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02100177 CITY OF CUPER'1'INO ' '�`—To&, BUILDING DIVISION PERMIT CONTRACTOR INFORMATION BUI1DpI!7/D@ZEs OHNSON AVE PERMITNg2100177 owrf¢jAlyl4SON LEE APPLICATPOYIZry2002 ONE: SANITARY NO. CONTROL NO, ARCHIL ECTlENGINEBR: BUILDING PERMIT INFO BLDG ELECT PLUMB MECIf 0 0 0 0 Op LICENSED CONTRACTOR'S DECLARATION bDCSCrI taco 1 hereby afprm that 1 am licensed under provisions of Chapter 9(commencing TEMP POWER POL p with Section 70iXd of Division 3 of Ne Business and Professions Code.and my license is m full three and effecl. License Class Lie.N p2Fp Dmc Contractor = G ' O—F'9 ARCHITECTS DECLARATION 6 U I understand my plans shall Is,used as public records m3LLLicensed professional Fop OWNER-BUILDER DECLARATION I hereby affirm that l am exempt from the Contractors License Law for the r 3 0 O w p p following maim.(Section 7031.5.Business and Professions Code:Any city or county Y n K$� which acquires a proud to construct,aper,improve,demolish,,r repair any structure �3< prior to its issuance,also roquires the applicant for such permino file a signed statement qqacm Nat he is livened pursuant ln the provisions of the Contractor i License Low?Chapter9 3S45Bt1IF1d01A@© Valuation 'rZ Ft•� (commencing wit Section 70010)of Division 3 of the B usinese and Professions Code)or that he is exempt therefrom and to basis for the alleged exemption.Any violation of Swoon 7031.5 by any applicant for a Permit subjects me applicant to a civil Penally of i JAPNN Occupancy Type notacme men five hundred dollars($500). 304 - ROUGH ELECTR CAL P Y YP O I,ss owner of to property,or my employees with wages as their sole compensation, will do the work,and she structure is not intended or offered for sale(Sm.7044,Business and professions Code:The Constructors License law does not apply to an owner of Required Inspections property who builds or imprms Thereon,end who am not intended h work himserredtrough M1f. own employees.provided lhn sveh nth is o d wit are nal arof mplacretl for ownaf, builder ,tcbuilding or den of pmcnlishat within one year of completion,toowner- / builder will have the burden nl proving that he tlitl not build or improve for PutPnu of sale.). ❑1,a owner of me property,am,Business contracting with:)ThoficarredConnuanom to construct the project(Sec.to an Business and Professions Code:)The Contractors ed Q Li- music law does not apply je an owner of Property who builds or Improves Contra,wed. wh; est,Law. fors ch Wnjccu with acaummnr(s)licened Pursuant to the Contracture Li use Law. / /p I exembv oder Sm. / .B ffi P C fur ,Nlsrcason r. d y/.�OIIPBNSATION DECLARIhereby aalty of perjury one of the following declarali,ns: I have and williOcaleofCovent to sel6Wuro for Wurkeri Com it sation,as providen 37W of me Isbor Curie,for to perfmmance of the work for which this permit is issued. O I have and will maintain Workers Compensation Insurance,as acquired by Section 37181 of to labor Code,for she Performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number are: Carrier. Policy No.: _ CERTIFICATE OF EXEM"ION FROM WORKERS' COMPENSATION INSURANCE (This section need not he completed if Me formil is Insure hundred dollar($Rg) less.) 1 certify tat in to performance of the work for which this reit is issued.1 shall not court any perm) an manner m opt�'mcs i the Workers'Co.r m.iun Lowe of Catif'o AP lican N m ;ing this Ceriicam of Exemption,you should Mcc ub orkc Compensmion provisions of the Iabnr Code,you must oz fnnhwilh comply with'tach provisions or Permit shall M deemed revoked. O CONS'PRUCTION LENDING AGI7NCY �4 I hereby alarm that there is a construction lending agency for the performance of a > to work for which this Komi l is issued(Sec.3W7,Civ.C.l "i 0 Lender's Name r7 z Under's Access U 0 1 certify Out I have read this aPpticalion and sum that to above information is IL (✓ cored.I agree to comply with all city and county ordinances and slate laws relating to DU building mnatapareion,and hereby auldmIlrz repreaeoubva of this city to enter urym the H.1 above-memionsed pmperry for inspection purposes. 04 (We)agom to axvq iademni fy and keep harmless the City of CuPmino against It liabilities,judgments,ensu and'f 4ND which may in any way accmc againu said Cily U z mconegnenre oflhegranlingof 's permit Il/ a .a/""/1 llhl••,v/ �+ APonso UNDERSTANDS sl WILL COMPLY WITH ALL NON POINT Issued by: Date URC :GULA IONS. co Sign he ----- °Date`')& Re-roofs HAZARDOUS MATERIALS DISCLOSURE Type of Roof HAZARD Will the ap Roast or future building ramel pant store or handle haraous material as colm0 by the uranin,Mmitcipal Craft.Chapter 9.12,and the Health end Safety once.$ Yesion zss3z('77 All roofs shall be inspected prior to an roofing material beim Installed. ❑Yes N,' P P Y g g Will lheapplicamorlum'1yytrbuilJingtaccupanlusccynipmenlmJcviccswhich If a roof is installed without first obtaining an inspection,I agree to remove emit bvaNuue air comm rmpts/s coined by the Bay Area Air Quality Management all new materials for inspection. District? OYv ON. I have mad the hazardous materials requirmacnu under ChaNrr6.95 of the Califmr ria Hem Gtec,Smrin.25515.x5533and]5534Jundcr.undtalifmohuilding drca nnl fa lave a Naanl,dl 1 is my rCsP,n9lhltly in notify IIIC Keupanl,l be req nldchmamImetN �I,iaaaanceofaCmiticateofar ancy. 41 tureofApplicant Dale 01 1 47 ° All roof coverings to be Class "B" or better no rt a r Dam OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent,spouse or child) will perform: v 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 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 (rev se side). Property Owners Signa y / ISate: ( n` y Job Ad ess' o _7 tiC� ✓R . Permit# Any changes to the information provided on this form shall be to the City of Cupertino Build Department. x CITY OF City of Cupertino Building Departine Torre CUPS_ INO 1 m: (408)777- ntIS2 ��R"�!! Phone: (408)777-3?28 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. )'f 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 compensalioi contributions. There may be financial risks for you if you do not cavy out these obligations,and these risks a re 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