03110149 'CITY OF CUPERTINO ' _'
BUILDING DIVISION PERMIT CONTRACTOR INFE7RMATIQN
BUILDING ADDRESS: ""'N'03110149
ERMITNOO3110149
ER'S NAME: PERMITISSUEDATE
ONE:
SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO -
BCJ �� CT PLUMB MEOCH
i0, LICENSED CONTRACTOR'S DECLARATION
set❑ I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description AUC
ZW
Ills
E License Class
with Section 7")of Division 3 ofim Business and Pnlcuinns Code,and my license is U/. 4
<o, in fanfaneaadaffect. ADD 1098 SQ. FT. P 2QQ
j Lie,g 4
ARCHITECTS DECLARATION
�v IundcrsnnJ my plan shellMuseJupublic records �®
LV
30y Licensed Professional
OWNER-BUILDER DECLARATION
<x 1 hereby anco arrrm o that 1 1. exempt from the resnims Co License Law for the
pO whowing.coon.(Shout](131.5,Businessdna Profusions Code:Any city or county
m which rcyulrcs a pcmtit to construct,eller,improve.demolish,or repair any etructum
_ya prior m its nouoncc.also inquires the applicant for such permit to file a signed statement
££SO that he I.licensed pursuanttothe provisions orthe conincmr'sLicenulww(chapter9 Sq.Ft. Floor Area Valuation
yr. (commencing with Sefton 7")of Division 3 of the Business and Profusions Code)or
but he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 703 1.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 761Vftjl0 Occupancy Type
not more Nan Eve hundred dollars(5500).
❑h u owner of Ne pmpcny,or my employees with wage u Heir seta compensator,
will do the work.and Ne swctum is not intended or offered for sale(Sec.7W.Business
and Professions Code:The Cuntemar's License law does not apply m in owner of Required Inspections
property,who builds or improves Hereon,and who does such work himself or through his
own employees,provided that such improvements arc not intended oroffered for sale.IL
however,the building or improvement Is said within au year of complction,the owner.
builder will have the burden of proving that be did not build or improve for purpose of
sale.).
1,oa owner of the properly,on exclusively contracting with licensed contractors to
cohswct the pmject(Sec.7044,Business and Profusions Cade:)The Contractor's Li.
came Law does not apply to in owner of property who builds or improve Ihemon,and
who contacts for such projects with a contractor(s)licensed purmanuo Ne Contracmr's
License Law. -
❑tomexempt- r ,BAPCfar this..an -
ORKER' OMPENSATION DECLARATION
l kmby affirm under penalty of perjuryone of the f0lbe�declarmiou:
❑I have and will maintain a Certihcue of Canunuo ulFlnsure for Workei sCompen.
cation,u provided for by Section 3700 of the labor Code,for Ne perfomance of the .
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,u required by Section
37W of be labor Code,for the performance of Ne work for which this permit is issued.
My Workers Compe oration Insurance carrier and Policy number am:
Carver: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS:
COMPENSATION INSURANCE
(Thu section need mabecomplemJ ifthe Permit is forest,hundred billam(SIW)
or less.)
1 candy that in the performance of the work for which this Permit is iuued,1 shall not
employ any person in any manner to u an become subject to the Workers'Compemaaon
Laws of California.Data
Applicant -
NOTICE TO APPLICANT:IL nfn,r making this Chorl,,m of Exemption,you should
become subject to the Water's Compensation provisions of the Labor Coat,,you must
.J O forthwith comply with inch previsions car this Permit shall he deemed rivalled.
'z tiCONSTRUCTION LENDING AGENCY
(-+ I hereby alarm that there is a construction lending agency lot be performance of
fk ti He work fur which this pernil is ismad(Sec.3097,Co.C.)
f31 Q Lender's Name
z Lender's Address
V p 1 minify that I have read this application and sum that the above information is '
IL H correct.I agree to comply with all city and county ordinances and sun,laws relating to
O U building construction,and hereby aumarimrepresentmives of Nis city to enter upon He
a abovcmentioncJ property for impecuon purposes.
f~ (Wt,)agree to save,indemnify and keep harmleu the City of Cupertino against
r/3 liabillmWedgmenu.costs and expemcs which may in any way accrue against mid City / a
V z APPLICAethis
AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEN�TdUNDERSTANDSUl,PT10N5. f�n
Signal o ptenUContncmr - ' Dan(elc_—r Re-roofs
HAZARDOUS MATERIALS DISCLOSU� Type of Roof
Will the applicant or future building oecupanumre or handle haiardoue material
as defined by He Cupertino Municipal Code,Chapter 9.12,and the Herb and Safety
Semon 25532(°)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ",
Will the applicant or future building occupant use equipment or deviecs which If a roof is installed without first obtaining an inspection,I agree to remove
emit bemoans air entaminanu u defined by the Bay Are Ail Guilty Managemenl all new materials for inspection.
Divan?
❑Yes VNo
Illve mad the hamadousmaterlab oaquiremcnu under Chapmn ti.95 of Nc Calker.
riaHealth&SgCLYCoac,Sodom25505,25533 and25534.1unkm dNathate building
Jos not currently haw a mount,that it is my responsibility,to nobly the Occupant of the
Icyuinmcnuphicht9psIimet poor miumnceofaC+n /r��r a �r. Signature of Applicant Date
Owner rt\ho7oY'rc/J"a_6cot Dnm 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:
— All the work authorized by this permit
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
J} 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 Signature: (iVlµ __ Date: I J-zv Lo
Job Address: t I JLA Cve, C T Permit# 2 11 f
AM changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
r=
City of Cupertino Building Departtn
CITY OF 10300 Torre Aven
C U P E IST I N O Phone: (408)777-3
i
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 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 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