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05050054 CITY OF CUPERTINO 57777717777777,77177, BUILDING DIVISION PERMIT yeCOtiNT 2AETO�11!Tlai �IATTON,� . But ADDRESS: GREGARY HOWELL PERMIT NO05050054 ( I OW NER'S NAME: PERMIT ISSUE DATE ONE: SANITARY OL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG EIP(.T PLUMB MECH l 0 I� 30p LICENSED CONTRACTOR'S DECLARATION JobDescrition 1 hereby affirm Nu 1 am licensed under provisions of Chapter 9(commercial P i with Secdan]OfIU)a(plWaton 3oflhc Business;orb Profusium Code.and mylittnee is n< in full forte and eaect. 'z License Clw Lle.N REPAIR GAS LINE (METER TOOV�UNN�IT){lr�� Dam used As pts FIY Vd LED G ARCHITECTS DECLARATION 6 �i I understand my plan ahtll M used u public records u 0 Licensed Pndcsconal OWNER-BUILDER DECLARATION I hereby Affirm than 11. exempt from We Cosions C s Cleanse taw for the pO which requires permit 711)1.5.BanesAnd tw,dedu.Code:Any oily 01 County J-- 2005 $r which)its Issuance, n e,aim re construct,alcor,Improv,demolish, file repair any tatuaum LU d ray+ that he its luuma,elm requires tothe thovisio s of for such rami m cense Law(Chapter pp < (com is licensed pursuant 7 drt provisions of theCBusinesWccnse Lawr9 Sq. F[. Floor Area UB[IO d (cat be I,exempt Section and the Division 3 the due egad exem t professon.Any Cade)or .. that W h exempt Nertfrom and Ne buB for dm Uleged exemption.Any violedon of 131 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 }g*gr0 0 c cy Type rat come than Rw hundred dollars(SSW). 01,ua of0hpmpmy,wmyemployeswithcagesu Noirsolemmpemdm, willdo Neworkmd Ne s uiumtsnotimm.dedoroRtmd(oraale(S .]OIa,B.ioess Required Inspections and prolamin.Code:The e Commutes License Law does not apply m an owner of q P property who but lds or im prows theater,and who does a uch work hinmir or through his ownemployees,provided Nu such immommenta art not invaded croRered fmsala If. however,Ne WildIrS m improvement Ice said within one year of completion.Ne...,- builder will boom the burden of proving that he did nut Wild or Improve for purpose of Asia.). 0 1,as owner of the property am exclusively contracting with licensed ecounm e,to construct Ne pmjec(Sec.7044,Business and Professions Cade:)The Conumves Lt. sena Law does not apply tom Owner of property who Wilds or improwa Merton.and who convects for such projects with a contractor(s)licensed pursuant on the ConvachYa License Law. 0 1 am exempt under Sea ,B&P C for this mason Owner Dam WORKERS COMPENSATION DECLARATION 1 hereby aflim under penally of perjury one of the following dalarsdons: I law and will maintain a Cerdfcam.fCo.em to self-Insum for Woftel Compen. en.M provided for by Section 3700 of dm labor Code.far the performanee of the 1M37M rk for which this permit is issued. 1 have and will maintain Workers Compensation Insurance,u required by Section of Ne Labor Cade,for Ndm e performance of work for which this permit is Issued. y Workefa Compensation Insurance artier and Policy number art: rtier. Polity No.: CERTIFICATE OF EXEMP770N FROM WORKERS' COMPENSATION INSURANCE (This secim need net becomplemC time permit ts for ane hundred dollars(SIM) or less.) I oeni(y that in perfomanea of the work fm hich Nis pmnil h issuW.l slWl not employanype many manners tab eco eabjectio Iona Compensation Lawsof ,Calif Applicant NOTICE L aft I f Exemption,you sWuW become subject b dte oher's Comp nsadon provisions of Ne"We Cade,you mus 0'Z, rarNwith comply with each proviaio.or this permit hall be dcemed remixed. z O 1. CONSTRUCTION LENDING AGENCY [.r I Wreby alfmn dust mcre h a Construction lending agency fm Be puformuux of ,7 mc work for which NB permit Is Issued(Sec.3091.Civ.C.) WQ Landcfs Name i3 z Lender's Address U0 I certify that I haw read this application and wan than die aWw infarmadm Is u. mmem I aSm to comply with all city and county ominances and sum Lava totaling to 0 building conmuaien,and hereby ambo en reprosenmiws of this city to enter upon the U7 aWw-mentioned property for IMpecdon purposes. (We)agnm to taw,indemnify aW keep harmless Bre City of Cupertino against req liabili0a,judgmenu,cam and expenses which may in any my amus against mid City U in con nee of the lerantini of thts permit APP C UNDERSTANDS LLC ITH ALL NON-POINT Issued by: Date sou R n s a Re-roofs Si ewroe Ap en on ser Data ARDOUS MATERIA ISCLOSURE Type of Roof Wit dm applicant er factum Wilding occu smeor WrWlehuallommaterial as defined by the Cupertino Municipal Code.Chapter 9.12.and 144 Halth and Safety cmle,amen zss3z(a)7 All roofs shall be inspected prior to any roofing material being installed. ❑yes ON. Will dm applicant m future building Occupant ice equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove hemdons air co antinems u dermad by the Bay Area Air Quality Management all new materials for inspection. 7i.LL i0Yo5 ONO I have mW the hazardous materials requirements under Chapter 6.95 of the Califar. Health& ar.iyCod..SCC a n"253115,25533am1255J uVh NBife m nes ally haw a ear Na mspo m uyNcutofduen mofOccuparmy. Signature of Applicant Date rOrautho d out Date All roof coverings to be Class"B"or better Community Development 10300 Torre Avenue ^� Cupertino CA 95014 1 Telephone(408)777-3228 OF Fax(408)777-3333 �UPEKTINO Buildin 'De artment JOB ADDRE S: n PERMIT# OWNER'S NAME: ~# PHONE # GENERAL CONTRAC170R. I FAX# . I am not using any subcontractors: 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 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 Yaw A� er/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 Ad e Phtate License # Type of work to -Mn be erformed 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(r se side). Property Owner's Signature: ff Date: ��/' �I Job Address: IQo7�s 5�� �71 /� Permit# Any changes to the information provided on this form shall be submitted to the City of Cuyertino Build Department. 1 City of Cupertino Building Department CITY OF 10300 Torre Avenue CU PERTINO 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 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 spedfic 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. lnfoimation about licensed contractors maybe obtaned 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 mit will not be issued until the verification is returned. you are aware of these matters. The building per Very truly yours, Building Department, City of Cupertino Printed on liacycted Paper I CITY OF CUPERTINO REPIPE/SEWERS/MAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN# 3 ? Dat Bulcj/ ress�A�/q s me O (er' Na : Pho :p � az a � / Contractor: Phone: 0/, License#: ©ten. Contact: Phone: Cupertino Business License#: Building Permit Info: Bldg ❑ Elect ❑ Plumb 11 Job Description: 47 i Tq5 -lele-t 1-6 V4111 Residential Commercial ❑ Cost of Pro' 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 `f 7 '7