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05060027 CITY OF CUPERTINO y�4�o.p�kgy + * *'�s�^�+i7(a '"}a,� BUILDING DIVISION PE Vl��?IVl"7 AlYwl1, BUILDING ADDRESS: 1111111,190 5 0 6 0 0 2 7 OWNER'S NAME: PERMIT ISSUE DAM E: ARMFRS INSURANCE SANITARY N0. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH e �10o LICENSED CONTRACTOR'S DECLARATION Job Description Um 1 Mrtby affirm that I am licensed under provision of Chapter 9(commencing < with Section Il11111)of Division 3 of the Business and Professions Code,and my license is �< in full force and effect. TI--INSTALL RESTROOM 5�?q License Clan o:t Dan.CUn nuDELL ARCHITECTS DECLARATION 1 understand my plans shall be used as public records at Licensed Pm(cuienel �10gm OWNER-BUILDER DECLARATION I hertby.Yens that 1 1. exempt from d r Commutes License Any c Law for tbe O I0 0 which minis .pearcdun 7f131.5.Business innd Professors;h,-1-ey city or county h $E which its apermit 1.techs;die eller.improve,deermitt nr repairanytatement v - F S^ prior Wiu ctmead pursuant rogoim dieapplicantfoursuch the Contractor's im Law(chapter Valuation < $ that hcencing itpunuant70th)ofDivionsnftheCOmrmessan C.YTaw(Chapkr9 Sq.Ft. Floor Area (xammencing with Section 7000)s(Divuionl of the Business and Profcuinns Cnde)or .. that he is exempt themfmm and the basis for the alleged exemption.Any=of Section 7031.5 by my applicant for a permit subjects the applicant m a civil penally of 3 �813ar0 0 Occupancy Type not mom than five hundred dollars($500). ❑I,as ownm of the property,or my employe.with wages As their ole camPensxdon, will do the work and theawcturt ts sot inkndcd oreRe.d reassert(See 704,1,Business Required Inspections and Professions Code:The Contrumrs Lkw ense ladoes col apply W an Owrcr of q p property who builds or improves thereon,and who does such work himself or through his own employ.a,provided that such impmmments art trot Intended m aRered for sok.if. however,the building or Improvement is acid within one year of completion,the owner. builds' will haw the burden of proving that he did net build or Improve for purpose of Ane.). ❑1,as owner of the property,am uclosively contracting with licensed unuumrs m constmct the pmjm(See.7044,Business and Professions Code:)The Conuactor's U- come law does not apply W an owner of propeny who builds or improv.thereon,and who contracts for such projects with a eonvutor(0 licensed purswnt m has Contraelnrl Licanu law. am exem . a ptBh PC for this moon Owner Desk 6 3 C WOE ER'S COM NS ON DECLARATION I hereby a(fnm under penalty of perjuy One Of the following deelaAntians: I haw and will maintain a Certificate of Consent o self-Insure for Worker's Compcn- Anda.,An provided for by Sectum 3700 of the labor Code.for on,peffomtum of the work for which this permit Is issued. ❑1 hew and will maintain Workers Compensation Insurance,u squired by Section 3700 of the labor Code.for the performance of the work for which this permit is Issued. My Worker's Compensation Insurance carrier and Policy number art: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE 7134 union need stile completed If the Intend Is person hundred dollen(SIM) or less.) 1 certify that in the performance of the work for which this permit is issued,l shall not employ any person in any manner set Mco 5a tur heworkcn'Compenvtien Laws of Califomia.Dale Applicant m, NOTICE TO APPLI :IL arts,making this Certificate of Exemption,you shwld become suhject to the Worker's Cam pensallnn provisions of the labor COO.you must .,O foMwidt comply with such previsions or this permit shall be dccmW mated. zCONSTRUCTION LENDING AGENCY4 I hereby WTmn Nm dkse At a construction lending agency for the perrormance or Cl the work for which Nb permit Is Wood(Sec.3097.Civ.C.) W Q Ianders Name 7 z Lender's Address IJ 0 1 unify that 1 haw mad Us Application And sue On the above information is Iy coned.1 agree to comply with all city and county ordinances and state laws relining to O building construction,and hereby authadu rtpreunwives of this city to enter Open the W ahovmmcntinned progeny for inspection purposes. (We)agree to saw,indcmnify and keep handless the City of Cupertino against t,y y liabilities,judgments,costs and expenses which may in any way mcroe against Odd City inconuenecoftholmoling.flitV APPLICANT UNDERSTANDS A1ND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date '6—e . SOURCE CATIONS.1 [> Re-roofs Signature of April. CN... De HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building Occupant stare or handle havardous material an definedby the Cupertino Municipal Code.Chapter 9.13,and the HcaW and Safety Code.Section 25532(a)7 All roofs shall-be inspected prior to any roofing material being installed. ❑Yes J;wu Will the applicant or It Wilding occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove mit havardous air contaminants.defitkd by the Bay Area Air Quality Management all new materials for inspection. District? p Yes " 1 haw mad the haurdnns materials mquiremenu under Chapter 6.95 of hC Califoo- is Heal"Safety Code,Sections 35505,25533 and 25534,I uoderm nd that if dk huilJing does not currently ham a tenant.Nat It is my responsibility W notil"y�t u upant or the nnpd e k me" tuumnduor.ccrtifc.krt V Signature of Applicant Date xeaasent All roof coverings to be Class "B" or better ownereradthori Off- CITY OF CUPERTINO0 CITY OF PERMIT APPLICATION FORM CUPERTINO APN# 3 / 3� O Date: Building Address: Mailing Address (if different from building address): -::>.,g" 2R C t Owner's Name: Phone #: C- Contractor: License #: Contact: Phone: 4W -%9L% 7-6o Oupertino Business License#: Fax Building Permit no: Bldg (/ Elect IT Plumb Mech EF-/ Job Description: _ Residential ❑ _ S �� ommercial Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occu ancy Group: O , — Type of Construction: Please check this box if the project is a second-story addition: ❑ Project Size: Standard ZII Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BB0ILER2 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 <_ I OOOA ELECTRICAL BELECI001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V<= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING IMF Iof3 Gbh OCITY OF CUPERTINOP CITY 0 CUPERTINO rERMIT ArrLICATION FORM ,QuantityFee 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 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 Heatin MECHANICAL BREMRESAPP Remodel Res App] ELECTRICAL 2of3 *CITY OF CUPERTINOP OF 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 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 y2 MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL / PPERMITFEE Plumbing Permit Issue PLUMBING Y 2 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 CITY OF CUPERTINO !m 1 of 1 PERMIT RECEIPT OPERATOR: conniew COPY # 3 Sec : Twp : Rng: Sub: Blk: Lot : APN . . . . . . . . .. 32632054 . 00 DATE ISSUED. . . . '. . . : 06/03/2005 RECEIPT # . . . . . . . . . : 29856 REFERENCE ID # . . . : 05060027 SITE ADDRESS . . . . . : 20735 STEVENS CRK BLVD # D SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : FARMERS INSURANCE ADDRESS . . . . . . . . . . : CITY•/STATE/ZIP . . . : CA RECEIVED FROM . . . . : FENG-JUI SUN HSU CONTRACTOR . . . . . . . : LIC # COMPANY . . . . . . . . . . : ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . : • FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL . ---------- ------------- ---------- ---------- ---------- ---------- ---------- BPERMFEE VALUATION 4 , 000 . 00 104 . 76 0 . 00 104 . 76 0 . 00 BPLANCHK PERMIT FEE 104 . 76 139 . 80 0 . 00 139 . 80 0 . 00 BSEISMICOM VALUATION 4 , 000 . 00 0 . 84 0 . 00 0 . 84 0 . 00 BENERGY PERMIT FEE 104 . 76 50 . 28 0 . 00 50 . 28 0 . 00 ELECTRIC SQUARE FEET 42 . 00 3 . 36 0 . 00 3 . 36 0 . 00 PPLBG SQUARE FEET 42 . 00 3 . 36 0 . 00 3 . 36 0 . 00 EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 MPERMFEE SQUARE FEET 42 . 00 3 . 36 0 . 00 3 . 36 0 . 00 MP.ERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 420 . 87 0 . 00 420 . 87 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ ------------------ CHECK 420 . 87 846 TOTAL RECEIPT 420 . 87 • 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 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 erformed ..................................................................................................................................................................................... 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 SignaMre-�1 — / Date: .4 Z�' ��— Job Address: 1y� 3-S S 411S' n—K v, l] Permit# 0S0600 7 Any changes to the information provided on this form shall be submitted to the City of CupertinoBuild Department. • City of Cupertino Building Department CITY OF 10300 Torre Avenls CUPERTINO '° `4°$'77'"3 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 goverment 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 compensatiore 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 ED JU 0 3 2005 PLOT PLAN CHECKM BY 6ATE p N G DATE RT.Dr- TF.➢T r 1 � Cn a n I � N O 1 00 N -n /Z1 rD i 1 3 N I � O ' r a I � a o a I 1 I Q� X - ti UN mm d 3 I lb ' a Pyramid Financial InterSpace Design 9 Y $ 20135 Stevens Creek, Suite p, Cupertino 152 H.S.. A,., Bente Clue.CA 95051 { ® 406.241,1161 7 2'- 2'-5 5 " n > ul 9 Z r I N 2'-9" 3 a 3 m77 _ N © o o 7U (� i = m � O O O d O w O 3 3 m a T I r _ E a D D m -I — U p p D o z 70 to I'-l" m .n 2 9 I o i i a C z a ° P Pyramid Financial Interspace Design � qc 20135 Stevens Creek, SuiteD, Cupertino 151 Hey..Av.. 9ente ue...c.+ 9sos� 108.211.1181 � I CITY OF CUPERTINO `�� " " "AAM Vftft BUILDING DIVISION PERMIT ; COL�iTRAC;TORINFOMe1�T14N , BUILDING ADDRESS: PERMIT NOO 5060027 91711'1"; qTEVENP CRK PT VD OWNER'S NAME: PERMIT ISSUE DATE E; SANITARY NO. CONTROL NO. ARCHITECTYENGINEER: BUILDING PERMIT INFO BIDG ELECTPLUMB MECH 0 0 986 LICENSED CONTRACTOR'S DECLARATION ^ !y 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description f7 a� with Section 7000)of Division 3 cribs Busimsmand Professions Code,andmY license is In full to=and affect Lkemeelass Lic.M TI--INSTALL RESTROOM �•.�,-��� Wu ARCHITECTS DECLARATION - �/ 1 understand my plans shall W used u public records7 !%r 3 o0i Licensed Professional OWNER-BUILDER DECLARATION I I hereby.(firm that 1exempt from the Contractor'sLicenseLaw for t Rel wing mow o fallowing (section 7(131.1. tlecs 3.Bus and Professionsons Code:Any city or county +�$ which requires a permit to construct.altar.improve.demolish,or repair any structure prior to its issuance,aim requires the applicant for such Permit to file a signed statement that he is licensed pursuant to the provisions of tie Comracmra Licence Law(Chapter 9 Sq.Ft.Floor Area Valuation Sp$ (commencing with Section 700))of Divulon 3 of the Business and Profcuions Codc)or 3. that he is exempt NemGom and the basis for that alleged exemption.Any violation of Section 7031.5 by my applicant for a permit subjects the applicant to a civil penalty of 3 2'V%ZN ftr0 0 Occas ane not mare Nm flaw hundred dollars(5300). p y Type ❑I,uawmrof Nepropeny,mmyemployeeswiLh {tan Wbmlaemnpensadm. willdothework.md Ne swctum is not Irundedorairercd burials(See.7014,Business Required Inspections and ProfessionalCade:The m Comroes License law does rot apply in an owner of e 9 P property who builds or improves tlterron.and who dms ouch work himself or through his ownemployers,provided Nnmuch improvementstaenmmu ted oraBercdforsale.If. however,Ne building or Improvement is sold within one yens of completion,stammer. builder will have the burden of proNng that he did not Wild or improv:for purpose of ales). ❑1,as owner of the property.am exclusively connecting with licensed mressiors to construct the pmkm(Sec 7044,Business and Professions Code:)The Contractor's I.I. cense law docs not apply in an owner of property who Wilds or improves thenen,and - who contracts for such pmkeu with a eo oma tor(0licensed pursuant to the Contractor's r License Law. am exemppt�t�uu/nWde{rL Sam B k P C for this reason _ Own".1; ` Data J WOIt ER'SCOM NS ONDECLARATION 1 hereby affbm under penally of perjury one of ale following declarations: have and will maintain aCoolkn a of Continuo self-Insure for WorkehCompcn- on.u provided rot by Section 3700 of the IaWr Code,for Ne performance of the work for which this permit is turned. - ❑I have and will maintain Worker's Compensation Insurance,u required by Section 3700 cribs Labor Code,for the performance of ale work for which this permit is issued My Worker'.Comper adon Insurance canine and Policy number am: Carrier: Policy No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (rhisexctrn need not W completed lithe permit isfo am,hundred Milan(3100) or leu.) I certify Not in Ne performance of the work for which this Permit is Wood.I shall not employ any person in my mannerwulu mery u the e Worker'Compensation Laws of Califoroia.Date — �'+ / /Q Applicantana NOTICE TO APPLIIf,after making this Confiscate of Exemption,you should become subject to the Worker's Compensation provisions of the tabor Coda you mum vZ forthwith comply with such provisions or this permit shall W deemed revoked. ZO CONSTRUCTION LENDING AGENCY F' 1Wrahy affirm that then is a constmcdon lending agency for the performance of D:> the work for which this permit Is issued(Scc.3197,civ.C.) WE E Lender's Name lander's Add. t.7 Q 1 sonify that 1 have read this application and mute that the show Information Is Is, F~' correct.I agree to comply with all city and county on iruacs and mute laws relating to CU building convection,and hereby whorim representatives of this city to enter upon the +,W above-mmumsel property for lupemion purposes (We)agree in caro.Indemnify and keep harmless the City of Cupertino against r VJ liabilities,judgments.costs and expense which may in any way acme against aid City t)7 in consequence of the grunting of this permit. v1- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date _4_<' ,o SOURCE RROWATIONS. Si{nuurt of Apph VCRe-roofs on Da HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will theapplicantser future Wilding c.Choccupant momor haeme Ralloumateriel u dcfited by the Cupertino Municipal COM.Chapar 9.12.and the HcaIN and Safety osis.sedan 25532(a)7 All roofs shall be inspected prior to any roofing material being installed. ❑Yes �pfa 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 119 hevarMus aircontaminmu u defined by the Bay Area Air Quality Management all new materials for inspection. V t C]Yes 81/6' I haw mad the Wardrumauriabrtquinments underChapa ru95af Uta Califor- v nu Health&SafetyCode,Sccdmts25505,25333 and 25534.1 undersand theOfthe Wilding does not cmmntly haw a Mmk Wt b u my=Mp bility m notify upant of the rcqulrcmc muuWm miaaangearaccmfieete of m Signature of Applicant Date owwr ser anmarivad.gem Date All roof coverings to be Class "B"or better Community Development 10300 Torre Avenue i Cupertino CA 95014 Telephone(408)777-3228 c o Fax(408)777-3333 IUPEkTINO Building Department JOB ADDRESS- PERMIT# ,f' C 4z a ,S-a G 6 e 2 7 O 'S NAME: PHONE# GENERAL CONTRACTOR z, FAX# I am not using any subcontractcqls: _ b 1 13010 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 Owner/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 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 erformed ..................................................................................................................................................................................... I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder Informatio n (reverse side). Property Owner's Si g+a �--a�, y � Date: ��3 d10r— Job Address:Q D 73 S/o���t� �lvv � Permit# D r0 6 o d of 7 Any changes to the informationyrovidet on this form shall be submitted to the City of Cupertino Build Department. i City of Cupertino Building Department *OF 10300 Torre Avenue C U PEi�TI NO Phone: 406 777-3228 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. you are an employer,you must register with the state and federal government as an employer and If 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 matters.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 m Recycled Paper