04010138 CITYOFCUPERTINO ��`°'''ss pa�••s's �^'�ppr' 7��'�G5a'" ♦♦ ii '77��TT -
BUILDING DIVISION
- PERMIT Pv.40S�4TQ1�yT11A' !?�IQA\
,.DING ADDRESS: MARTY ZIMMERMAN PERMITNo04010138
OWNER'S NAME: PERMIT ISSUEDATE
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BO ELECT PLUMB ME�CH
moo LICENSED CONTRACTOR'S DECLARATION
1 hereby arum that I am It
ttowed mode,provisions of Chapter 9(come
mncing - _Job Description
Z� with Section 7000)of Division)of me Busincv and Professions Cnc.a
dnd my license is
e e mfull License force m Class Lic.N
art«t. REPLACE FURNACE/ADD ROUGH GQL
3Fp Date Cantmctor �t
ARCHITECTS DECLARATION
lunderstand myplans shell Mused as public records
A;w LicenudPmressinnel U
o Oat I am exempt
from
DECLARATION p 9�
aY 1 hereby.Sect that I em exempt from me Contractor's is License Law for the
po followhich Iequires a.(Smit to construct,alter,
and improve,
demolish.
Code:Any city or counre 6T `0 0
_ which its issuance,
a pedir m construe,slier,improv,demolish,or repair any structure M\-IY - 0
iy tracheo itscensed purse minims the
ovisiosofcant forsucthe Cohpermit toicensle ae ga (Chaps em
< 2000
(comae(commencing
sectio 7 the of Division
ivision or
Conmormr'snd Pmfixw (Chapter 'Sq.FL Floor Area �Jg. Valuation
y=t$ (commencing with Seaton]tlI0)of Division)err NC Business and Prafcssians ut)0 �lWO
Nal he is exempt dentition and me basis for the alleged exemption.Any violation of .�.p
Section 7031.5 by any applicant for a permit subjects me applicant to a civil penalty of 3 MN.�T,�5*eer0 0 Occupancy Type
out more man five hundred dollars(3500). P Y YP
❑1,u owner of to property,or my employees with wages as Neil sole compensation,
will dm the work,and Ne overuse is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Conm ear's License Law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who dues such work himself or 0tmugh his
awn employees,pruvided Natsueh improvement em out intended orolfercd far sale.If. -
however,the building or improvement is sold within one year of eompletion,Ne owner-
. builder will have Ne burden of proving Nat he did not Wild or improve for purpose of
sale.).
❑1.as owner of Ne property,am exclusively contracting wit licensed contractors to
consumer the project(Sec.7044,Business and Professions Code:)The Contractors Li-
mned Law door not apply to an owner of property who Milds or improves Ihemon,and
who contracts for such projects with a eomractor(s)licensed pursuant to the Contractor's
11' nse w
em ptu it ,B&P C for this recon
Dam 1 29 pM
WORT •R'S 1PENSATION DEC
Ihercbye and pc alt ofperju"Cox or Me lot
Due,
I have and will mainut 'mos of Consent m sclM1imureforWorker'sCompeer-
ration,as provided for by Section 3700 of the Labor Code,for Ne performance of the
work for which tis permit is issued
0 1 have and will maintain.Wurkers Compensation Insurance,as required by Section
J7W of the Labor Code,for the performance of to work for which this permit is issued.
My Workeri Compensation Insurance carrier and Policy number am:
Cartier Policy No.: -
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
(Thtuctirm need not M completed if the permit Is foram,hundred dollars d$RxE
or less)
I certify th him..R nnanec or tc work for which this permit is isswd,1 shell not
employ any any main�y�ss�efxh..subject to the Woders Compemation -
LawsofC m.net
ppitca )'N"' M
TO APPLICANT:If,after making this Certificate of Exemption;you should
to e subject to tc Worker's Compensation provisions of the Labor Carlo,you and
,JO fonhwilh comply with such provision.or this permil ahallM deemed invoked,
.'Z,a 7) CONSTRUCTION LENDING AGENCY
.N. Ihereh affirm tat there is a cmtswninn lending agency for Nc
F y s ' Performance of
gC the work(ser which this permit Is issued(Sec,709),Civ.CJ
W Q LendersName
7 z 1<nder'a AddrAdda
ess '
U Q 1 cenify that 1 have read this application and some that the shout infonnuion is
W F torten.l agree to comply with all city and county ordinances and sumlaws relating or
U atowngconswction,and hereby auNonprptesenmtivss or Nis city 1p,meruPon the
4k) ehovcmemioned property for inspection puTwes
d (We)agree to save,indemnify and keep harmless the City of Cape, against
In liabilities,judgments,casts and expenses which may in any way accrue against amid City l)
U in consequence of the granting of this Permit 4l//
" A CANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S CE GU ATIONS.
Re-roofs
gnawr April AZA DOU'ChoS MATERIALS DISCLOSVRE °a� Type of Roof
Will li for mare building Occupant store or handle harsrdeus mdenal
as defined by Ne Cupe unicipal Code,Chapter 9.12,and On,Health and Safety -
Code.Second 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes Q�No
Will the applicant ar'mo`r,building occupant ma„gmipm,m o;d,v;e,:which If a roof is installed without first obtaining an inspection,I agree to remove
tit hazardous it m nmmir ams as defined by the Bay Area Air Quality Management all new materials for inspection.
etel?
E]Yet; 9i"lo
I have mad to hazardous materials requirements under Chapter 6.95 of the Called.
at.Hall or&SafnyCodc,S,auded 25505,25577 and 25534.1 underabo d tut if the building
new currently haw a moan,that it is my mspmuihiliry fo duty IM recupant of the
regi which stbcmelpdorwisuanmoraCcniGcamra"I"IY p4 Signature of Applicant Date
o man d Or
as 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. k' 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. Fes' CEI
I
2. A state licensed contractor will be hired to do: 2004
A. All of the work
B. _ A portion of the work (complete sectio glow)
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 hisurance 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 (revgse�5side).
Property Owner's Signature\✓ I Y Dat I J 24 o f
Job Addr 10 bs m L c Permit#
C vk f6RTI
AM changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
i
City of Cupertino Building Department
CITY OF 10300 Torre Aver
Phone: �4Og,777-3
CUPEI�TINO j
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 i
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 j
(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 inY our community or at 1020 N Street,Sacramento,Califonva 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 an Recycled Paper
CITY OF CUPERTINO
AT1011
FURNACE/AC ° 13
UPERTINO PERMIT APPLICATION FORM
APN # Date:
31e. - 21 - oso -
Building Address: LAR E N
1 0l �5 ill PLAcG 64?-irrao� ckl- 4.
Owner's Name: Phone#:
AR l 't r"-r�Ce-mft.) uo8- 11� �S4Y
Contractor:}1�/ P}},one: License#:
0 \ 1MARTY �n rnER�AN (IuY �f F)
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Description: ru�^'�c�
RF�QLgcE 10TC(L k A DA Rou6'H Ifv coNt- /=mR TLkTUR�
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1" floor ❑ 2"a floor❑
Adhere to min set back requirement❑
VjFor Commercial Installations:
Replacement same weight ❑ Additional weight(structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project: poo Type of Const ructio Occupancy oup:
Strapped ❑ On Platform ❑ Bonded H Sq.Ft. Floor ea:
New Location ❑ Re lacemenY
Qt , if
A li ble Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING