04060145 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �CONTRpC�"TOR INORMATION'
BUILDING ADDRESS: ROBERT ZEHM PERMIT NO04 0 6 0 14 5 - -
10541 RANDY LN
OWNER'S NAME: PERMIT ISSUE DRIB
ROBERT ZEHM 06/16/2004
ONE: SANITARY NO. CONTROL NO.
ARCHI'IECTIENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
t� 0
u00 LICENSED CONTRACTOR'S DECLARATION Job Description
�a 1 hereby affirm Nat 1 am licensed under provisions of Cbaptr 9(commencing
^� with Section 701«0 of Division S of the Business and Prefcaslon,Codc.md my license is
Laren mreaana serest. ELECT. SERVICE UPGRADE (300 AMP)
5
License elm. tie.«
^
pppp Dao:
Connector
YY F� Com
ARCHfECT'S DECLARATION
[Understand and mypins As public records
� •
'6U
3� Licensed Pnttcssional
S OWNER BUILDER DECLARATION
02 I hereby a0irm that 1 1 eB..f from the Canmacmon LiAny c Law for my ,
2t' following fortunes
3 Pani.1 ]0313,Bualnes and W.dmoti Conic:Any city or county
$ whichhits iseap.also retires eellerimprosudcmolu t ore a sig my edstfuctunt SOO
Fzy pnormitsiensedprsant in the lhovisios,ofcant for mehpctor's ems,,Law(Cha mem
< lhot hciscing cdpursuanttthcpfDtel.nso the oftheBllnew.nmnsclaw(Chaptr9 Sq.Ft. Floor Area Valuation
�a $ (cat he is ingwllh Section700(y)and the
basisofro(theeged exemption. siaviladon Conic)of
Net he u exempt Ihc¢from and Ne btu for the alleged exemption.My vlolavon of
Section 7031.5 by my applicant fora permit subjects the applicant a a civil penalty of
not mom thm nee hundred dollen(5500). Dr Occupancy Type
❑L u owmer of and
proprny,ar mY emplane with wage u lheif mth campcns inns
will dolhewmlt ands:no Cont is nota License aw do fs sn apply ON,Business Required Inspections
and Profession,Code:The Contractor's License law does rot apply lf rt owner of q p
property who boIpro arMmowa Liberman,and who dues,tens work h tuffs edNmune his
own employee,pmvidrrl that mens improvements in not year
oft maBered fortune.rt.
however,the Wilding or improvement Is mid a did
one year of completion,pu nom of
builder will have the Wrden of proving that he did nm Wild or improv for puryose of
Asia.).
❑1.As owner of the property,am eacleively contracting with licensed contractors to
constmet the project(Sec.7044,Boston.and pretensions Code:)The Contacmr's Li.
cense law dean not apply to an owner of proper who Wilds of ro
impve m
theon,and
who contracts for such projects with a comrector(a)licensed pursuant in the Contractor's
License law.
Fskn exempw er See .B At P C(ordlis,��0o
O u Dae
WO KERS COMPENSATION DECLARATIO
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will matntein.Certificate of Consent to an If.I anre for WorkcfaCompcn-
u0on,u provided for by Sermon 37M of the labor Code,far the Fort....a of Ne
amok for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insunnw,u required by Section .
7]lp of dm tabor Code.for Ne perfarmmec of the work lm which Nis permit isissued.
My Worker's Compensation Inmnnce carrier and Policy number art:
Cartier. Policy No.: +
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ibis sectim need not hccomplew lithe permit Is forma hundred dollars(Stran)
of Ice.)
1 certify that in the performmcc of the work for which this permit is issued.I shall not
employ itrytpcmOn in any manneryynnu hcco subjen to the Workad Compensation
Laws.and ia.Date ! l w
Appli
NO- TO PPLICANT:If.after making this Certificate of Exemption,you should
subject m the Warta's Compensation provisions of the laWr Code,you mel
.JO runhUM..,iy with ouch provision,.,,his penoilahW hat decreed revaked.
„z„ CONSTRUCTION LENDING AGENCY
(••+ ice+ I hereby anirm that there is a construction lending gency let the performance of
a'
the wurk for which Nis Permit I.issued(Sec.3097,Civ.C.)
Q Lender's Name
a z Lender's Address
V O I cerify that I lure road this application and sum that the above infomauun is
E' correct.I.gree to comply with all city and county ordinances and stat law,relating to
OU building construction,and hereby authorize representatives of this city to enter upon the
Lkl shave (We)a agree
property for inspectionindemnify
Apurposes /•�
lL (Wc).gree s,ave,indemnify and keep harmless the City of ruCupensts against
A in
eunce Of Use
costs And OfPcnsuwhtch may in anymysume against said City
V z A APPLICANT
of UNDERSTANDS
of this permit.
^' APPLICANT UNDERSTANDS ANO WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU CE ULATIONS.
(_ Re-roofs
ign t a Appli HtrAZARDOUS MATERIALS DISCLOS REContrac,orT Dam Type of Roof ,
Will the applient or future Wilding omupangtom or Its Wlc heemi matamd
ans[u defmby the Cupanhm Municipal Cade,Chxptr 9,12,and due Health and Safety
oda,
S.c.
edeYe tiea 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑
Will the applicant or tumV building memant vee rgtP rmL of device,which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazurdnus air mnu ninanu u dcfincd by the Be,Area Air Quality Mma,chrmt all new materials for inspection.
District'
❑Veno
I he.reW the W Aodousmau W,requirements oodo,Chapmr6.95 ofthe Califon
nia Hand"Safaycole,Sections25505,25533 and 25534.1 understand thnifthe Wilding
docs not currently boat a mmnt.that it Is my resp.nsihility m an the mcupant of the
L"62
require ichmost be met poor inissuance oraccrufcamormePiney Signature of latent Dale
Owner or.UIh Anzcdagent atb 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
L___..e..cs—..
ttttca
'vc cat u
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 Sioature: c - D*Ye:
job Ad�Eess: . ILL( Zf!-410k //'i.&AA 71" �i � Permit#
Y
Any hanges to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
City of Cupertino Building Department
CITY 101 10300 Torre Avenu
C 1 I p Q r' 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 compensationo
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 lntemal 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.
Vera,truly yours,
Building Department,
City of Cupertino
Printed on Recycled Paper
CITY OF CUPERTINO �� S
CUPEIZTINO PERMIT APPLICATION FORM
QPKPN# Date:
Building Addr ,: Mailing Addres (if diffe nt from building address):
Owner's Nargj�. Phone#: �3-7^ SZ 3
U��"i'i G�— �C'"1•u t �
Contractor;+ License
Contact: Q Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Job Descriptio Am
Residential St�CUl<_(�_ V9&9-A_1)6 Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: D Occupancy Grou
r
Type of Constructiont Please check this box if the plAWct is a
second-sto ad 'tion:
'TProject Size: Standard ❑ Laze ❑ Major ❑
Quantity Fee ID Fee Description FeeGroup
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> I OOK 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
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' a - CITY OF CUPERTINO
cir o
CUPEI�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
BOVERTIIvIE 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 rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
IMF 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
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> l OK 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
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CITY OF CUPERTINO
�I* O PERMIT APPLICATION FORM J`
CUPEkTINO
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
BSEISNIICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Insection 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
PPLEIGPlumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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