05120033 CITY OF CUPERTINO '+' "+� ? � " "`•# '
BUILDING DIVISION PERMIT CONTMWI QR INFORMATION �.
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BUILDING ADDRESS: - DAVID & BARBARA KOPELS PERMITND.05120033
668 HALE PL DUPLEX
-R'S NAME: PERMIT L55UE DATE
DAVID & BARBARA KOPELS 12/07/2005
E: SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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ups LICENSED CONTRACTOR'S DECLARATION Job Descri tlon�
tel F I hereby affirm that 1 am lieued under provisions of Chapter 9(commencing p
�2W with Section lUlk))of Division)of the Busincnsand Pmfcssinns Codc.mdmyliccnscis Nv
C. in run rpme arta erten. REPLACE WATER LINE (METER TO you(' )
dZ License Class Lie.g �44
�Fp Dau Con
pp7W ARCHITECTS DECLARATION
y I understood my plans shall he used As public records0. �(^
7yU f
L o t, Licensed Professional
OWNER-BUILDER DECLARATION �O
.'�<I I berehy affirm hat1 em exempt from Ne Conuanofs License law far the
0 o following reason.(Section 7031.5.Business and Professions Code:Any city or county ✓
K m which acquires A permit no ennswn.elm,,improve,dcmnlish.or ispair Any structure ,� $500
Yin prior ter its issuance.also requires the applicant(orsuch permit to file a signed statement
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that he is licensed pursuant to tM provisions of the Contractor's License law(Chapter 9 Sq.Ft. Floor Area �Yalua[ion
xis-$ (commencing with Section 7WO)of Division 3 of the Business and Professions Code)or
_ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil pcnslty of r Occupancy Type
not more than Rim hundred dollen(SSW).
❑1,As owner of the property,or my employees wish wages u Neu sole compensation,
will do Ne work and Ne swnure is not intended or offered tonal.(Sec.1004,Business
and Professions Cade:The Co menu's License law docs not apply In In Owner of Required Inspections
progeny who builds Orimprows Nercon,and who ducssuch work himself or through his
awn employers,provided that such improvements Are not intended oroffemd for sale.If,
however,Ne building or improvement is sold within one year of camplcuon,the owner-
builder will have the burden of proving that he did not build or improve for puryme of
AsIc.)./
21 I,as Owner of the property,am exclusively contracting with licensed Commotion to
construct Ne project(Sec.1TX4,Business and Profctsions Code:)The Contractor's U.
cense law does not apply in in owner of propeny.who builds or improves thereon,and
who contracts for such projects with a eomracmr(s)licensed pursuant in dm Contractor's
Licenae law.
1 am ezertt t antler /<� D.B e P C(Or Nis moon
1 n IA-9-,p S
WORKER'S COMPENSA NT�ATION
1 hereby Orion under penalty of perjury one Of the following declarations: -
a ham and will maintain a CenfOeate or Consent an aelf-insure for Worker's Compcom
tutor,u provided for by Section 37M of the tabor Code.for the performance of the
'` work for which Nis permit is issued.
❑1 have and will maintain Worker's Compensation insurance,as required by Section
3100 of NC labor Code,for the performance Of the work for which this permit is issued
My Worker's Compensation In unaxe canner and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thuacction need not be cwnpleted iruse Permit is forone hundred dollars(SIM)
or mrs.)
1 certify that in the performance of the work for which this Permit u issued,1 shall not
employanyperson in any manner umbccomcsub' othc Workcri Compctuation
Laws
or callremiate� ,7— -f�
Applicant ra
NOTICE TO APPLICANTIf.arm,looking this Cettfoone of Exemption,you should
become subject to the Worker's Compensation provisions Of the LAW Code,you most
.J O foMwiu comply with such provisions or Nis permit shall be deemed revoked.
Z'-" CONSTRUCTION LENDING AGENCY
F-i rte.. I botchy AT
that there is A cio.1inn lending agency for she performance of
CL 7 One work(or which this permit is issued(Sec.3041.Civ.C.)
W� A Lender's Name
=1 z Lcnder's Address
U O 1 certify that 1 have read this application And state that the above information is
coven.l agree to comply with all city and county ordinances and sum laws relating to
V building construction.and hereby authorize represematiml of this city to enter upon the
ahom-mentioned property for inspection purposes.
F+iy (We)agree to save,indemnify and keep harmless the City of Cupertino against
Icy liabilho..judgments,costs And expenses which may in any way accrue against said City
Uz in conscqucncc of the granting Of Nis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCEULATIONS.
_ �� Re-roofs
Signature Of ApplicanVConuanour fDau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hvallous material
Aftefrood by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
.Se Y.355A(a)1 p p y g being installed.
-� OYns eta All roofs shall be inspected riot to an roofing material bei.
v Will Nc applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
axardous air Contaminants As defined by the Bay Area Air Quality Management all new materials for inspection.
7ia
❑Poe &l1�I have read Ne hoard...materials requircmcnta under Chapter 6.95 of the Califm-
caIN&gafctyCadc,Scctiwa 35NI5.355JJ anJ 255N.1 underpand Thazif dte building
not currently have a Tenant.Nat it is my reapmnslEility tu nou(y the occupant of the
rtm ata In h Un be mel pnprm enra rtifeamuraaparuy. Signature of Applicant Date
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Owner Or authomN agentP D,te All roof coverings to be Class"B" or better
< Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408) 777-3333
�UPEkTINO
Building De artment
JOB ADDRES : '� PERMIT #
0 eL/ r/ G -Q_ s 2,003 3
OWNER'S NAMR PHONE # I-,do g"- 4 _ o0
GENERAL CONTRACTOR: F`AX #
I am not using any subcontractors: [rail e iO /-�?— ?—
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
Owner/Contractor Signature Date
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform
A. u 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
i3C `12 iSl:L:G4
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
O 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/Fnm 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 Signature: n, Date: / 7—y S
Job Address: 7974- 4v 611,670 )44A Permit#
Any chanes 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
CU PERTINO Phone (40B,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 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 goverment 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 US.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 •
Pnntad on Recycled Paper
-� CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE
ICUPEkTINO, PERMIT APPLICATION FORM
APN # Date:
*3. 261d 4
Building Address:
-!vg
Owner's Name: Phone#:
Contractor: Phone: License #:
Contact: Phone: Cupertino Business License #:
GT�v-he I�
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑
Job„Description:
Residential [Ly GvJ ComYnercial ❑
Cost of Project:
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Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Repipe of Fixtures PLUMBING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEW ER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
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