05080001 CITY OF CUPERTINO '
BUILDING DIVISION PERMIT `CONTRACTOR INFORMATION.
BUILDING ADDRESS: KITTY SZETO PERMIT NO.05080001
869 LILY A
OWNER'S NAME: PERMIT ISSUE DATE
KITTY SZETO
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
±op LICENSED CONTRACTOR'SDECLARATION Job Description
in� th
I hereby affirm at I am licensed under proviaiarn of Chapter 9(commencing P
with Section 7001)of Division 3 of the Business and FmAdadior Code.and my he..is
+ „ in full force and effeee GAS LINE FOR RANGE & DRYER
jail License Chia L'c.N
^p Date Conusctor
YY7W ARCHITECTS DECLARATION
C I understand my plans shall W used u public records
JyU
s a Licensed Pmfeuinnal /
`ro3
OWNER-BUILDER..Ifir DECLARATION
n o 1 Wroso affirm that 11. exempt from the Cantracm a license Law far the
oO rollowhich re mason.remit
7031.3,Businessand w.derom Cade:Any city stcounty
d Iii which its requires a pctmit re quire due,Blur,improve.demolish or a asig any uronurit 10 0
e—'^ prion.its issmnm,alsu requites tW applicant for such pennitto file axigned sutemem
> that he is licensedpursuanttothepmvisiomofdidConuacmrsLiccnsclaw(Chapter9 Sq.Ft.Floor Area
a
YFG
(commencing With i�$ enfn70W)of Divisionl afhesand...foment Cae)err
Nat he u eumDt necrtfrrom and Be tar far de alleged cacmpsion.
Any violation at '
Section 7031.5 by my aproiarn for•permit subjects the applicant in a Civil penalty of er U Occupancy Type
nm more Nan Eve hundred della.($YXD.
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work.and the structure is not intended or offered for sale(Sec.7041,Business
and Professions Cade:TTe Comm odes Licenses Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and whodocuuch workhimself Orth ough his
own emplayecs,provided that such improvements ere not inuMed proffered for We.If.
however,the building or impmseirmL is sold within ane year of mmplcuoq the owrcr-
builder will ban the burden of proving that he did not Wild or improve for purpose of
sale I
I,as owner of the property,am exclusively convecting with licensed contractors to
co duct the project(Sec.7014,Business and Professions Code:)The Contractor's Li.
Conti law it=not apply b in owner of property who Wilds or improve Ncteon,and.
who contracts for such pmjecu with a contracmrEd licensed pursuant to the Contractor's
License law.
❑lam eaem urS .- .B&PC is on
Owner Date /h
' V RK SATION DECLARATION
1 hemby lin union orally of perjury ore of the following declan imm
I have and will maintain a Certificate of Comes to self-insure for Workcri Compen.
sation,ss provided for by Second 3700 of the LSWf Code,for Ne performance of the
work for which this permit is issued. .
❑1 have and will maintain Worker'sCompensation Insurance,as required by Section
37W of Inc Lith er Code.for rhe performance of the work for which this permit is issued.
My Worker's Compensation Inunnm Cartier and Policy number art:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed Rahe permit is for one hundred dollars C$100)
or less.)
1 Certify that in the perfomearom of the work for which this permit is issued.I sM11 no
employ any person n y manner m as to became subject to Bre WorkerifCompemxtion
Laws of Califum'
IC m
NOTICE TO PPL I
NOTICE kinF this Certificate of Exemption,you should
become subject m c Wor c s Compcmadon pmvisiom of the Tabor Cada you must
Q z foMwith comply with such pmvis nm or Nu permit shall W deemed rovaked.
Z'O CONSTRUCTION LENDING AGENCY
PT hereby affirm that there is a construction lending agency far the performance of
C4
7 the work for which this permit is issued(Sec.3097,Civ.C.)
Q Q lender's Name
a
z Lender's Address
U
V Q I ttgree Nn I have rad this application and dart Net tW al Information
ng u
ly F COMM 1 agree to comply with all city and county ordinances and sou laws relating to
Q w above-mentioned
and hereby
orimauNonp rposes. timsCf Nis city to Cour upon Oc
r0. above-(We)aree 1. ny findmnify add keep
haf~ 4. (We)agree to cove,indemnify end keep harmless the City of Cupertino admit
N inconsequne of dr,cosuang expenses which they in anyway acme against said City
C)z APP
APPLICANT UNDERSTAN of LAND WILL COMPLY WITH ALL ON-POINT Issued by: Date
-
SOURC GU�ONS.
� - f Re-roofs
Sign urc AppDate
DISCLOSURE Type of Roof
Will the applicant or future building occupant stow or handle havvdous material
as deftned by the Cupenino Municipal Code.Chapter 9.11,and the Health and Safety
We,demon sss3z(an All roofs shall be inspected prior to an roofing material bei.
[D Y. ❑Na P P Y g g installed.
Will the applicant or future building Occupant use equipment or dcvicca which If a roof is installed without first obtaining an inspection,I agree to remove
it ha'rardous air conuminants as defined by she Bay Arm Air Quality Management all new materials for inspection.
isvict?
-- ❑Yes 0 N -
I ham real the 1CO dtws materialsroquirommus under Chaptcr 6.95 ofthe Califor.
ria Best"SafetyCede,Sccumu 255(15.25533 and 25534.1undcrumd thin ifthc Wilding
docs not cummijI hnma moan mit6my resportahility m notify the occupant of the
requimm t must ormi eadeeofacyrofiate45 a Signature of Applicant Date
Owner ores thoria J gent Date
All roof coverings to be Class"B" or better
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
A. 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(reverse side).
Property Owner's Signatuurr'e1: Date:
Job Address: rl'h�/X r 111 ,. 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
CITY OF 10300 Torre Avenue v
C U p E[?T'N 0 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 vourself 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 compensations
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
Printed on Recycled Paper
CITY OF CUPERTINO
os
REPIPE/SEWERS/MVIAIN SERVICE `
CUPEkTINO PERMIT APPLICATION FORM
APN# 3s o3 0 Date:
1 Job
Building Address /
Owner's Name: UPhone#:
a%
Contractor: U vPhone: License#:
6 e/.
Contact: Phone: Cupertino Business License #:
Building Permit In ql?,J-
Bldg ❑ Elect ❑ Plumb C�
Job Description:
Residential Commercial ❑
Cost of Project:
i�
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
/ BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
/ BENERGY Energy BUILDING
BUSLIC Business License BUILDING