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BUILDING Drv[SION, PERMIT
rxCONTRACTOR T�NFOI�MATION
BUlLOINGADDREss:
1 1; _q TANTATT All
BARBARA HASELDEN
PERMITNO.03120104
OW NER'S NAME:
PERMIT ISSUE DATE
BARBARA HASELDEN
9/1R/2 R
ONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACIVR$DECons
Job Description
of CON
1 hereby affirm tiro 1 under Chapter 9 (commencins
p
3 fthe Btl
with Sudan ]pfd of Division 3 a(du Rusinessand Prufmuium Code, and my license is
d Proons tt
-
inbneClass errem.
License Clue Lic. N
DEMO THE (E) POOL '
Dam Contractor
ARCHITECTS DECLARATION
1 understand my plans shall tr used As public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I em exempt from the Contractor's License law for the
following routun. (Section 7131.5, Business and Professions Code: Any city m county
'
which requires a permit to construct. alter, improve, demolish. Or repair any ureclun,
Prof In its issuaue. also requires the applicant for Such Permit o fele a signed sutemem
that he is licensed pursuant to the pmvislon..r Ne Contractors License law(Chapter9
(commencins with Section 7000) of Division 3 of the Business and Profusions Cudc)ur
4000
q; Ft. Floor Area Valuation
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that he IS exempt therefrom and the basis for the alleged exemption. Any viola---- of
/ '� / 1.
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of
3 sil�aji0 0 - ccupancy Type
nor more this five hundred dollar, (S500).
1, u owner of pb pmperty, m myemploym with wqu a Nair ask eompenution,
will do Ne work and lhestrucwre is not Intended oroResed for W, (Sm. 7W. Business
- r
R Irlsp
and Pmfeulons Cods: The Conuutor's Li=me law data not apply m an owner of
It 0d tions'
progeny who buildsorimproves Nereun.and who doessuh work himself-rtivough his
\�V1 /
own employees, provided Nn such improvements arc not intended oro02red for set&If,
however, Ne building or improvement I. within one year of completion, Ne owner
�. %
builder will haw the burden of proving Nu he did not build at improve for purytuse of
tale.).
❑ 1, a owner of Ne property, am exclusively contracting with licensed convectors to
construct the project (Sec. 7014, Business and Professions Code:) The Contractor's LI-
mam Law dau not pply he an owner of property who builds or improves Marton. and
who contracts (or such projects with a eontrsemr(s) licensed pursuant to dm Contractors
License Law.
m lam xemptunderSu , B A P C for this, reason
w ,A D te 1 • it
WORKER'S COMPENSATION DECLA ON
I bemby afrnm under penalty of perjuryone of t all -wing deduations:
I Mw and will maintain aCcriRcaut of Consent to self -Insure for Worker's Compmn-
sed.n, u provided for by Section 3700 of the labor Code, for Ne pmformance of the
were for which this permit is issuN.
❑ I haw and will maintain Wonder's Compensation Insurer=, u required by Section
3700 of due labor Code, for the Performance of the work for which this permit is issued.
'
My Wafters Compensation Insurance terrier and Policy number art:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
,
(Thia Auction need notbecompleted lrrhe Permit is fortune hundred dollars($100)
or leas)
1 certify Not in the performance of Ne work for which this Permh Is issued, I shall nut
in Any m
employ any portio an rim - O�e wbjuutu tM Workcn'ComPensaOon
Laws of Cdif�mjn D�
NOTICNOTICnt
E TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject m Ne Wohefs Compensation provisions of 0m labor Code. you most
forthwith comply with such Prnvlsioa or Nig permit Nall AS dimmed ranked.
'
CONSTRUCTION LENDING AGENCY
1 hemby.mrm Met them I. smashuctimt Rnding.geney for the crituromea of
the work for which this permit Is issued (Sm. 3097, Civ. C.)
Undoes Namc
Lower's Address
I cenify Nu 1 have real this application and tote that the above inform Won is
correct, I gree Wtcomply core ell city utl county ordinancessof and sole laws
building construction, And hereby solitaire r upon e
of Nu city m enter upon Ne
prtpresenud.ra
clave-mcmion purposes
property for Inspectionif
re to S A
(Wm) agmen Ise taw, indemnify and keep harmicu the City -(,agmina id City
inconsequeceofM, Louis And expensof this Permit. may in any coysecme.salns nidi City
of D RSTAN of This Permit.
A APPLICANT
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
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Issued by: at /
GULATIONS.
Re -roofs
Type of Roof
"04pplicanVCuntrutor
Date
HAZARDOUS MATERIALS DISCLOSURE
e applicArt or future Wilding occupant tom or handle huudous material
AS tlm Cupertino Municipal Cade. Courtier 9.13, end Ne H.IN tad Safety
rSacti.O
Code,to 2ss3x°7All
roofs shall be ins ected rlor to an roofin material bei--
INa
Installed.
P P Y g ge.PpOa.nt
a roof is installed without first obtaining an inspection, I agree to remove
m (arum banding occap.nl trAu egaipmerl ar dcvicu whishIf
us air contaminants as defined by Ne Bay Are. Air Quality Management
all new materials for inspection.
❑Yes Nu
I haw mad the huaNms materials requirements under Chapter 6.95 of 0te Califor-
nialdeal"Safety Coca, Sam= 25505.25533 and 25534. l undenmM Nu if IM building
docs not currently haw a tenant that It is my responsibility m nodfy Ne aeuPem or the
Oc-span-y,
rcyujmmcnts which mustmmelp�prto "Mmol
Signature of Applicant Date
-C,
dyGV 17j803
All roof coverings to be Class "B" or better.
Ow 7>V
r tar..Mmucd agent Data
} OWNER -BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform
A. V 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 perfonaed
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.
PersonyF rm 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 Signature: ��rl/LP a/Lr-C(i Date:
Job Address: Cl l< S . 'f W T- CSUPL---12=T-LK-JD Permit# G / Z::2 4
• Department.
Dear Property Owner.
City of Cupertino Building Department
10300 Torre Avenug
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
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CITY OF CUPERTINO D � a o
DEMO
PERMIT APPLICATION FORM
APN # 3 D o
o
Date: 12 14 3
Building Address:
I tj -rAN TAU AVE
Owner's Name:
Phone #:
Contractor:
(.bvkiyu.ci
License #:
Contact:
Phone #:
Applicant/Contractor:
Building rmit Info:
Bld Elect Plumb c
Job Description:
Residential: POOL DC- HO W TIC4 l Commercial:
Sq.Ft. Floor Area:
$/Sq.Ft.:
Architect/Engineer:
Valuation.t
Type of Construction:
Occupanc , Gro p:
Qty. if
Annl%ble
Fee ID
Fee Descrintion
Fee C;rnnn
BPERMFEE
Bldg Permit Fees
BUILIDNG
BSEISMICOM
Seismic Commercial
BUILIDNG
1
BSEISMICRE
Seismic Residential
BUILIDNG
BPLANCHK
Plan Check Fee
BUILIDNG
BUSLIC
Business License
BUILIDNG
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