03080014 CITY OF CUPERTINO "o-m ora z ;.a.� InAs'� � < *•
a BUILDING DIVISION PERMIT ''CONT RAC�TO INF;ORN ATION '
BUILDING ADDRESS: MARK SMITH PERMIT N003080014
771 PENDERGAST A177
t OWNER'S NAME: 18771 PENDERGAST AVE PERMIT ISSUE DATE
MARK SMITH
ONE: SANITARY NO. CONTROL NO,
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT -^r LUMB MECH
0 0
+o ZO LICENSED CONTRACTOR'S DECLARATION bble ri "tion
UM I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
nZ1 with Section 70e10)of Division 3mf Ne Beeineund Profersinns Code.and my license is
- s� i
m rase aims and erre°' CLEAN-OUT LA S W R PIPE S DE LK
O Z License Close Lie.N
Dau Comncmr I,{
e ARCHITECTS DECLARATION ILJ'
E 1 understand my plans ahtll be used a public records
�Cy Licensed Profesriooal
$ J OWNER-BUILDER DECLARATION
A<F I hereby affirm Nal I em exempt from the Commerce,License Law for the
p O following noon.(Section 7031.5,Business and Professions Codc:Any city m county
5$ which requima a permit m concoct alum,improve,demolish,err repair by nrucwm 81700
prior to its issuance,also require the applicant for such permit to File a signed suumcm
pp < for is licensedpunuanmtoshe provisions ofthe Conwct..U..Law(Chapter 9 Sq.Ft. Floor Area Valuation
2 $ (commencing with Section 7")of Division 3ofthe Busincesrmand PrormsimuCode)or 37527035 . 00
..
that he Is exempt Ocmfrem and ftbasis for the alleged exemption.Any violation o!
Section 7031,5 by any applicant for a permit objects Oc applicant to a civil penalty of APN Number Occupancy Type
not mom than Rve hundred dollen($500).
.yl1,as owner of the prepeny,or my employees with wages u their sole compensation,
WiB%"ih work,and to sWcmm is not intended or offered fouale(Sec.7044,Business iUb - kQn$,
and Professions Code:The Contractor.License Law does not apply to an owner of 202 - UNDER 251 N G
property who builds or improve thereon,end whodoes such wart himself or through his
own employee.provided that such improvements ort not intended moRemd for Sale.IT, 301 - ROUGH PLUMBING
however,the building or improvement Is Sold within one year of completion,Ne owner•
builder will have the burden of proving that he did not build or improve for purpose of 302 - TUB & OR SHOWER
am.1. - 502 - FINAL PLUMBING ENERGY
❑1,as owner of the properly,am exclusively contracting with Hamad common in
construct the project(Sec.7W,Business and Profusions Code:)The Contractor:LL 506 - GAS TEST
cense law does not apply to an owner or pmpeny who Wilds or improves thereon,and 507 - FINAL PLUMBING
who contracts for such projects with a convator(s)licensed pursuant m the Convacto s
License law.
❑ l am exempt
order Sec. --, B&P Cpfor tris n
Owner s/Nle .. if s DIO O V
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury oro of the fallowing deulantions:
I haw and will maintain a Certificate or Consent to self insure for Worker's Compere
nation,as provided for by Section 3700 of tW LaWr Code,for the performance of the
work for which this permit is issued.
❑1 haw and will maintain Worker's Compensation Insurance.a recruited by Section
3700 or the Labor Code,for the perlormance or the wort for which Nis permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu action used not be completed irthe permit Is forone hundred dollars($1 W)
err less.)
1 mcnify that in the performance of the work for which this Permit is issued.I shall not
employany person in anymanner t c�m subject Otho Workcri Cnmpcnsetion
Laws of California�D]t
Applicant �{'((�<�
NOTICE TO APPLICANT:I,sfTr InaMg this Certificate of Exemption,you should
Wwme subject to the Worker's Compensation previsions of tW lahm Code,you must
=0 forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat dart it contraction lending agency for the Performance of
Ys the work fur which this permit i,issued(Sec.3097.Civ.C.)
W Q lender's Name
jZ Leader;Adder..
..9 O I certify that I haw read this application and sum that 0,aWm Inramtmmn is
y F correct I agme to comply with all city and county eminences and sue laws rt1.0.,to
U building eonswction,and hereby authority repussmatives of this City to enter upon the -
5i d ahovcmemioned pmpony, m
far inspection Ponu,.
(We)agree to an,indemnity ad keep harmless the City of Cupertino against
fn Habilitles,judgmenu.cosu and expenses which may in any way scans against aid City
J 7 in consequence of the granting or this Permit.
'^• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the e Cu ert uor mfMuni Wilding occupant store or handle Health
sd Safety a ty
u defined by the Cupertino Municipal Code.Chapter 9.11,mJ the Health and Safety
ode,S ijon25532(gl [� All roofs shall be inspected prior to any roofing material being installed.
❑Yes �No
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haamous air comuminanu a dchand by the Bay Arca Air Quality Managcmcm all new materials for inspection.
arict'
❑Yesn
I have mad the hemodma materials mquircmrd,under Chapter 6.95 of the Califon- -
hO Him th&SafetyCode.Sem 1!25505,25533 am125534.I undersand that if dte Wilding
does not currently haw a temnt,Nat it is my rtspomihility a anti l'y the mcupot or Ne
mcruire en which ,uctpria nae reCcmOcateofOccu er. Signature of Applicant Date
Owner or authotireJ~:gent ���03 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
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.
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: Date:
�:�v�J�' Date: S 3 D
Job Address: /!377 PeA&j acr Permit# o 3 o Tool
AM changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
City of Cupertino Building Departmen
CITY OF 10300 Tone Avenu
C' IpEQTINo Phone: (408)777. 22
Dear Propel 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 vourself 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
peravts 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
CITY OF CUPERTINO 0 3 8 p o !
REPIPE/SEWERS/.MAN SERVICE
CUPERTINO. PERMIT APPLICATION FORM
APN# 7S� a 7— D 3 S Date: D o�
Building Address:
Owner's Name: Phone#:
M/9-1 '708 - 3 Y3- azo 0
Contractor: License #:
Contact: Cupertino Business License #:
o La k)
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
Rt /a[m Ae&e fx!/ G f4 -eltf.
Residential ;K ommercial ❑
Cost of Project:
� 1700. Oa
Qty. if
Applicable Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
� z7 7
t