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04010004 CITY OF CUPERTINO y� - "r��,�k y�^', 'y� '' •s•' BUILDING DIVISION PERMIT CONTRACTOR INE©XtMATION:` BUILDING ADDRESS: - PERMIT NO04010004 .4010004 OWNER'S NAME: PERMIT ISSUE DATE .NE: SANITARY N0. CONTROL N0. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 "oz LICENSED CONTRACTOR'S DECLARATION U 1 hereby affirm that I am licensed ower provisions of chapter 9(commencing Job Description z with Section 7")of Division 3 of the Busmossand Professions Code,end my license is ^>H in full force and effect. zy�z Llcenm Class Lin.as PARTITION THE FAMILY ROOM- eF,p oatc Contractor MASTER BEDROOM qq 7W ARCHITECTS DECLARATION WU 1 understand my plans shall be used as public mcnrds Licensed Pmfcssional S OWNER-BUILDER DECLARATION < I herchy affirm that I am exempt from the Contractor's License Law for the 88 following reason.(Seedun 7031.5,Business and Pmfcssimu Cult:Any city nr county k S� which rcyuims a permit to construct,alter,improve,dcmnlish,Or repair any structure °Zj- prior o its issuance,also mquima the applicant FOrseeh permit to file a signed satemcnt =`o that he is licensed punuanuothe pmvisionsuf the Contractors License Law(Chapter 9 Sq.Ft. Floor Area Val", gyi000 (commencing with Section 70XB of Division 3 or tM Business and Professions Code)or that he is exempt 0m.fine and Ne basis for the alleged exemption.Any violation of Section7B31.5 by any applicant for a Permit subjects the applicant to a civil Finally of ccu ane APN Number OType not mom man rive hundreddo)lam(gsW). Occupancy YP ❑I,as owner of the property,or my cmpluyew with wages u melr sole compenss0on, 31630070 . 00 will do the work,and the structure is not intended or offered finish,(Sac.7044,Business and Professions Codc:The Convacmfs License Law dozy nal apply to an owner or - Required Inspections property who s provided raves thereon,and who adoes n not in work himselfor his ownemployees,ping ori provehimprowmcntsrtenot intendedproffered for ale,If. however.Ne building or improvement sold within one year ofimpro don,the owner, builder will have me burden of proving that M did not build or impmw for purpose of ®;1,as owner of project Be"propOrty,.B exclusively contacting with licensed contractors 1. sense La me es out (Sec.o an Business antl property who bus.ma Code:)The e&mason, nd S cense law does not apply a an owner of property who builds or improves thereon,and j who cantata for such projects wird a conaacmr(s)licensed pursuant to the Connector'. License Law. (,l ❑larm exempt antler S.C. BkPC(nr this reason �( ' oT� tum 1/1/OLr WORKER'SC NSATION DECyA?ATION 1 hereby grim under penalty of perjury one of IM following declarations: Of have and will maintain a Certificate of Consent to self-insure for Workeh Comrsm. smion,as provided for by Section 37W of the lobar Code,for the performance of the work for which Ni.permit is issued. ❑1 have and will maintain Worker's Compensation Insurance,as required by Sectio 37W of the Labor Code,for thc performance of Ne work for which this pcmtit is Issued. My Worker's Compensation Insurance carrier and Policy number art: Carrier: Policy No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thu section need not M completed Btbe permit is foronc hundred dollars(1000) or less) I certify that in the performance of the work for which this permit is issued,I shall net employ any person in any manner so an In become object to the Workers'Compensation Laws of California.Dam Applicant NOTICE TO APPLICANT:If,after making this Cordricate of Exception,you should become subject to the Workeh Compensation provisions of the Labor Code,you must .JO forthwith comply with such provisions or this permit shall be deemed invoked. z.i " CONSTRUCTION LENDING AGENCY - 'rrte-, 1 botchy Afire that there is a comtructlan lendingfor the Performance of ages C the work for which this permit is issued(Sec.709'i,Civ.C.) - W� Q nr's Name �,z U1<ndeder's Address U 0 1 certify mu F have read this application and Rain that lM above infonnuiun I. U. F romem.I agree to comply with all city and county ordinances and sate laws relating to C U building construction,and hereby amhorim representative$of this city to enter upon the W ahowucl,JUonetlpmpeny for i expenses purpowhich ms. (We)agree Io save,indemnify and keep humless the City of Cupertino againsl UZ inconsegjnce of cowing of this esmit. may to any wayaccmc againnsaid City C.3 'L A consequence of the granting of this permit. " APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. f amre of App tcanVContramo Dam Re-roos HAZARDOUS MATERIALS DISCLOSUR Type of Roof Will the applicant or future building occupant stare or handle hazardous material , o defined by the Cupertino Municipal Codc,Chapter 9.12.and the Health and Safety - Code,Section 2as32(a)1 ❑Yes �t4o All roofs shall be inspected prior to any roofing material being installed. ' Will the applicant or future building Occupant on equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. District? P ❑Yes KNu I have mw the hazardous materials rcquimmena under Chapter 6.95 of the Califon, ma Health A Safety Cade,Secduns 25505,25533 and 25534.1 undeamnd that ifthe hmiding Coca no,Currently have a tenant the it is my responsihility,to roafy the 000upmt of Ne rcyuimmena which etpdafm issuance nracerdream agent �ra�uPffyj-/0� Signature of Applicant Date �l<SX/c >" All roof coverings to be Class "B"or better ur amhoriud Oam Community Development *C10F 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 Fax(408)777-3333 #UPEkTINO Building Department JOB ADDRESS: PERMIT # - IIII I , N1erv;fi{ Dr. o006 OWNER'S NAME: DeYeK G Ah A PHONE # 4.0$- n3 GENERAL CONTRACTOR: Uwne y' FAX # I am not using any subcontractors: 4PY. -)- 7 . oq- Signature Date Please check applicable subcontractors and complete the followin information SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date OWNER-BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent,spouse or child) will perform ' A x 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 VC C[L VLYlG4 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 erformed ..................................................................................................................................................................................... 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: Date: Y ' y 4 /1' Job Address: 1 I Permit# OL(-61 OOOL/ An Kchanges 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& Phone: (408)777-3228= CUPEkTINO 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: J 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 an Recycled Paper