', Name
_
Lcmlu,'s Address
I Certify that 1 have mad ads application and sort that the chose infoonaauh is
correct. I since to comply with all city and county ordinances and sure laws relating to
Wilding construction, and hereby authors mpmsenu(i.cs of this city to chair upon the
above-mentioned pwpc,ty far mpcetion purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities ,jadg n¢costsand expenses which may in any way accrue against mid City
in cansequencc NC BnnIing of Ihia permit.
APPLICANT VNIERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date,(� �-f�
SOURCEREG ONS.
B<
O — Or
Re-roofs
Type of Roof
signatumorA Ii anVCo awror Data MATERIALS DISCLOSURE
Willthe pplicant or future building Occupant store or handle hmallous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 25532(.)?
All roofs shall be inspected to any roofing material being installed.
❑ Ycs �N/
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building acupam use equipment or device. which
B n..ardoas an eanommamts a.rincd by the Bay Arca Air Quality Mmagcme^I
all new materials for inspection.
istric"
❑Y. No
I hav ad the hamaNiusmawrialsmquimmenoundcr Cbapwr6.95of(hcCalifor-
niaHealthA afety Code,Secdans25505,25533md25534.lun&mmdthuifthc building
docs not curt my have: a tenant, that it is my responsibility to madly the occupant Of the
mquiremenas,hihmustWme( pin ortosauanaofacerdfi.(cofoccupancy.
Signature of Applicant Date
6S
All roof coverings to be Class "B" or better
owncr &.d
or so agent rhi�-
Owner/ Contractor Signature
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
-to -os--
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. Apo rtion 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.
I declare under penalty of pi
Owner -Builder Information
Property Owner's Signature:
Job Address: t03(.G
Type of work to be
that the above is true and correct. I have read and understand the
se side).
Date: % - t 0 -0 S
Permit #
AU changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
a
CITY OF
CUPEkTINO
Dear Property Owner.
City of Cupertino Building Department
10300 Torre Avenue
Phone:
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 vrotect 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 an Recycled Paper
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ain
CITY Of
CUPERTINO
CITY OF CUPERTINO
DEMO
PERMIT APPLICATION FORM
APN # '3(.9 - l `l — v 3
Date: to U S
Building Address:
1v36� GQEE-3wev0 C' Cupea..`n►.� .CIA gSulq
Owner's Name:
Jc'F-cb �=
Phone #:
(P Sb 520 `fS,G
Contractor:
O p
License #:
Contact:
ILkA-Sor�S
Phone #:
fo!�b S2.o `fFr�
Applicant/Co
tractor:
fJ
Seismic Residential
BUILIDNG
Building Permit Info: R.®Mouiutr Eear.—( Wc, q dbt- Tb eaN—
Bldg Elect Plumb ✓ Mech ✓
Job Description:
Residential: Commercial:
Sq.Ft. Floor Area:
$/Sq.Ft.:
Architect/Engineer:
Valuation: 4t Uab
Type of Construction:
Occupancy Group:
Qty. if
Applicable
Fee ID
Fee Descrintion
Fee (;rnnn
BPERMFEE
Bldg Permit Fees
BUILIDNG
BSEISMICOM
Seismic Commercial
BUILIDNG
/ BSEISMICRE
Seismic Residential
BUILIDNG
BPLANCHK
Plan Check Fee
BUILIDNG
BUSLIC
Business License
BUILIDNG