04060067 CITY OF CUPERTINO CCL11V�R�iC�TOR�IDik'QI2.Mt1�TI
BUILDING DIVISION PERMIT
BUILDING ADDRESS: JESSE SALEM PERMIT N0.04060067
826 SEPTEMBED nu
IzEItlNT ISSUE DATE
OWNER'S NAME:
JESSE SALEM 2 04
SANITARY NO. CONTROL NO.
NE:
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRALTOR'S DECLARATION Job Descriptign��Gu�p � �
Wu 1 hemby affirm MALEC
1 am licensed under provisions of Chapter 9(commencing t�'"'
iU with Section 70M)of Division 3 of the Business and Profession Code,and my license is
in fall mrmandaffect. EXTEND GAS LINE FOR .COOKTOP AUG lb 26x4
�,Z Liccnm Class Lic.R
n t•p Date Contractor ,
S ARCHITECTS DECLARATION
—t 1 understand my plans shall be used as public records
3 G� Licensed Professional BUILDING
3 OWNER-BUILDER DECLARATION
1 h..A. alarm that1 1. cBusin Business
the Cnmramofs Liccnm Law for the
o o following reason.(Section 703 1.5,Business and Profnsinns Cede:Any city or county
Kee which requites a permit m Construct,ebur,improve,demolish,or repair my structure 1000
yZi prions its issuance,also requires the applicant(orsuch permit to tire a signed statement Valuation
Fsao
Cut the pursuant e is licensedpursuanotheprovisionsoftheContractor'sLbanmlaw(Chapter9 Sq.F[.Floor Area
mt (commencing with Section 70M)of Division 3 of the Business and Professions Code)or ,
i 3 that he is exempt therefrom and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant Io a civil purely of 3 WM lUi6er 0 0 Occupancy Type
not more Nen five hundred della.($500).
❑1,as owner of the property,ar my employees with wages as their sole compensation,
will do outwork.and Be structure is ootiatendcd reoffered for sale(Sec.7044,Business Required Inspections
and Professions Cade:The Convector's Liana Law does not apply N An owner of q P
Property who builds or impmvcx themom and who dues such emak himself or Nmugh his
own employees,provided deatsuch improvements arc notinunded or offered for sale.If.
however.Ne building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving Net he did not build or improve for purpose of
sale.).
❑1,as owner of the properly,am exclusively Convecting with licensed convectors to
consumer the project(Sec.70".Business and Professions Code:)The Cantrmtm'A Li.
cense law docs not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Convactar'a
License Law.
1 am ex under Sec. B&P C for this reason
ow 6i1 o�� Date
WORKERS COMPENSATION DECLARA ON
1 hareby offs.under penalty of perjury one of Ne ewial dalamiams:
I have and will maintain a Cenifiea,e of Cement to scl6imam far Worker'sCompen-
sation,as provided for by Section 37W or the Labor Code,for the performance of dee
work for which his permit is issued.
❑I have and wilt maintain Wmkcr's Compensation Insurance,as required by Section
3700 of the labor Codc.for the performance of the work for which this parent,is issued.
My Warkefa Compensation Iam..A carie and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mda section need not heeomplead if Ne permit is fmanc hundred d.r.(SIM)
or less.)
1 unify that in Use performance of the work for which Nis permit is issued,I shall not
employ any Person in any mmner W as m bacomgmbject to Ne Workers Compensation
Laws of Calto
W
NCANT:IL after making this Certificate of Exemption,you should
beWorker's Compensation provisions of the labor Codc,you must
Z fath such provisions or this permitshall x deemed revoked.
ZOCONSTRUCTION LENDING AGENCY
E•a I I hereby affirm that there is a Construction lending agency for perfummne,of
the work rut which this permit is issued(Sec 3097,Co.C.)
W A Lender's Namc
G Lcnderi Add.
U C 1 certify that I have mad Nis application and state Net the above information is
W F Correct.I agree to comply with all city and county ordinances and aunt laws reining to
OC) building convection,and hereby authorize mpruennedrxs or Nis city to enter upon the
W ahovmmentioned pmperty for inspection purposes.
G (We)agree to save,indemnify and keep harmless the City of Cupertino against
N liabilities,judgments,casts and expenses which may in any way accme against mid City
U Z in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT Issued by: Da
(/
SOURCE REGULATIOO S.
'��62 0'/ Re-roofs
urc of Applicant/Convaaor to r
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ser future building W upantsmrc or handle hanNous material
as defined by Ne Cupertino Municipal Code.Chapter 9.12,and the Hnith end Safety
Cade,Section Z5532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea �Ne
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 hazardous sh-comaminanu as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 W NO
In=mad the hamrdous materials requirements under Chapter 6.95 of the Carter-
nia Health&Sdf Ly Cadc,Sccdons 25505,25533 and 25534.1 undc.wd thotif arc building
docs not currently have a vnant Net it is my maponsihility,w notify the occupant crow
myviremcn�wgirn maatxmn viler kora Camp to rccpancy y Signature of Applicant Date
Cd+ � �=/`� All roof coverings to be Class"B" or better
daaaLe zfeufetmrivcd Meant Dau
i
FURNACE
1/IPIPE
20'
6 9'6' '
n
STOVE
1 "PIPE 3/4"PIPE
REDUCER EE
. .D.
14,
k:F, G.
STOVE 01600
�1
FURNACE 800QD BTD`�
DRIER 22000
WATER HEAT BTU
coz
O
OVOER-BUILDER VERIFICATI&T
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
a,c cca vauacaa
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 Signat+�
Job Addr Pe)lit t o y o 6 d 0 6 7
AM changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
•
City of Cupertino Building Department
OOF 10300 Torre Aven
C U P E RT I NO Phone: (408)777-32
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 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
vtITY OF CUPERTINO• D 6 a
aCnf PERMIT APPLICATION FORM 7
CUPEIZ,TINO
A Ilk
1WPN # 36 z U Z Date:
Building Address: g o1 ` SQ p T Q M b h Mailing Address (if different from building address):
br .
Owner's Name: Phone#: wog_ 5
`Jesse So.�e,w. 7- Jg ?$
Contractor: License #:
O o, •ner 8 r,) k�,,
Contact: Phone: Cupertino Business License#:
Fax:
Build
Permit Info:
BYO Elect ❑ Pumb�<?- Mech ❑
Job Description:
Residential ,l Q ?4--y d AS / /n e, Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: ; 0-7� Occupancy Group
Type of Construction: Please check thi bo ect is a
second-story addition: ❑
ro'ect Size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
t13. BAPPLOTHER Other Appliances MECHANICAL
BBOILERI 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
ZS' 7� L
1 of 3 0
A'r *ITY OF CUPERTINO*
CUPE
1mr,r NO 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 InstallIAlter 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
BREMAUUiAN A/C Units<= 10,000 cfin MECHANICAL
LLL BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Fumace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT I Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BRENC RAP 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 CUPERTIN#
ClTM0 PERMIT APPLICATION FORM
CUPERTINO
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
BSPECIAL 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
ZADDCHG Address Chane BUILDING
•
3 of 3
CITY OF CUPERTINO ^'�w777777777777T=
BUILDING DIVISION PERMIT
p '.��..gxTOR TN�'f1VItTTUN�s
BUILDING ADDRESS: JESSE SALEM
TE PERMIT No.04060067
826 SEP
OWNER'S NAME: - PERMIT ISSUE DATE
JESSE SALEM - 06/07/2004
E: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i o 0 LICENSED CONTRACTOR'S DECLARATION
a 1 hereby affirm thm I am Became under provisions of Chapter 9(commencing Job Description
e wi@S.omu7000)mf Divislon3of Ne Busiwuend Pmfasionx Code.end mylicenm ie
n � inBrOmrceand er@ct. EXTEND GAS LINE FOR .COOKTOP
j Z License Class Lt..#
le-, Dau Conlnnar
YARCHITECTS DECLARATION
un
rt 1 understand my plans shell M used as public records
G Licensed Professional
S OWNER-BUILDER mDECLARATION
C<Y hereby affirm them 11. xempt from Be Canuectoo e:Any
Law for the
i m o which mason.(Section]o L5,eusiness and Improve,
de oli Cade:Any city or county
whichitsrequires issuance.permalso re enres the,attic,Improve,h peraii t or repair any structutatemeni S1000
prienoiucensedperms re to the the applicant for suchpermiuorite aicense ned Law(Chapter
y'Z< to numencing edpurstion71 duprovisiomnfthe ortheBusines andPrulaw(Chapur9 Sq. Ft.Floor Area Valuation
t$ (commencing with Section]OW)of Division]of me Bmineanand PmresNam Code)or
y 3 But he is eumpt therefrom and the baso for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Occupancy not mom Nan Bve hundred dolor(55110). P y • Pe
0 Lome ,t.Ne propeny,ar myempleer wimlengesu.k,(S.ecompenmmm
will dofework anile so Contractor's
omms not intendedn Lawddmashie(Sec.to an
and enywh bas Code The Co moment.License Law doss not apply lf an owmr or Required Inspections
property who builds or moment.and who doessuch work himself or through his however,meeea,provided m Improvement
old wit are not loaded m llertd to owner.
Wilde, Ne building or improvement is hold within ore year or completion,Ne owner
builder will have dsc burden of proWng Wt he did not build or improve for pvryosc of
sid
1.
j.
0Las owner of the propene,amB exclusively contracting with licensed C ronhadosa i- 00,
conswct the pmjen(Sec.]044,Business and Professions Code:)The Contncmra Li-
conic Law does not apply m an owner of property who builds or improve,thereon,and. '
who cor newforauch Projects with a contmemni.)licensed pursuant to the Contractor's
License Law.
lam ex under Sec. .B&PC for this reason D�
Ow Data G 7
WORKER'SCOMPENSATIONDECUAR, ON
I hereby ellirm under perulty of perjuryone of awing declarations:
have and will for
Section37M
37M ofConsentr Code.surefor Workra Compete
sabot, r which
far by Section 3700 of the Labor Code.for me performance of the
work for which Nis permit is issued.
0 I have and will counters Worker's Compensation Ina miner,as required by Section
3700 of the labor Co@.for the performance of me work forwhich thin permit is issued.
My Workers Compensation Insuunce carrier and Policy number are:
Carie, Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisseetion need not Wcompleted if the permit isforone hundred dollars($100)
or less.)
1 certify met in me performance of Bic work for which Bills permit is issued.I shall not
employ any person in any manner an as to bccoplJe subject to the Workers'Compensation
Laws of Cal au ^ f!
APPllmn a2- — -
NOTI P (CANT.If,after making Nis Cci ificau of Exemption,you should
became ffibleel in me Workers Compensation l rovisions or me labor Code,you must
run hwi romply with such provisions or min permit shall he deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
'r work
which
lhu there is sued(mdi 0 lending agency for me performance of
all the work for which Nis permit is iuuctl(Sas:.]097,Cie C.)
Q Lenderm
's Nae
.7 z
Lenders Address
U Q I calmly that I have mad Nis application and some met me above information is
Vk correct.I agree to comply with til city and county ordinances and suss laws relating to
OU building construction.slid hereby mmorie,representatives of mi,oily to enter upon the
above-mentioned property for inspection purposes
W
W (We)agree 10 save,indemnify and kap harmless the City of Cupcnino agaist
n
rayrA liabiliticajudgmeusicosts and expenses which may in anyway accme against mid By
U Z in emook Unice of On granting of this permit.
APPLICANT UNDERSTANDS A D WILL COMPLY WITH ALL NON-POINT Issued by: Da
SOURCE REGULATIO S.
PS �`J Re-roofs
urc o(AppH=UCantrector ate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant m future building occupant stere or handle hamNoua mauriei
a deRncd by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
ndc.Section zss3zea>? All roofs shall be inspected prior to any roofing material being installed.
0 Yes �Nu
Will the spuld seam or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hit.onus air conuminanu as defined by me Bay Arca Air Quality Management all new materials for inspection.
District?
DYes No
I have mad the humorous materials msluiremenb under Chapter 6.95 ar the Califon
.is Health&Safety Cade,Sections 25505,25533 and 75534.1 understood that if me building
does not curmndy he.a o nano mat it is on,responsihilay in notily the eccupanm of the
reyuimmen 'chmusk Wmet pdoru a eeraartir teofOccupanc. Signature of Applicant Date
lQ �6�;7
au Dale All roof coverings to be Class "B"or better