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06020009F CUPRINOCITY 'r`"`" B UODIVISION PERMIT Ifi O^• N qmIRMATNG : BUILDING ADDRESS: PE "" ND.O 6 0 2 0 0 0 9 10225 PARKSIDE LN OWNER'S NAME: PERMIT MUEDATE 9NE: BRAIN CAMPBELL 02/02/2006 SANITARY NO. CONTROL N0, ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION o Job Descri UOn I herby :Rim Nat 1 am limead undo Previsions of Chapmr 9 (mmmcncing p naefon fDiviuSof the Bosoms and Professions Code, and mylicense is iulSmtinoedfeeC int. INSTALL RECESSED LIGHTS IN KITCHEN License Clan Lle. a Da¢ Contractor ARCHITECTS DECLARATION I mMcrsand my plans shell he vactl u public rtenrds Licensed Profcuional OWNER-BUILDER DECLARATION 1 hereby affirm 1 em exempt from Ne Comncmh License Law for the on Bulinus and Psofnedo li Cole: My city .s runty t 7 contract. following sins a Permit Improve, m any whlell Rte $2000 aterm.1 stat o e,.hl re rims tiro ppliMuc h permit t e. si, prior um ill issuance, also nt to An the applicant for such permiuu file a signed sammcm dot pursuant the provisions of the Ll¢me Law mrY Sq. Ft. Floor Area IUatlOn me ccenscd ons Cor theeged exeand Code) or (commencing with Srmi.n of Division3 eBusi Business on. Any. vi I Net he u exempt therefrom end de buts for the alleged exemption. Any violation of and the r Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of fire not mom than hundred dollar: tssBB). 1, u owmr of me property, cur my emplayaa with wegu u thea sole compensation, Required Inspections willdo thework. andthestrmmmtsnotimmuEcd muQerni forule(Sec.70M, Burrow and Professions Code: The Contractors Liana Law docs not apply m an owner of e q- property who builds or improm thereon, and who does such work himself or through his own employcu, provided that such improvementsare not intended oroRere4 forsale IL however, the building or improvement is sold within one year of complcuon. the owner. builder will have dm burden of proving that he did not Wild or improv for puryue or sale.). tq/1, as owner of the property, am exclusively contracting with Remand rontractors to exam. act the project (Sec. 7014. Buincss and Profeesl.ns Code:) The Conuanor'a Li. . came Law door not apply to an owner of property-who builds or improve dome, and who contracts for such projects with a conuacmr(s) licensed pursuant to the Cnnuamoh License Law. ❑ 1 am exempt undrocc. . B & P C for this reason -�—� r �2cR•a— %/ pyyva�MN�'Dam —�' WORKFASC ENSA ON DECLARATION 1 hereby since under penslty of perjury ore of the following declarations: 1 have and will maintain a Certificate of Consent meelf-insure for Workch Compen. ration, ses provided for by Section 37M of the Labor Code, for the performance of the work for which this permit is issued. 1 bars and will maintain Worker' Compensation Imuran:, as, required by Section 3700 of the LaborCa(e. for the perfmcla. of the work for which this permit is issued. My Workers Cnmprom ion Insurance tinier and Policy number am: Cartier: Policy No.: CERTIFICATE OF EXEMMON FROM WORKERS' COMPENSATION INSURANCE (Oto scrim need not he completed if thc permit is forom hundred dollars ($100) or less.) I certify that in the performance of the wart for which this permit or issued, I shall not employ any person in any manner en as to becomo subject o the WorkersCompensation Laws of California. Data Applicant NOTICE TO APPLICAMr. If, after akin, this Conifam of Exemption, you should become Subject on the Worker's Compcmation provisions of the Labor Cods, you mot forthwith comply with such provisiom.r this permit Nall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hemhy off ran that mere isa Construction lending agency for the padcOnan¢ of An work for which this permit is isaucd (Sec. 3097. Civ. C.) , Lenders Name Lenders Address 1 certify that 1 hare mad this application and sole that the eburs informed.. is correct. I agree to comply with all city and county Columns and so m laws relating to Wilding Conswction, and hemby authorim mprommatives of this city to enter upon Ne ahovc-memidgm property, for inspection purposes (We) agree m rave, indemnify and kecp harmless the City of Cupertino against to costs and eapemcs which may in any way:come against aid City in coiuu.jurce of Of the this lcrmit. A APPLICANT RSTAgrantingof APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 2 _� l SOURCE REGULATIONS. _U Re-roofs — i - zxz/od Si dum ofA icam/Comoicmr f (Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant cur future Wilding .reupmsstom or handle Ismardou ream sed u defined by the Cupertino Municipal Code. Chapter 9.13. and the Hcalth and Safety Code, Section 25532(a)7 pYns Kiva All roofs shall be inspected nor to an roofing material bei. p p y g g installed. Will the applicant of future building occupant One equipntmt or dewiou which If a roof is installed without first obtaining an inspection, I agree to remove emit Iu'udnus air contaminants as dcfmncd by the Bay Arta Air Quality Management all new materials for inspection. P Dindct7 ❑ Yu t< I have mad Ne hommr 11 tsmamrials requirements under Chapmr 6.95 of the Calif.r- nix Health & SafetyCode, Section 25505.25533 and 25531.1 undersand therifthe building does our eurtemly haw a mnam, that it is my mcspomihility to nosily the meupmt Of the requirements which must be met prior to harmce of a Certificate of Occupancy. Signature Of Applicant Date All roof coverings to be Class "B" or better owns .r:.t><dagC am 4 1 of 1 r, L J CyYYt�2�K41�Pf:iili� i% PERMIT RECEIPT Sec: Twp: Rng: Sub: Elk: Lot: APN ........: 36904048.00 DATE ISSUED.......: 02/02/2006 RECEIPT 4.........: 33044 REFERENCE ID # ...: 06020009 SITE ADDRESS .....: 10225 PARKSIDE LN SUBDIVISION ....... CITY CUPERTINO IMPACT AREA ....... OWNER ............: BRAIN CAMPBELL ADDRESS ..........: CITY/STATE/ZIP .... , RECEIVED FROM ....: BRIAN J CAMPBELL CONTRACTOR .......: LIC # COMPANY ..........: ADDRESS ..........: CITY/STATE/ZIP .... , TELEPHONE ........: OPERATOR: suem COPY # : 3 FEE ID ---------- UNIT ------------- QUANTITY ---------- AMOUNT PD -TO -DT THIS REC NEW BAL BENERGY PERMIT FEE 1.00 ---------- 34.86 ---------- 0.00 ---------- 34.86 ---------- 0.00 BSEISMICRE VALUATION 2,000.00 0.50 0.00 0.50 0.00 EPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00 TOTAL PERMIT ---------- 73.73 ---------- 0.00 ---------- 73.73 ---------- 0.00 METHOD OF PAYMENT ----------------- OTHER TOTAL RECEIPT : • AMOUNT NUMBER ------------ ------------------ 73.73 MASTERCARD -_-_---73 73 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 i __c_m„a 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: Job Address: /0225 parhsia✓c ZOP72 , Lu' ,Peyhuo Date: y2120o6 Permit # Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. 0 CITY OF CUPEkTiNO Dear Property Owner. City of Cupertino Building Dep 10300 Torre An application for a building permit has been submitted in your name listing yourself as the boulder 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 comnpensatiole 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 US. Small Business Administration). For more speck 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 maybe obtained by contacting the Contractors State License Board in your community or at 1020 N Street, Saaamento, Califorrna 95S14- please 5814please 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 P,irod on Recycled Paper l' y CCE.. . arr o CUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM 4�96 Da6D� K, o6 oy v / Fee Description Fee Group Date: 21212006 Building Addresss:Mailing -Parkside- Address (if different from building address): /0225 latae_ Cf( ?50/x/ MECHANICAL Owner's Name: Boiler > 100K to 500K Btu MECHANICAL Phone #: 3n -a, t C 2Gn % MECHANICAL BBOILER4 0$-2Zb Contractor: BBOILER5 Boiler > 1.75M Btu License #: TBD Construction Tax BUILDING BCONSTAX Contact: Ceq Phone: yon 22o-5238 Cupertino Business License#: `(3r'= e� CLvLam Fax: Con. Tax for B Q Zone BUILDING Building Permit Info: y y{ul�i rub ecessea� Ccaw) (i9l ks ik kikclae,� Cox s ?� c� Bldg ❑ Elect 19�/ Plumb ❑ Mech ❑ Job Description: Elec 600V <=1000A ELECTRICAL Residential ❑ Elec 600V > 1000A Commercial ❑ Sq.Ft. Floor Area: Elec Svcs 600V <= 200A ELECTRICAL q.Ft.: Cost ofProiect: 42000 (esiiww+e� 1 BUILDING BENERGYADD Occupanr� Grn: Type of Construction: BINVESTIGA Investigation fee Please check this box if the project is a �JN second -story addition: ❑ o'ect Size: Standard ❑ Laze ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu MECHANICAL BB.OILER3, 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 BCONSTAXB • Con. Tax for B Q 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 Cl 1 of 3 llf h CUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMFIIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTEVIE 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 BPINTERCEP 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 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 Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfm MECHANICAL BREMAIl2HAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways. ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREAENHOOD Installation of Hood AIECE ANICAL 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 Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 CITY of CUPEkTINO CITY OF CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Sigris, 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 BUII.DING BSPECIAL Special Inspection BUILDING BSWIIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERAI 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 PPERMTTFEE Plnmbing Permit Issue PLUMBING PPLBG Plumbing Foe sq foot PLUMBING PLLONGRNGC Planning LR Comme/ Multi PLANNING PLLONGRNGR Planning Lon Ran a Residential PLANNING ZADDCHG Address Change BUILDING 11 3of3