05060206 CITY OF CUPERTINO �`�
BUILDING DIVISION PER CC1N,n�RAC ;OR�TN ,o ON:
.
BUILDING ADDRESS: LAWLOR STEVEN C PERMIT Ncb S 060206
TV rT
W NER'S NAME: PERMIT ISSUE DATE
LAWLOR STEVEN C
ONE: SANITARY NO, CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMS MECH
30o LICENSED CONTRACTOR'S DECLARATION JobDescri tion
I humby affirm that 1 am licensed under provtsiov Of Chapter 9(rommenting P
with Section 7")o(Divislon 3 of NC Business and Professions Code,and mylic rre is
in0t0to.and ofrem. REMODEL MS BATHROOM .
(@(p(g{ Z License Class LIc.M
' �� Dale Cemmem,
L ARCHITECTS DECLARATION
11 Y d 1 understand my plana shall W used as public meads
+3 G Licensed Profruianal
g
OWNER-BUILDER DECLARATION
CMO
1 Mmhy affirm on 1 em exempt from the Conine Co Limine Law for the
C m O which
mason.Permit
t 711315,Business and Professions Cod,:Any city m county
$ which mghims a permit ro cnntwcl,time improve,dcmnikh,nr.,air my awcluro 86000
_Zj- poor w its issuance.aim requires the applicant for such pcmtit m rile a signed statement
<
that he is licensed pursuant to the pmvisimu of the Conuecmr's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
ptL$ (commencing with Section 7000)of Division 3 of the Business and Profvonns Code)or
that he Is exempt thmefrom and the basis for the alleged compiler.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant m a civil penalty of er0 0 Occupancy
not mart than five hundred doll..(S500).
�YPe
1.u owner of the property,or my employees with wages as their sale compensation,
will do the wary.and the swttum Is not intended or offered for We(See.IDµBusiness Required Inspections
and Pmlevione Code:The Contractor's Liam law does not apply m an owner or q P
property who builds orimpmw dmmon,end whodmsauch work himself ter through his
own howuildin orimprowmed that such mprovemenuamne year
of completion.
mlecred for Owner. _ l
however.employees,e building or improvement roved within one you of cemp offered
Nr owner-
builder will have the bollen of proving that M did not build or Improve for purpose of
W.J.
co s,as owmr ofjcc, property,.m exclusively and
contractingfesswith licensed mnmcmrs m
construct to es noa(Sec.tom omBusor end Pr mini ml Code)TM Cantramon. LI-
who craw date nm ah pty m an owner of propeny.wce sed a or umpmvss Conran,and /
who contracts for such projects with econusstortq licensed pursumtsethe ConmdoYa�
1 License Lew, -
of.../Patunder We�'^' B h P C for)thin rcuon
wnarvl�—� Data ,•. !C7 D
WORKERS COMPENSATION DECLARATION ,1
I MmbY effrm under pmWty of perjury one or the following dOclvations: V
❑I hamand will maintain.Certificate of Covent toulf-Insure for WoM1SYs Compcn-
satlon,as provided for by Section 3700 of the labor Code,for the performance or the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance.as required by Section
3700 of the labor Code,fa the performance of the work for which this permit is issued.
My Worker's Compensation Insurance coffer and Polity,number art:
Cartier. Policy Nu:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu vection need not be com plated little permit is Forma hundred dollars(SIM)
nriaa)
_ 1 mnify Nat in the performanceof the work for which this permit u Issued,l Nell nut
- employ any person in any manner nu in mumnanhoct IMhe7 ljpg%JL9ingpesedon
aof Cyfirufla
Applicant
'< NOTICE TIT'PPLICANT:If.aAcr making this Ccnincate of Exemption,you should
become subject in the Worker.Compensation provisions of the Labor Code,you most
0� fonhwilh comply with such Pon alnv or this Permit shall M deemed revoked.
z1 , CONSTRUCTION LENDING AGENCY
[••r 1 hereby affirm that there Is a construction lending agency for the Performance of
a
the work for which this permit is rssoed(Sec.3097,Civ.C.)
W�Q Lendc',Name
z Lender's Address
U 0 1 certify that 1 he.rad this applicali..and sure that the above Itinerant..Is
{k.F coned I agree 0 comply with all city and county ordinances and state laws relating to
0U building construction.and hereby authmia,mpraenuthos of this city to enterupon the
W shave-mentioned property for inspection purposes.
(We)agree in save,indemnify and keep harmless the City of Cupenmo against
„y a liabilities.judgments,coos and expeller which may in any way same against said City
V in consequence of the sterling of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU e��cuj TIONS_
� �C � �� Re-roofs
Si nature of Appiican'Conuacmr Data .
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant smrc or handle ha.ardoa materia
as de0ned by the Cupertino Municipal Code,Chapter 9.13.and the Health and Safety
Coda,Semen 255330)7 All roofs shall be inspected prior to an roofing material being installed.
El YO. No P P Y g g
Will the applicant or f building occupant use eyuipmcnl or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hnaardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Disvia1
❑Yea 'gNo
I have mad the ha firms materials reyuimmenu under Chapter 6.95 of the Califor-
nia Hui"SafetyCodc,Sections 355)5,35533 and 25334.1 undcrsurW thv irate Wilding
does not currently have a mount.rhes it is my responsibility in notify the Occupant of the
.4. amms ich must be met Pat r I flounceofaCcrtiGcawofCoca mee.. Signature of Applicant Date
a/ J All roof coverings to be Class"B"or better
Owner or authorized agent Date
O ER-BUILDER VERIFICATiJON
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
be perfonmed
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.
PersorVFirm Address/City Phone Number Type of work to be
erformed
1\1145 RI Pe-&> S a,08667 4-1-L
L7nKJce.4
O
.....................................................................................................................................................................................
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: Date:
Job Address: g0 L(l C,-44 o f Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
City of Cupertino Building Department
4CITYF 10300 Torre Avenu•
CU PERTINO
phone: (406)777-3226
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 compensatiole
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 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
Pdnted on Racycled Paper
I'M
OHIO
H
E-E�
Zs EN�TI S T
• ao -
CUPEkTINO
Assessor's Parcel Number:
Nameofowner.
Project address. C7—
Contact person. I�5A-710 Phone. -//03 2-57
Fax.
Net square footage of lot.
Existin Proposed
Square footage: First floor:
Second floor:
Garage:
TOTAL:
• Are there at least two 10 foot by 20 foot clear spaces inside the garage? Y N
Is privacy protection planting required for the project? Y N
On what floor(s) is work being'
eing done? 5'1:FCo1J1::;>
Brief description of work. OPI
),II MA57eeZ, ZA-71; 0 5�1�- II
Code editions:2001 CBC (Y - N)2001 CFC (Y-N)2bo 1 cmc (Y-N)
2001 CPC (Y - N)2001 NEC (Y -N)
Effective 11/1/02
Plan Review Process Work Book Page-8-Revised 4/28/04
zNzm PFA y Z r O
,
G -toil, N
l.
�; -
CD
oir, i4
An
IR
� N
i
� O
i
n
L--7
*CITY OF CUPERTINO* 0 2
PERMIT os APPLICATION FARM
CUPERTINO
APN#�C� r, //-
O�1i Date: 3"')
2 „ oar J
Buildin Address: Mailing Address (if different from building address):
Owners N Phone#: DD 2✓7 j982
Contractor, /45
Con //LPP� License #:
tact: /Y/ , f7Y Phone:�(4-11e j5– Cupertino Business License#:
Fax: 2064-9
Building Permit Info:
Bldg ❑ Elect Plumb Mech ❑
Job Description: 897h%�? M
Residential Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: D Occupancy Group:
Type of Construction: Please check this box if the project is a
Adik /vbDD second-story addition: ❑
— Pro'ect Size:- Standard ❑ Laze ❑ Ma'or ❑ -- -----
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone 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 Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA . Investigation fee BUILDING
-3
1 of 3
3� 7, `�
+CITY OF CUPERTINO
CUPE3f�TINO PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTNIE Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL -Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP 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 rinklerBackflo PLUMBING
BPSTORM StomVRain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10,000 clip MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Fumace> l OK btu MECHANICAL
BRENMAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BRENUZZ"P Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
2of3
OITY OF CUPERTINO
CUPEf OF PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL, Special Insection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
y� ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
y� MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
y PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Chane BUILDING
•
3of3