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02110073 CITY OF CUPER'11NO BUILDING DIVISION PERF CONTRACTOR JNFORMn OM.,. iUfjJ"i5)PRI;MERRITT DR CLOUD RUSSELL J AND JOY L PERMIT V2 110 0 73 ,BW LOUR: RUSSELL J AND JOY L APPLICA11T f1![Tr2002 PHONE: SANITARY NO. CONTROL NO. ARCIIInC*UENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MF-CD �a0i00 LICENSED CONTRACTOR'S DECLARATION b resp IherenyallirmlM1m[am liccn.ttJuMerprnvisinnsofChapter 4lcommcneing REPLACE TOILETS ft��/WOOD DAMAGE with Section 70(XBof Division Sol me Btimmisaand professions Gouraud my license is F.Ow in full tone and officer. Licc ¢O$$Z n.¢Class Co. INALE® Oz-0 LicN Dam Y n C F=�wj ARCHITECTS DECLARATION �M I understand my plans shall M used as public record.. LLo� Lieensedprotcssional NOV 7 2002 3 OWNER-BUILDER DECLARATION z'yT a S I hereby affirm that 1 am exem l from the Contra dm,License law for the C 2 O O O w_oo Bdhwsmgreamn(Sect 070315,Business and ProfesslonsCode:Any city Orcounty BUILDING $2000 a w$� which requires a permit to construct,alter,improve,demolish,or repair any structure t-za Pont it)its issuance,also mquirea the applicant for such premiuo file aligned statement ;hal he is licensed pumuanno the provisions of the Commclor's License Law(6taPmr 9 3B'6610o'}A&Q Valuation ver0 (commencing with Section 7000)of Division 3Of the Business and Professions Cole)or mar he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any aPNicamt for a permit subjects the applicant to a civil Penalty Of UAPN Occupancy Type not mom dean five hundred dollars(S500). 102 — PIERS ❑ I.as owner of the propcfty,or my employees with wages v their vile compensation, will do the work,and the suucwre is nor intended or offered for sale(Sec.]DSC,Business 1E)5 UPER andPnNcsvinns Cude:Thns e Comment's Limlaw does not apply to an manor of 104 — REBAR Required Inspections pmprny who builds or improves thefemn,and who does such work himself or through his own employees.provided mm such improvements am nm intended or offered for sale.If. 105 - ANCHOR BOLTS however,the building or improvement issold within one year of completion,them met. 106 — SEWER & WATER builder will have the burden of proving mat be did not build or improve for propose of sale.). 202 — UNDERFLOOR PLUMBING ❑I.asswnerofthepmpeny,emexclusivelycontractingwithLicensedcommons;no 203 — UNDERFLOOR MECHANICAL command the Project(See 704,1.Basin.and ftemasira.Code:)The Comm cwrx Li- censeLow does not apply toanowner ofproperty who Wilds orimproves thrown.and, 204 — UNDERFLOOR FRAME who contracts for such projects wish a contrachund 1lcerawd pursuant)me Contractor's 205 — UNDERFLOOR INSULATION License Law. Fl I cam exempt under Sec. -��/ {�- B&PC for isreason 301 — ROUGH PLUMBING �Z4l�SD t °L 302 — TUB & OR SHOWER � 40 OIN Its CO ENSATIONDECLARAT 303 — ROUGH MECHANICAL I hereby affnnt under penaltymperjwy one of following declarations: 304 — ROUGH ELECTRICAL ❑l have and will maintain a Cenificale of Consent us self-insure for Worker's Comprm 305 - FRAME scion,as provided for by Session 370)of dm labor CsMd.for me Knionnancc of the work for which this permit is issued. 306 — HOLDOWNS I have and will maintain Workers Compensation Insurance.as mquirea by Section 307 — INSULATION 3700 of one Labor Code,fur the performance of the work for which this permit Is Issued. My Worker's Compensator;Insurance carrier and Policy number an: 308 - SHEETROCK Cartier: Policy No, 309 — EXTERIOR LATH EX CE RTIPICATEOFEMPTION PROM WORK ERS' 31O - INTERIOR LATH COMPENSATION INSURANCE (Thtasechmn necdnm twoma leledifinepcmmisfoore hunireddollmalSU)(p 311 — SCRATCH COAT tole".) 313 — ROOF NAIL 1 cenify matin the rfomwnce of to work for which his permit is issued.[.,hall nor 501 — FINAL ELECTRICAL ENERGY employ any Pc coo"' aht Iib`suhjcnmthc wnrkcrs'ComPcnsation Lmal C .Date A 502 — FINAL PLUMBING ENERGY APIA —!. ryOTt[ETO APPLIC/NT:IL afterr mg this Cerificaw of Excmpion.you should 503 — FINAL MECHANICAL ENERGY csuhjccuo the\orkerk Compensation provisions of the Taber Code,you most 504 — FINAL BUILDING ENERGY 1Z mwnh comply with won provisions or this permit shall be deemed revoked. z 505 — FINAL ELECTRICAL CONSTRUCTION LENDING AGENCY p.'4 Ihemny aRrm mm mem isaamamathnlending agency for perbrtmamz of 506 — GAS TEST �> the wool,for which this Permit isissued(See.3097.Cos.C.) 507 — FINAL PLUMBING U 0 Undcr'1 Namc - u tlersAddress 508 FINAL MECHANICAL Z)O I ccnify mat I have rcaJ this appliretion and sum What the aNrvc inGsrmmion ie 509 — FINAL GRADE Pcorrect.I agree FINAL PLANNING to comply with all city and county Ordinances and sum laws miming to - �U building construction.and hereby authoriee represonutives Of mis city to crime uponme 5 aMwe-mcndoned property for mspccthm purpoea. 5 4 — FIN BLIC ORKS FW (We)agree m save.indemnify and keep harmless me City of Cupenioo again. I, liabilities,judgments,costs and expenses which may in any way aecmc against said City V Z in consequence of me graining of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: t&W Date SOURCE REGULATIONS. •a Re-roofs gnamrc ofA IicanVCnmracmr ❑am HA'l,ARD SMATERIALS DISCLOSURE Type of Roof Will the upplicant or future building tccupam.ore or handle hvardous maerial as defined by the Cupertino Municipal Calc.Chapter 9.12,and the Ilealth and Safely ode,Section 2s532(a)'' �{�, All roofs shall be inspected prior to any roofing material being installed. ❑res Pkin Will mea applicant or future Wilding ant weequipment or devices which If a roof is installed without firs[obtaining an inspection, I agree to remove Pp dby the emit ict? uxaircomaminanuasJetincdstymeBuyArcaAirpualiryMawgeme^t all new materials for inspection. District? ❑Yes I�No I have read me nnamous materials nquimments under Chapter 6.95 of the Cali lor- ninHealth&Safety Code.Sections 25505,25533 and 2553x.I umkmund that if one building does not currently have a tenant,mat it is my resrymsihility to nmufy the occupant or me quiemantawhich mum kmet pus ortoissuariecor.Cenificamofoccupancy. Signature of Applicant Date O x. a thmi ed age t Date All roof coverings to be Class "B" or better t � OV 1 Sa 2002 II C�ry LY, Eel ��i�1� APPROVED IN ACCO DA E WITH THE CITY CUPERTI�C iDE�p .' AP'd / R*"IVCES DATE SIGNED This set of s be kept on fhr P'elf,cations MUST al all times and It is on lawful to m,;,k any changes on same .wth u Iv, or alteration The burn tten Peimission from The ssmu.� OIPIII City of Cupe,hno. 8 da., p an nd s 31441 NGI tr u specification, icProval 2t thev, a;I npoian.,in" .x to be an I[ d n'n n , Slata, provision, 1 I a,nr OeiER-BUILDER VERIFICAT& 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 Perfonned • 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'sSignatur� � ate: job Ad>os: Per atit#. 6— 11 oo7� �— 5 Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. CITY OF City of Cupertino Building Departmele C U PE IST I NO Ph10300 Torre Avenue Phone: (408)777--322228 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 a a CITY OF CUPERTINO U 2- PERMIT APPLICATION PERMITAPPLICATION FORM CUPERTINO APN # Date: ✓ ILA-)dV t7Z Building Address: J 1g65'( t.✓r/�T ��j�L Owner's Name: Phone #: Y DTK- zS 7-5-W 3 2u.ss Glouv� > Contractor: License#: " Contact: Phone#: �1 �vs Glor.� 6"- ZY8- 3/0-7 Applicant/ ontractor: Fax #: .0 Bm di Permit Info: Bldg Elect PlumMech Jo escription: y Residential: - Sq.Ft. Floor Area: Architect/Engineer: Valuation: ype of Construction: Occupancy roup: Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances 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 BMITIGATC Comm. Housing Mit. Fee BUILDING BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Family Res MECHANICAL BNEWMULTI New Multi-family Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING 1 of 3 va av, CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEI,TINO Quantity Fee ID Fee Description Fee Group BNUMULTI New Multi-family Res PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pb1g Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPIN'TERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i eOfFixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee - BUILDING BREMACOVER A/C Unit> 10,000 cfrn MECHANICAL BREMAIRHAN A/C Units<= 10,000 din MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > 1 OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP . 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 Re air/Alter Heating MECHANICAL, BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREIvITHEATR Theatrical Lighting Fix ELECTRICAL 2of3 idsCITY OF CUPERTINO• CITY OF PERMIT APPLICATION FORM CUPEkTINO . Quantity Fee ID Fee Description Fee Group BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING tj BSEISMICRE Seismic Fee Res BUILDING BSF&2FAM Single & 2 Family BUILDING BSFNA Single Family New Add BUILDING ' BSPECIAL Special Insection BUILDING BSv, M Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING 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> 1.75 M Btu MECHANICAL 3 of 3