03070157 ! CITY OF CUPERTINO xy,'+ ' ° '� a;rov�k "
BUILDING DIVISION . Pi RMIT CONTRACTOR INFORMATION '
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auILDINC ADDRESS: MAPLES M D ET AL PERMITND03070157
a
NAM PERM L95UE DATE
APLES D4 n 21 Al
ONE: SANITARY O. 'C 'kOL NO.
ARCIiITECfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uo0 LICENSED CONTRACTOR'S DECLARATION O O O O
la Fp I hereby affirm that 1 Am beeucd under Frovsma of Chapter 9(commencing Job Description
<W with Section 7(1 of Division 3 of the Buataessand Profetsians Code.md my license is rCBry�B� �
e m in full farce and effeeL
12 z— Lima.Class Lie.0 REPIPE
Dale Contractor
yy ARCHITECTS DECLARATION JUL 2 8 2003
Yyr at I understand my plans shall be used As public meet&
�yU
3 u.o t; Licensed Professional
S OWNER-BUILDER DECLARATION BUILDING
UI ryING
V.a 0 1 hereby afflon on 1 1. exempt from the Comas Co License Law for the a•g I�GJGtV V
p O following reason.Permit
t ]1131.5,Business and Professions Code:Any city n,county
which its issuance,
snpermit tomcnnsvue alms improve,h Permits care a signed
ig any structure
FZt Fdar in became!IF I...ey.the .,si.O Amitent for sucCrmoarmit micerse gacdsnlcmcnt
££xx (Commencing
Comms became! ttheB sinecssndProfeswlChoder9 Sq.Ft. Floor Area Valuation
CF$ (commene xempth Section 700C)x00)of Division3 ofthcegod 1ssmd Pr.Any vi Code)tion oor
f
.- Net he b exempt thcmfmm and die basis for Be,alleged cxemFbon.Any violation of 1264gooc; nn
Section 7031.5 by any applicant fon permit mbjccts the apPlicmt to A civil penalty of APN Number Occupancy Type
not mon than firs hundred dollen(SSW).
0 1,as at,of the pmprny,or my employees with wage as Muir to eompenssti.a.
will do the work.and on, nnurt is at intended or attend for u]a(Sec.7044.Business 106 - SEWERK&W ectlons
and Profession.Cade:The Conusctor's Li¢nee Law dors not apply to an owner of q
property who builds or improves Herron,and who does uch work himmiror through his 202 - UNDERFLOOR PLUMBING
own employees,provided that such improvements are not intended or offered for sale.If, 3O1 — ROUGH PLUMBING
however,me building or improvement is mid within one year of completion,me owner-
builder .will have the burden of proving tht he did not build or improve for purpose of 302 - TUB & OR SHOWER
sale.),
D I,ss owner of the property,em exclusively contracting with licensed contractors to 502 - FINAL PLUMBING ENERGY
construct the project(Sec.7(44,Business and professions Code:)The Contractors Li. 506 — GAS TEST
cense law m Apply 1.moaner of PnoPeny,who wild.o,bmpmves them..,and, 507 — FINAL PLUMBING
who cont eta fo Usti projeeu eonmcmr(s)licensed pursuant to die Canmsaors
Lice9� w.
Q'f un em u der See 4 IQ 'B
IPP C An w r Day m
WORKER'S CO P AT)W DATI
Ihcrcby affirm under Faulty of perjury ane of Afollowin declarations:
1 have and will maintains Car ificam of Cnnent m self-inn.for WorkcM1 Compcn.
cion,u provided for by Section 3700 of the Labor Code,for the performance of the
work for which this Permit is issued.
C"1 have and will maintain Worker's Compensation Insurance,u required by Section
319.1'the labor Code,far the performanec of the work for which thia permit is issued.
My Workeri Compensa ion Insurance carrier and Policy number art:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Mia meirm need not be campletctl If the Permit is foram hundred dollar.(SIM)
or les..)
1 ecnify that in the performance of the work for which this Permit is issued,1 Nall net
employ any person in any mannerm As to become subject o the Workers''Compensation
Laws of California,Data
Applicant
NOTICE TO APPLICANT:If.after making this Ccnif¢uc of Exemption,you Should
become subject to the Worker's Compensation provisions of the Lahor Code,you must
- .,O forthwith comply with such prnvirmns or this Permit Mall be deemed revoked.
ZCONSTRUCTION LENDING AGENCY
�--a.N. I hereby afrrm that them is a construction lending agency far the performance of
�� the work(,,,which this permit is issued(See 3197,Civ.C.)
ly Q Lender's Name
0.
D Lendo,'s Address
V Q I ecnify that 1 have rod this d noun and.ole that me save information is
Ig,F bonen.)agree m e comply beim all City
And county
Sa
oo if and sat hat elating
J huconstruction,and rcbyeueepemnutivaii of this to enter upon the
man
-mrty for yn purposes,(We)Agnm to scow,indemnify and
kap harmless firew City of Cupertino against
.Uzliebilif dgmcnhe costs and expenses mit, they in any we cmc egeinat said City
Uz inc sCAN cof the gaming his Permit.
CAN UNDERS D ND WILL COMPL H ON-P NT Issued by: Date
SOU ULATIOjFj
Re-roofs
Sig re of AppheanUComrmmr e
HAZARDOUS MATERIALS SCLOSURE Type of Roof
Will the applicant car futue building.acupem.1m,or handle terminus material
u defined by the Cupenino Municipal Codc,Chapter 9.12,and the Health and Safety
Code,Section 25532(¢)? � � All roofs shall be inspected prior to any roofing material being installed.
0y. CtN'u
Will the applicant or fmuehuildingac tion um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
tet. ih hgvrdnus air conuminerds al defined by the Bay Arca Air Quality Management all new materials for inspection.
uin7 V
❑Yes [I No
Ihv rcaJth uramu"mamrial y t menu under Chapmr695 of the Calif.,.
Bis Health afayca ,Set,..k 25511 53 d 255341 understand at f the wilding does net bene caw a semi,thin i i res sit ty o noljly c cupmt of c
rcyulmmc ks ich st ctd 's ccn tri o tC: c' � natUTC of Applicant Date
0 or h ridarco 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. 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 penaltyof My' that the above is true d correct. I have read and understand the
Owner-Builder Informatioterse s'
Property Owner's Signaf Date° 3
Job Address�A& s Ai oo 1�..lp Permit#
Any chanes to the changes to the information provided on this form shall be submitted to the Ci�of Cupertino Build
this form shall be submitted to the Ci�of Cupertino Build
Department.
f �
1
City of Cupertino Building Dep
arfinen
CITY OF 10300 Torre Avenu
C U PEt�TI NO Phone: (408)777-322
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 vossible 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 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 confine 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
Pnnted on Recycled Paper
CITY OF CUPERTINO
REPIPE/SEWERS/MAIN SERVICE L?
CUPERTINO PERMIT APPLICATION FORM
APN# Pi / Date:
�/ U I
Building Address ' 1
� ct v G CJ
Owner's NameA / ( 4�2 Phone#:
Contractor: D Phone: License fht
Contact: Phone: Cupertino Business License #:
Building Permit Info:
Bldg ❑ lect ❑ Plum
Job Description:
Residenti 12ommercial ❑
Cost of Project:
• d
Qty. if
Appli 1p Fee ID Fee Description Fee Group
PPERMITFEE --Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pb] . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
Z 2--1