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05040057 • CITY OF CUPERTINO `^ BUILDING DIVISION PERMIT ° CON AM-TORANZ+ORMATI®,N' = BUILDING ADDRESS:_941 D4QRT4NC1Q DR RICHARD SUE ` PERMITNO.05040057 • OWNER'S NAME: PERMIT ISSUE DATE ONE: SANITARYO. OL NO. lin CHIIEC(ENGINEER: BUILDING PERMIT INFO BLDG ELEL7 PLUMB MECH [ t� LLICENSED CONTRACTOR'S DECLARATION IbDi tion 1 therebyeby affirm that I am licemed under provisions of Clupuoescrpr 9(commencingNSmem7000)of Dividon3of NeBusirrss feWonsCodc.mdmylicmreuI■ 0/ \LEfull forte and eRett 5'q? LicenscClasstic.. UPGRADE ELECT SERVICE (200 AMP) 4�r,J` ARCHITECT'S DECLARATION ^n0' 1 understand my plans shall W wad u public acoria / J Dau 3 u F Licensed Profoamm al OWNER-BUILDER DECLARATION ®�BB E a p I hmaxo a(Erm Not 11. exempt from the Contractors o License law far the BUILDING s6i O O following mason.(Scotian](131.5,Business and Professions Code:Any city.county $ which requires a permit m construct,alter,improve,demolish,m repair my strucum F i< prior m its issuance.alma requires,the apPlicam for such permit W Bk a signed sumnent dtathe is licensed purmannothe provisions ofthe COntmcWrs License law(Chapt.9 Sq.Ft. Floor Area Valuatio ¢�$ (commencing with Section 7000)of Division 3 of NC Businessand Professions Cohoor 5.. dist he ts exempt mourns.and the basis fm the alleged exemption.My violation of Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of not mom 3-�eYper0 0 Occupancy Type Nan five hundred dollars(SSW). ❑1,as..ofdo,Property,may employeeswith wages as their solemoopevadem, will do Ne work.and the structure is not imended or Offered for sale(Sec.7W,Business and Profevsiam Cade:The Centimeters Liave Law docs not apply W in owner of Required Inspections propenywh0 Wilda or impmws Nereon,andwho doesaech work himself.through his ownemployca.provided that such improvements art not intended oroRered formic.IL however.the building or improvement is mid within ane year ofcompletion,the owner. Wilder will have de Wrdcn of proving that he did not Wild or improve for purpoe of sale.). ❑1.as owner of the property,am exclusively contracting with Beraud contractors to convect the project(Sec.7044,Bruins,and Profession Code:)The Conracwr'a U. cense Law dors not apply W an owner of property who Wilds or borrows Ncmon,and who concocts for such projects with a conuacwr(s)licensed purro m W the Comonewes License law. 0 l am exam funder See. __ B&P C for this Mason Mai n, _ .KEWS /_j- a Data Y•//-Os - K R' COMPENSATIONDECLARATION:Dow Ihcmby Mot under pevlry of perjury mwof Ne fallowing decimations: I have and will maintain aCerdficate of Cave¢W self-insum for WorkerSCompen- Saitn,as provided for by Section 3700 of the UW,Cade,for Ne performame of the work for which this Permit is issued. ❑1 have and will maintain Workers Compeesadon Insurance,as required by Section 3700 of the Labor Cade.for the perfarmso.of the woh for which this permit is issued. My Workers Compensation Insurance carrier and Policy number are: Carver. Policy No.: CERTIFICATE OF EXEMMON FROM WORKERS' , COMPENSATION INSURANCE (This sccdon need not W complcmd if the permit is for one hundred dollars($lip) or less.) I our if-v Nat in the performance or the,work for which this Permit is issued.I shml not employ any Applicantpermn in anymannermasW come subject toted Workers'Compevation Laws of Califopia.��W Y'!�-es�e NOTICE TO APPLICANT:If.after making this Ccnins of the Exemption,you should Wcomchcompy the Worker's Im COmpcor this pmotmaiof thelabor Code.you must .JO forthwith comply with such pmvisiwu orthu permit shall Wg.mcd rewked. Zy CONSTRUCTION LENDING AGENCY [—m I hereby affirm that Nem u a convection lending agency for the pertormana or rL the work for which this permit u issued(Sec.Mr?,Civ.C.) 1 !antler's Name Z lenderi ss Addre U 0 1 certify that 1 have read this application and sure that the about information is Iy.F correctl agree m comply with all city and county ow inances and sum laws relating W 0U Wilding consrvction,and hereby authoin mpicsenutives or Nu city to enter upon dm rty 1'M aWveWs,judnedpmp oat for inspection purpowhich m. py (We)agree W save.indemnify and keep harmless the City of Cupenth,against t.)z in consequence of ts.the Starting espenmsmit. may in anymyamuc against mid City n consequence of the granting or this permit. ^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGU TIONS dA,Z of Re-roofs Signuuof Apphc mra l/ ocmr Sat —//Cam m HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will Ne applicant or future building occupant am or handle hmardous maunal as defined by Ne Cupenirm Municipal Code.chapter 9.12,and One Health and Safcty CO ic,Section 25533(a)? ❑Yue pNa All roofs shall be inspected prior to any roofing material being installed. Will the applicmt or future Wilding arupant ase equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove it harardnus air contaminants as defined by ted Bay Am.Art Quality Management all new materials for inspection. isriet? 0 Yes gAu I have mal the hvaNrms ma W rials nquimmenu under Chapter 6.95 of the Califor- OiaFlralth&Safety Cache,S lions 25505.25533 send 25534.IundenuM that if the Wilding does not currently haw a Wnan4 Nm it u my responsibility W notify tM meupmt nr the rugal¢ ntswnknm melpnorWisscencro certiOeaWaraapanry. Signature of Applicant Date Owner car aut dagmr p,OS All roof coverings to be Class"B" or better Community Development 10300 Torre Avenue i Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 �UPEkTiNO Building De artment JOB ADDRESS: PERMIT #� O�IOO,-T IDL.q I 111 - QC �z k V&= OWNER'S NAME: R(r-k rd L, Shellc 4SOErry-4- PHONE # (40a -7_42 y / GENERAL CONTRACTOR FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors ai d com Tete the following 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. ✓ 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 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. PersorVFirmr 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: Date: q'1/-os_ Job Address: 1196 y/ No en5n-2)r/ v e Permit# D S� �0 '�� Any changes 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 C U P[kT I N O Phone: (408)777-3228 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 compensators 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 CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM S CUPERTINO APIN# �l�J OI y � I -0^ Building Address: Mailing Address (if different from building address): 10 4 1 fn o rz.l O 2 Owner's Name: Phone#: L. Su6 E She-lle: S. C,If'" (408) ;z Contractor: License#: Sel F Contact: Phone: Cupertino Business License#: Fax: Building Permit Info: Bldg ❑ Elect ® Plumb ❑ Mech ❑ Job Description: 0700 c rn p Residential cakc Cleo �i ,w SerVice PaneCommercial ❑ Sq.Ft. Floor Area: S/Sq.Ft.: Cost of Project: Occupancy Group: r 300 Type of Construction: Please check this box if the project is a second-sto addition: ❑ Pro-ect Size: Standard ❑ Lar e ❑ Ma'or❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL 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> 1.75M Btu 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 BIN VESTIGA Investigation fee BUILDING Z z7 Z 1 of 3 / �I Q- CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINfERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL 13REMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > I OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res A liance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT RcjRtl, Switch & Outlets ELECTRICAL IML BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Re air/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2of3 aITYOF CITY OF CUPERTINO PERMIT APPLICATION FORM CUPEI�TINO Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Inspection BUILDING BSWrM 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 Meeh Permit Issuance MECHANICAL PH: FEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fees foot PLUMBING PLLONGRNGC Plannin LR Comme/Multi-Fam PLANNING PLLONGRNGR Plannin Lon Ran a Residential PLANNING EEE ZADDCHG Address Change I BUILDING 3of3