02110066 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
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ARCHITP.0(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
wpp LICENSED CONTRACTOR'S DECLARATION
I herchy.Riom that 1am uc,n d under pm•isions of Charter 9(commencing TEMP POWER Job Description
ws In
with S,aian]INNB of Division 3nf Or Uodnes�Pmfewhed,Code,andmy liven.,.,
lull t1ox' Jcllcet.
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ARCHITECTS ATION
2ysS i I understand my plans shall he used as public record'
NoV
w30g Licensed Professional 1 5 2002
1p'=o OWNEm ,ohmOER DECLARATION
ConfaON
as <F. I hereby a0 eel dim 1.m cIlmir from the Cssion,nos e:License Law co the $300
m 6 p o Which re requires
a (Section]IHLS.Ilamncsn and improve.
den oli Cod,:AnY city m county
u K$, which requirexae.also.+amnrtheialcor,impnwc.demolish,lire a siranyelrualurit �1 pp,Iadr
pnnrmits issuance.also requires the applicant for such permit ole signed stalcmcm Q�,er^e, r (3b7 A
,,Zi IhabeiscttnWitPmction
Int)of Division
vtheeBusiess Liaxm,lnd umn ChohO or "`W61Y111VUSJI�.1lL� yw Valuation
sem° On,(comm
is ruen ;th Senirce.and the
bans for oft heegedfsaption.An, hGula or
$ mat he is exemps tbcmfmm and tC basL for One alleged Caemption.Any violation of '
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty'd PN N999Z Occupancy Type
not morethan frvehundred Ol(E500). 304 — ROUGH ELECTR CAL
I,as owner of the property,or my employees wit wages as their sole compensation,
will do the work,and the svuctom is not intended or offered for sale(Sec.9044.Basilicas
and Professions Code:The Contractors License law does not apply to an owner of Required Inspections
propsny who builds or improves thereon,and who doessuch work himself or trough his
own employees.provided tat such improvementsare not intended or offered fors Ile.If.
however.to building or improvement is wild within one year of completion.to owner
builder will have the burden of playing that he did not build or improve for purpose of
side).
I.es or,of the property,am exCuaiorly contracting with licensed contractors In
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
senu law does not apply to an owner of pmpeny who builds or improves former,and
who contract for such projects with a enntracoo(s)licensed pursuant o Or Contracwr's
l.c-ense Law,
r7Ctam exempt under See SPC for this reason
// net (� Dam
w KER'S COM ENSATION DECLARATION
I hereby alfiml under Penalty of perjury one of the following declarations:.
]have and will maintain a Rnificam of Consent o self-insum for Worker's Camper.
cation,a provided for by Section 2981 of the labor Code,for the performance of the
work for which his Permit is issued.
I have and will maintain Worker's Com,venxation Insurance,.'required by Section
J%N)of one LaMu Code,for the pediumantt of the work for which this Permit is issued.
My Worker's Compensation Insumma,carrier and Policy number arc:
CaMc: Policy14
ERTIFICATE OFEXBM PION F WORKERS'
COMPENSATION( ANCE
(This section need not be cnmplemJ if the Permit is lin.n,M1unJreJ dollar'1E IIXB
lir lessJ
I certify that in I c pml once of the work for which this permit is issued.I shall not
cmPlnyanypersn manner car acro hcn+mc subject hnhc Workers Compensation
Laws of California. a n
Ap
NOT( n O APPLICANT: is alter making this Cisions of of Exemption,you should
becnm,subject y with
Worker's pr Compensation orthis
provisions of to Labor Cake You man
O z InnhwiN comply wllh such Provisions lie this permu shall the J,cmcJ revoked.
2 O CONSTRUCTION LENDING AGENCY
r (ill I hereby oirm to there is a construction lending agency[or the Performance of
CX 7 the work for which this Permit is issued(Sec.3097.Civ,C.)
Lal a tender's Name
C. Lender's Address
V C I wi ilY that I have read this application and state that the al ow inflammation is
V. r correct.I agree:to comply with all city and county ordinances and'fair laws relating to
0U building comcwnim.and hereby radii representatives of this city m enter upon the
r aMwc-memiooeee to sa y for inspectionifakeep hs. ]
1 (We)gme to rove,indemnify and kith harmless the City of Cuprnsts agaid City
eF. fp
liabilities.judgments,cults and expenses which may in any way.terve against said City
U Z in consequence of the granting of this permit
e-y APPLICANT UNDERSTANDS AND WILL DMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RIiCII ONS
Re-roofs
gnaturc tar P aidemrachn Dam
I IAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will apphCantorfntare boildingtwlipanuume.,handle hetamommaterial
a[defined by the Cu,scnino Municipal Gine.Chapter 9.12,and the Health and Safely
code.Si❑mrian 25532D)r All roofs shall be inspected prior to any roofing material being installed.
es �rv`1
Will the applicant"2."bbuilding+wcupam use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit harallous air contaminants as delioed by the Bay Arca Air Quality Management all new materials for inspection.
Dinrict]
❑Yes No
(have road foe havar tic mamriaL mqui mems unJerChapmrfi.YS.10 c Callfnr
mallealO&Suctycodc,Scc 1 1355115,255, and 25514.1 unJcrseanJ thaif he holding
foes not current havc a¢nam,foto it Ise m�ims,Le�msihility t.nn'ly the rccupanl CI the
r,qu;rcrocnts most it I.
,raCenmealo 'e.pancy. Signature of Applicant Date
o roe tied lit Date 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
S_. B. _ A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below. R�+ CidVF�
2. A state licensed contractor will be hired to do:
NOV '817M
A. _ All of the work BY
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 penalty of perjury that the abo7ise and correct. I have read and understand the
Owner-Builder Information(reve asidProperty Owner's SiignatdCre. � 4ate: — d
s: LO 9-Oaf Z--
job Ad esa4 fA 1vt Otn fe Permit#
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 Departme
CUPEkTINO 10300 Torre
Phone: (408)777-377-3
228
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 compensatiot
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
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