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05030029 w CITY OF CUPERTINO r'I TUReiNVORMATI0 BUILDING DIVISION PERMIT aCONTRAC BUILDING ADDRESS: PERMIT N$5 0 3 0 0 2 9 A"771 opNnggaAST Ali OWNER'S NAME: PERMITMUEDATE MARK NE: SANITARY CONTROL NO. ARCHTIEOT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MRCH L� o 10o LICENSED CONTRACTOR'S DECLARATION Job Description 1 bunchy arnao that 1 am lsenaW under provision of Output,9(commencing wrath Section 701111)ofDivWan 3af Max Busileu and Pmfcw—Code.and my bcmrse s :n iaemseto=andtrtet ELECTRICAL/TUB REPO AND FAN nZ Licen Clw Lk.1 r J Dam Coronation, ARCHITECTS DECLARATION oil I underm nd my pts..hail be used As public tmnrds U Licensed Professional OWNER-BUILDER DECLARATION E D E 1 hereby.(firm(Section n 1 a1.exempt from the Commerim'sCo a:My c Law for the r.O 0 fallowing mason. ermitt703 LS,Bualner.and Improve, de au Code:My city os county uC$� which malumus a issuance,also ac cnnMe4 dant hnprove,h Permit or repair any atmmum 9ZA primmiunsedpalsamqulma Me parwpions of forsuch Rlese,Lawdnatemcm < that he(commecinwdpumsuemoth)of Division of the Conusem/sod Pmecdon(ChapterCode) Sq.Ft. Floor Area Valuation �$ 'At M is exempt Scctloo thanufforn NICK)the basis r M the Business edexe and on.Any rte CMa)un .. Net Fe s esempl therefrom and Ole bub for Oe alleged exemption.Any violation of Section 7031.5 by airy applicant for a permit subjects the applicant an a civil penalty of 3 7AW15WP0 0 Occupancy Type not owe Nan Bw hundred doll.($500). ❑Las owner of the property,m my employees with wattles their mle compmaadon, Q will do Nad eworh.md lhe.trum I saw Intended oraRemd I....sec.7044.11mis s Re ui_reiLIns[)ections and Profesaton.Code:The CmuscmrS License Law dots not apply m an owner of properly who bulldsorimprowsthereon,and who doessuchwark himselforthroughhis own employees,provided Nn such Improvements arc not intended ararteaed for We.lf. however,Ne building Or Improvement is mid within om year of completion.Ne owner. Milder will have n ho did Oe burden of proving Ndid not Wild or Improve for purpose of sale.). ❑1,M owner of the property,am exclusively contracting with licensed malrmlon to construct the pmkcl(Sec.7044,Business and profwions Cade:)The Contractor's U. \ tem taw does not apply An an owner of property who Wilds a,improves,themon,and, 'PI � who contracts for such projects with a commucter(0 licensed punumt m the Coruscate, SII I' License Law. ❑lam exempt under Sea .B&PC for this mason Owner Data WORKERS COMPENSA71ON DECLARATION 1 hereby aRIM under penally of perjury ane of the fallowing declarations: have and will maintain•CeNfiateaf Consent m se16m 1nmfon Woeux sCampua- n,u provided for by Section 3700 of the Labor Cade,far the performeme of the 10371CO, for which this permit is issued. have and will maintain Worker's Compensation Inwrance,u required by Section of the Labor Code,far the performance of the wort far which this permit b issued. orkefa Compensation luurame artier aM Polley number w: ier. Polity No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This anion need notbecomplened it the perenh IsforoM hundred millama(510() ar less.) 1 cenify Nn in the performance of the wort for which this permit Is Iwed,I shall not employ enypcnmn in my manner an As to become object to Oe Wortca'Compewdan Laws of Califoram.Dam Applicant 7 N0710E TO APPLICANT.If,after making this Certificate of Exemption,you should become subject an Ne Worker's Compensation provisions of the Uhor Code,you must forthwith comply with each pnlvidans or this permit Nail W deemed ranked. z rA CONSTRUCTION LENDING AGENCY I hereby arttrm that them Is a construction lending agency for the performance or IY the work(car which this permit is issued(Sec.7(197.Civ,C.) 157 Q Lendcea Name z Lmndees Addmns U Q 1 ml that 1 have mad this application am slate that Oe show information Is kL E 00roM.I agree to comply with At city and county ordinances and sum laws resting to O building convection,and hereby euthorlm representatives of Nis city to enter upnn the above-mentioned properly for inspection purposes.E (We)agmento saw,Indemnifyandkeep hay In the City of mutant id City / y liabilities,We)judgments.to cave,and expenses ad keep may anywry maneupertno.&City _ V in couegucnee of the granting of this permit. O APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. Re-roofs Signature afAppliaData HAZARDOUS US MATERIALS DISCLOSURE Type of Roof WIII tho a Cupertino m town building uc Chapter more orad M husNou mace As de.Sed io the 32(a)? o Munklpal Code.Chanter 9.11.and the Health and Safety Code.Section l5571(a)? ❑Yes ❑No All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future Wilding maupeal use equipment or&vima which If a roof is installed without first obtaining an inspection,I agree to remove 'I hayardwo sit contaminants u defined by the Bay Arta Air Quality Management all new materials for inspection. icl? ❑Yes 0 N I how mad the huudmu materials requirements under Chaper6.95 of the Califon- nsHealth&SafdyCodc,Soctiarts29505.25533 mu25534.1 unamoma lIhulfNe Wilding does nal currently haw a maanl,Net It is my responsibility to Maly the Kcup al of the mquirements which must be met prior to issuance or a cenifeate oroccupancy. Signature of Applicant Date Owner or agent Data All roof coverings to be Class aBa or better psp3oozq A CITY OF CUPERTINO CUPEI�TINO PERMIT APPLICATION FORM APN# 3 -7 5--117o 3 Date: 3 a- o Building Address: Mailing Address (if afferent from building address): 19771 a o &,sr- /{-✓� Owner's Name: S� / � Phone#: Contractor: License#: C�� t:7/ 5 Phone: r7 I— A " Cupertino Business License#: !r // Fax: Building Permit Info: Bldg ❑ Elect 19Plumb Mech ❑ Job Description: Residential §Z r1CG»-i'ca.( 7w6 r lac.Zw.e, Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy Group: p S O /'r Type of Construction: Please check this box if the project is a second-story addition: ❑ ro'ect Size: Standard Lar e ❑ Ma'or ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILER1 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 BINVESTIGA Investigation fee BUILDING Iof3 CITY OF CUPERTINO CUPER,TINO PERMIT APPLICATION FORM 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 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 BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFD{T Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace> IOK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL 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 2of3 CITY OF CUPERTINO CUPEkTINO PERMIT APPLICATION FORM 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 BSPECUL Special Inspection BUILDING BSWIM 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 Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Chane BUILDING 3 of 3 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 Owners Signature: 26 "!e���✓^/ n Date: job Address: 77 Tetd!! W- — Permit# Any changes to the information provided on this form shall be submitted to the City of Cuyertino Build DeRaartment. City of Cupertino Building Department CITY OF 10300 Torre Avenuigm C O P E'L I N O Phone: (408)777-322 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 compensation contributions. There may be financial risks for you ff 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 Recydad Paper Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 aClOF Fax(408)777-3333 4WPERTINO Building Department JOB ADDRESS: PERMIT # OWNER'S NAME: yh 1J PHONE # 3-% — 94 y GENERAL CONTRACTOR: '/ FAX # I am not using any subcontractors:�iLt.�Gf 3 2 OS- Signature Date Please check applicable subcontractors and complete the following information SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting AMhj 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 SignatureatD e