04040161 CPPV OF CUPER'fINO
BUILDING DIVISION PERMIT CONTRACT("ryIR INTOIZMATION:.
BUILDING ADDRESS: STANLEY R. BRUNO PERMIT N004040161
1122n IA QTJA CT
OWNER'S NAME: PERMIT ISSUE DATE
STANLEY R. BRUNO 4
ONE:
SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG. ELT:CT PLUMB MEGA
0 0 0 0
v00LICENSED CONTRACTOR'S DECLARATION
F 1to'my aftlmthe I tom littered unde r provisions or Chapter Roomencing Job Description F0f-,�f3 ri �❑
z IIII,Soueon](sXR ofDivlam,3aide Buslmess and Profession,Code,and my license is uV/'L-1v,3,
flfuumreeamdeffeet' REPLACE ELCT PANEL (200AMP)
=_a
j2 cc �.ieerse Carr Cc,If Dale Commnor MAY v — 2004
ARCHITECTS DECLARATION
I understand my plans shall be used as public retards
Licensed OWNER-BUIDER DECLARATION SV BS
,HNSS
L Q I hereby afllrm dill I i,m cFempl from tire Continuous License IAw fill the
yY
00 fnlowmeg reason.(Section 7031.5.Business and Profersiuns Cade:Any sty tar emery
i(m w which m,i ills a permit In mm,l...t,alter,imitative,demolkh,ar repair any stoccome
Y y or prior to IL issuance,also mimics the applicant Pal seen parmll to file aslgne,l statement
qyy� that he is licensed pmson lmthaplmmsmmnnbe emtmetor'.s License 11w(Chnptm9 Sq. FL Floor Area Valuation
y'FQ (cam mowing wit[,Scotlon700(bof Dii,Wcu 3 of the B uslncssand Prufersinns Cade)or
i .. that he is exempt therefrom and this basis for the alleged exemption.Any violation of
Section 91131.5 by any applicant fm a pcmil subject,the applicant o a civil penalty of 3 5Aff1ZDI ffi-1cr0 0 Occupancy Type
not mnyC than five hundred dollam(55(10).
Lti'I/ rofthe property,or my employees with wages as their sole compensation,
oe work,
will Jo do work,and the he Cont is not ifarmos m offered do for sale(Sec.9Bb1,Business
and Property cane:The vsmtmSnla and
Law docs or apply m art..net is Required Inspections
.memory who huipro i improveschemnn.and who alms such work or offered
ed horror.
his
owncer,the cs,provided pr svehentissld witarenot Tear of completion,
moffered for own IL
builder @c buildingor improvement of c prove for the ore of
Sale). will have de burden of proving Nm he did not build or improve for purpose o[
sale.).
❑I,as owner of the properly,am exclusively contracting with licensed cnnmacmrs to
instruct the project(Sea R94,Business and Professions Codm)Ile Contractor's L4
cense Law docs flat apply to an owner of property who builds or improves thmmum and
who contorts far still,projects with n cmose m(s)licensed pursuant to the G,oracams
License Law.
❑ l am exempt onJa Se ,11&P C_fr tbisal sen
Owner�L�f� Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the fallowing declarations:
J I love and will maintain a Ceni icata of Consent to self-insure for Worker's Comped
somal,,as provided far by Section 39W of de Labor Code,far the psaffor ante mile
work for which This Fermis is issued.
❑I have and will maintain Worker's Compensation Insurance,as squired by Sectio
390()of the Labor Gale,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance cause and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed lithe Permit is for one hundred dollars 091(X)
r less.)
I certify that in the performance of the work for which this permit Is Issued,I shall net
employ any)cede in any manner.w as to become suhjen to the Workers'Compensation
Laws mf California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ccnilicam of Exemption,you should
became subject to the Workers Compensation provisions or the Labor Code,you must
.,z forthwith comply with such provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
E-s ice+ I hereby affirm mal here iso eamarunmnn tendon,agency ter the pelivmone.of
Ix > the work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
rD z Lender's Address
U Q 1 court that I have read this application end sum that the above information is
fL H coned.1 agree be comply with all city and county mdimates and state laws relating to
QU building construction,and hereby authorial representatives of dos city to enter uponthe
r W above mentioned progeny for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
,,G Iiabilities,juJgmcnt,,cusu andexpcnscs which mayor any way accme ageimisaid City
U z in consequence critic granting of this permit.
�+ APPLICANT TINDER TANDS AND WILL COMPLY WITH AL NON-POINT Issued by: Date
SOURCE RC S.
O Re-roofs
Sign. roof APPlm SrVCommcmr Date
HAZARDOUS MATERIALS UISCLOSURF. Type Of Roof
Will the applicant or future building occupant store numeric hazard as material /
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,s Section 3s533(an All roofs shall be inspected prior to an roofing material beim
El Yes ❑Na P P Y g g installed.
Will me applicant ill stare bumming n«apanl nsc egthFmem or devmes wmen If a roof is installed without first obtaining an inspection,I agree to remove
nil hmtardntia air contaminants as depend by the Bay Arca Ail Quallly Management all new materials for inspection.
)&Hchl
❑Yes [I No
I have read de hatzNmus materials requimmcnu under Chammr 695 of the Caliber
nim Hcct®&Safety Ccdr,S eons 25505,25533and 255341 reflectional Eatlfde building
Wits not cu fined,have a tenant Wat it is my responsibility In cram,the care and n'do
mgmrtmeats IMmelpdmmiratmmeaneenihcatenrat.p ay, Signature of Applicant Date
46
Ogem,atidari,.ed aged ate 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
UPE DT INO
Building Department
JOB ADDRESS: PERMIT# /
//22tj 44 /0z-,4- ' —j 6 6(� 0/6
OWNER'S NAME: PHONE # 253-5/
GENERAL CONTRACTOR: FAX # -7 /
I am not using any subcontractors: CvSf" t/ �u � GCc o
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
ner/Contractor Signature to
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform
A. "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. AIl f e work
B. ortion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
VG GSL V14iC4
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 Pho ber 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).
X Property Owner's SignatureeZ14-
"�y Date: Z( Dy
/ Job Address: //; 7? ULC�9 CT Permit# Ll,�o41016�
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
dam
City of Cupertino Building Department
CITY OF 10300 Torre Avenue
C O P E f�T I N O Phone: (408)777-3228,
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 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 all 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
�(eF CITY OF CUPERTINOCITY O
o o
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
a
Building Address: Mailing Address (if different from building address):
//�� ✓OL! 4 !pI/27–
Owner's Name: Phone #:
Contractor: License #:
641.055 z
Contact: Phone: Cupertino Business License#:
Fax:
Building Permit Info:
Bld ❑ Elect ( Plumb ❑ Mech ❑
Job Description:
Residential ❑ �Od �P �/>/�4F&CWl-ommercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost ofproject: Occupancy Group:
Type of Construction: Please check this box if the project is a
second-stor addition:
Quantit Fee ID Fee Descri tion Fee Grou
BAPPLOTHER Other A fiances MECHANICAL
BBLDGFEE Bld Permit s . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> l OOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOFLER5 Boiler> 1.75M Btu MECI3ANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/ uasi BUILDING
BCONSTAXBQ Con. Tax for B one BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax –Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <=200A ELECTRICAL
BENERGY Ener BUILDING
BENERGYADD Ener Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housin Mit. Fee BUILDING
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CITY OF CUPERTINO
CUPEI'TINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
13OVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINI'ERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain & Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water HeaterNent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit > 10,000 cfin MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switeb & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Sips, Marquee ELECTRICAL
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luryo
CITY OF CUPERTINO
CUPEPERMIT APPLICATION FORM
QuantityFee H) Fee Description Fee Group
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems DIECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERNHTFEE Mecb Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
Pp Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chan e BUILDING
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