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03100208rz ; 00 (uF soot �00 -Z� 0 F -4 ' CITY OF CUPERTINO`sa: ;=,i3n'=x. - m BUILDING DIVISION PERMIT CONTRACTOR INFQRMATION::'", ;T BU ILDINC ADDRESS: MAKDISSY TOM S AND CAROL M PERMITN003100205 1" LA RODA DR OWNER'S NAME: PERMIT LSSUE DATE MAKDISSY TOM S AND CAROL M 10/29/2003 NE: SANITARY NO, CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECTPLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description 1 herby affirm that 1 am licenacd under provisions of Chapter 9 (commencing - p with Section 7001 of Division 3 of Ne Business and Prufcssinm Code. and my license is in full fare and effect REPIPE License Clara Lic.g Data Contractor ARCHITECT'S DECLARATION I understand my plana Aha11 he used As public records Licensed Professional OWNER -BUILDER DECLARATION 1 botchy affirm that I ore exempt from the Contractor's Licenac Law lot the following rwsan. (Socdun 7031.5, Business and Professions Code: Any city ter county which requires A permit to construct, alter, improve, demolish, or repair any strucaun $4500 prior to its issuance, also requima the applicant for such permit to rile a signed statement that he is licensed pursuant) the pmvidmas of the Contractors License Law (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Scnion 7") of Division 3 of the Business and Professions Code)or 36933024.00 Nat he is exempt therefrom and the basis for Ne alleged exemption. Any violation of Section 9031.5 by any applicant for a permit subjects the applicant to A civil penalty of APN Number Occupancy Type not mar than EK hundred unit... ($500). ❑ I,uowner of the propcny, or my employco with wegesutMir sale compensation. will do the work and the swcture is not intended or offend for sale (Sm. 7044, Business and Professions Coda: The Conmmo's Liens Law data not apply to an owner of Required Inspections property who builds or improves tbenon, and who docs such work himself or through his own employees, provided that such improvements an not intended oroffend formic. If. however, the building or improvement is sold within one year of completion, the owner. builder will ban the burden of proving that he did not build or Improve for purpos of +ale.). El 1. as owner of property, am exclusively Protracting with:)censed connectors l. construct the Project (Sec. loan, Business and Professions Code:) The Contractor's Li chose Law does fluContractor. r V nor roan of who commolorty whocontractsncr for ouch projau wiNecomnnort+7liansd puravenno the ConBanoh such ith a sed purrimpto tho ��� Li e ❑Ins emptundm cc. Bh PC for Ni. ..an BUILDING WORKER'S COMPENSATION DLARTIC 1 hereby affirm under penalty of perjury one crude following declarations: A I have and will maintain a Cenificate of Cmtsem toself-inmre forWorimes Compere u provided for by Section 37W of the Lala, Code, for due pe8amome. of the k for which Nis permit is issued. r[3DI�l I have and will maintain Worker's Compensation Insurance, as mirtimd by Section of NC Lobar Code, for on KOkurdance of Ne work for which this permit is issued. My Worker'. Compensation Insurance carrier and Policy number am: Cantor. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not M complctad if the Permit is forone hundred dollars (3001) ter less) P cenify that in the performance of the work for which this permit is issued. 1 shall not employ any person in any manners as to become subject to the Workers' Compensation Laws of California. Data Applicant NOTICE TO APPLICANT: IL After making this Certificate of Exemption, you should become subject to the workers Compensation previsions of the Labor CMP, you must forthwith comply with such provisions or this Permit shall h deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is A consbuehun lending agency Or the Performance of Ne work for which this permit is issued (Sec. 3097, CO. C.) fender's Name Lender's Addmss 1 cenify Nat P have mad this application and+uta that the about information is ' correct P agree to comply with all city and county ordinances and sure laws miming to building construction. And hereby authorin mprmenmivrs of Nis city to enter upon the ahovetmcmidgm nropc for Inspection (We) agree to save, indemnify And keep hamleas dint, City of Cupertino against IiamonAea,judgmc costs which may ng capassct which may in any way ecrnse Against said City the gran i Aconsequcncc of the Braining of this permit. APP ANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINT Issued by: Dat S E REGULATIO / !� °�S �Z�un Re -roofs gn4ure of Ap ican✓Contracrnr Ata HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building Occupant store or handle han nous material As defined by the Cupertino Municipal Code. Chapter 9. 12, and the Health and Safety semen 25532(.), ❑ Yc+ gQ u All roofs shall be inspected prior to any roofing material being installed. 1de. win the applicant or future building occupant use equipment or dcviun which 1, If a roof is installed without first obtaining an inspection, l agree to remove ha,ardou. air contaminants As defined by the Bay Area Air Quality Management all new materials for inspection. District? s DYc+ �Mf' P have mad the basanlnus materials nquircmenrs under ChaPtar 6.95 of the Califon m.H "SmctyCode,Sa8uru25585,25533and U534.1 understand thaddc Wilding d currently have a tenant. Nat it u my respmuibilay w artily the occupant of the m i yfenuwnic mu mm prior 1. imitart dins e.wrtfOccup y. Signature of Applicant Date All roof coverings to be Class "B" or better owneraraamnrixedagent Date OWNER -BUILDER VERIFICATION 1. (Check one) I or//my immediate family (parent, spouse or child) will perform: A. X 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 erformed I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner -Builder Information verse side). �,/ Property Owners Signa �it Tate: /10 Job Addrgs %�ec._ Permit # Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. J ;Dear Property Owner: City of Cupertino Building Department 10300 Torre AvenuA 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 L 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 95514. 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 • .7 CUPEkTINO CITY OF CUPERTINO a3 o Zoe REPIPE/SEWERS/MAIN SERVICE PERMIT APPLICATION FORM APN # i � J Date: is -a '7- �3 Building Address• Ia5753 7 b BPREPIPE Owner's Name} / Phone #: y / Codtractor: Phone: License #: Contac • Phone: Cupertino Business License #: Building Permit Info: Bldg ❑ r7 Elect ❑ Plumb ❑ PLUMBING Job Description: Main Water Service PLUMBING Residentialv rommercial ❑ Sewers Cost of Project: r , BPSEWAGE Qty. Aivli a161Fee ID Fee tlecrrintinn Fen r:rnnn PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE Re i e of Fixtures PLUMBING BPERMFEE Bldg. Permit Fees BUILDING BPFIXTURE Pbl . Fixture PLUMBING BPWSVCS Main Water Service PLUMBING BPSEWER Sewers PLUMBING BPSEWAGE Sewage Disposal PLUMBING BU LIC Business License BUILDING 3627