04050008 CITYOFCUPERTINO ,^ etwtm+'
BUILDING DIVISIONPERMIT' CONTRACTOR INFORMATION
Bu1LDINGADDRESS: ROBERT BRUSHWYLER PERMITNcb405OOO8
ERS NAME: PERMIT MUE DATE
ROBE
ONE: SANITARY NO. CONTROL NO.
ARCHITECrfENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
tiOOZ
LICENSED CONTRACTOR'S DECLARATION Job Des �
C I thereby af0rm that 1 am lammed under Pro^Sou of Chapter r(Commenting 1,
U
withSectionndk)te Division3of the Business asW Profruiou Cote,end my license is
in mB mree anaerrea'' REPLACE FURNACE & A/C
t,m Z Liccnx Class Lic.N
jil- Dab Contractor OCT £ 2004
ARCHITECTS DECLARATION
�i l understand my plans shall W used u public records
pyU
;oto eensdPmfbyafflo BUILDING
OWNER-BUILDER DECLARATION
i�n o I Wrthy.(Gere n I em exempt froms an Ne Cantrms Ca License Law for the
y p O which
reason.Permit
(Section]tO L4 B.idicss improve,
ve,de ions Calc:Any city or county
cruse
$Pi which mquircs a permit re rnnsWCL applicant
improve,demolish, file
repair any aweure
that mits issumm,alwrequires the applicant for such Permit m Glcnsiga(statemem
E�E�< that he is lieenscd Punvam in the provisions of tiro Contractor's Limnx law(Chapurr9 Sq. Ft. Floor Area Valuation
y�$ (commencing with Section 7000)of Division 3 of the Business and Profusions Code)or
Nat he ts exempt therefrom and the bests for the alleged exemption.Any violation of
section 7031.5 by any applicant for a permit Subjects Ne applicant o a civil penalty of 3 24a`N39L5&er0 0 Occupancy Type
not mom than five hundred dollars 4500\
wi L o the work.
and
Property, rem notimende with wages u then(Sec.
mmpcnxdess
will da the end e: he Core is tot's License offered wdo s..I apply in an Owner
Required Inspections
and property
wh ons Code:The ves trabfa License taw does not apply to an owner of q p
Own employees
s provi impmvuchncon,andwho sm not Intended
himxlfmNmugh his
own employees,provided of
that such impmsemmts art not intended oroRered finale If.
however.the Wilding or improvement is told within one year of mprove for the owan
builder will have the Widen of proving that W Oitl not Wild or improve for purpose of
akJ.
❑1,as mmor of due property am exclusively contracting with tieemCo mneacbm in
construct the project(Sec.7044.Business and professions Code:)The Convector's Li-
come law does not apply m an owner of progeny W ilds or improves Nemon,end
whoconvacts(or 6aM1 tswiNamnvecb li nxd pursuansb Ne Conuatoh
License law.
Iem exempt un rex ,B&PCforthboaon
WORK OMP S ON DEC RATION
1 h by air.under penalty cduty am of On,following declarstiou:
I have and will maintain a Certificate of Consent to self-insure for Worker's Campcm
cation.as provided for by Section 37W of the Labor Code,for the performance of the
work for which this permit is issued
1 have and will mainuin Worked Compensation Incurious,as requited by Seeuon
37W of the labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Inmm m carie and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissection need not W complexed Rite,permit Is for onchundred dollars(SIM)
or less.)
1 certify t in Ne performaoee of the work for which this Permit is issued.l shall not
employany y net xa m subOa the Workeri Compensation
Laws of Ca' .Da
Appli �-
NOTIC APP C : f r m ng Nu Ceni bate of Exemption,you should
become jen fM1c arke Compcnation provision of Ne labor Cade,you most
3z foMwiN comPl W such Or s or this Perot,shall W deemed evoked.
ZO CONSTREN
UCTION LENDING AGENCY
1-, l hembyilOrm that there isaconstmction lendingagency rimula perfummxne'd
C> the work for which this permit is issued(Sec.3037.Civ.C.)
W QLenders Name
C. Londa.Address
(, I certify that 1 have read this application and state Nat the above informauun is
{L F correct 1 agree to comply with all city and county oNinmces and aux laws relating to
O U Wilding construction,and herebyautWdae mpruenmires of this city to court upon the
W
above dmentioned!
mentacny land exposes Purposes /
(,CL (We)gree 10 save,indemnify and kap harmless the City of Cupertino against
to IiabiliOes.judgmenu,costs and expeua which may in any way ettme against aid City
U Z in consequence of %roofing of road.
.. APPLICANT U R ND A WILL COMPLY WITH ALL Issued by: Date
SOURCf.BS.
Re-roofs
Signatu fAppliceoOCa uanor Data
Hnz DOUSMATERIALSDISCL uRE Type of Roof
ell the;Cupent or fwumc Wilding s.Chapter
atom2, ad t e hasabons maxedil
I
tied by Lb;
W Cupertino Municipal Code,Chapter 9.11,and the HeaIN and Safety
c.Section 15531/e)? ww All roofs shall be inspected prior to any roofing material being installed.
C]Yes YNu
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future Wilding Occupant use equipment ordevices which
7D�xui,,7
t hammous air contaminants a dc0ned by One Bay Ara Air Quality Management all new materials for inspection.
❑Yes
I have mad Oxe Wrardtms Isrequiremenv under Clexpxer695oftheCalifonHealth&S.na ode,Seco 355,3553 a mMs.s.l un dcrnand Naz if the Wilding
amtcu Wraate ( tittsmuire ,o ich �I met dorm':aanccaraccr4G rop �� Signature ofApplieant Date /
araramm�nse gang Dax All roof coverings to be Class"B"or better ✓
Community Development
R *.
J130 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
PEkTINO
Building De artment
JOB ADDREW PERMIT# of 6 507,�
/0/ 5'3 /-1r"'C2cs7 ¢ o
OWNER'SN j: o3c-d7 IPHONE # 'FF( - /s>0
GENERAL CONTRACTOR: I FAX #
I am not using any subcontractors, ' 3a
i tyre Date
Please check applicable subcontra ors and com et e the followin information
66 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Adffik 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
0
r6ter Co c r Signature ate
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
✓c cu vau�cu
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 t the a is true and correct. I have read and understand the
Owner-Builder Information (rev s side)
Property Owner's Signa e: Daae:
G U7�U0�
Job Ad ess: L I�/3 /��� Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
/ � Department.
i
City of Cupertino Building Departm
CITY OF 10300 Torre Avenu
U p[kT I N 0 Phone: 408 777-3228
Dear Property Chvner.
An application for a building permit has been submitted in your nate 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
Gecurity taxes,workers compensation insurance,disability insurance costs,and unemployment compensatiois
ontributions.
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,
uty of Cupertino
Printed on Recycled Paper
CITY OF CUPERTINO P�
FURNACE/AC
eP� 0 PERMIT APPLICATION FORM
APN 6
Building Address: L/
Phone#:
Owner' Name: YGd �j 96 - /J7
Contractor: Phone: License#:
0Cf n/24c-
Contact: Phone: Cupertino Business License#:
0c4-„jLFk- Q�rb -�S?J d' S2 - C,F&
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description:
Residential Commercial ❑
For Residential Installations:
tic ❑ Is' floor ❑ 2"d floor❑
dhere to min set back re uirement❑
or Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation
New installation Plannin A royal Required ❑
Cost of Pro ect: Type of Construction: Occ c o
�s G
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
licable Fee ID Fee Description
Fee Grog
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A1C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License-/-/ b BUILDING
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