05090135 CITY OFCUPERTINO �
BUILDING DIVISION PERMIT CUN'�IZA bliiTNT'C"1LM, TTU�1 "
BUILDING ADDRESS: RAYMOND BATEH PERMITNO.O 5 O 90135
19210 TILSON AVE
OWNER'S NAME: PERMIT ISSUE DATE
Alk RAYMOND BATEH 19210 TILSON AVE09/20/2005
NE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELP.CT PLUMB - MECH
E t7
o 1 LICENSED CONTRACTOR'S DECLARATION Job DaSCrI 071
e 1 hereby a?rm that l am licensed under provisions of Chapter 9(comm ocing p
with Scelion 7")of Division 3 of Ne Business and Prafcssinu Code,and my license is
a in full fosse andcffem. ELECT. PANEL , '
Z License Class Lic.g
$ Dau Contract., 7S.
E6 ARCHITECT'S DECLARATION - OG "+'`✓
u5o++ 1 ander and my plans shall be used As public records
J 0 O�a Licensed Professional �C
3 OWNER-exempt RDECLARATION ✓
1 mem .(Erm on i 1. exempt from the Conuactor's eLicense Ac Law for sec
O O fallowing moon.(Section HD construct,
Business and improve,
is demolish.Cale:Any city or county -/
$ which requrea a permit re ato eller,improve, ermittor repair any (AMI= if 8� .'i..MSe� $200
�, prix m its issnsed Innocent
requirestohe de applicant for such Permit to Bic a cense Law(humero �
p < (commecingwidpurwion700epmvivioua(the ofwe0raursniccnseLaw(Code)or Sq.Ft.Floor Area ryYaluation
y (est he is
(commencing its Section and the
Division rth thceged enew examp on.ProAny mCnde)of `y
tNt he b exempt therefrom and the buts(.r the alleged exemp0an.Any vlolallon.f
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of -5 AP14
not mart dun live hundred dollar.(MOO).
r Occupancy Type
❑1.an owmr ofthe propcsty,or my employees with wages an their sole compensation,
will do thework,and theanmam is notmamdad or.ffund unale(See.7044,Business Required Inspections
and Profeulona Code:The C.nuaclorY License Law dao not apply to an owner of Q p
Property who builds or i mprowa Bowman,and who does such work himself or through his
own employees,provided that such Improwmenu arc not intended or offered for sale,if.
however,the building or improvement is said within aro year of completion.the owner.
builder will have W burden of proving Nn he did oat Wild or improve for purpose of
.1.L
[3 1.as owner of the property,am exclusively c.nuaming with licensed coonctas to
construct one project(Sec.7044,Business and Professions Cade:)The Com memr's Li.
cease law does not apply in an owner of property,who Wilda or improves themon,and
who sancta for such pmjeeu with a conuactogs)licensed pursuant to the Connctor's
Lkense Law.
[3 lam exert nderS ,B&P C for this reason
Owners I
WORi COMPENFAT701IN DECLARATION
I hereby of inn under penslty of pesJury one of the following declarations:
I have and will maintain a Certificates of Covent tosel6insure for Worker's Compen.
tion,an provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is blued,
❑1 have and will maintain WorkerInsurance,As Worker's Compensation Insuran , required by Section
370Dof the Labor Code,for the performance of the work for which thin permit is Issued.
My Workers Carp maation Insurance canner and Policy number no:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ThtaseNoe aced not W complced ifthe permit Is fmronc hundred dollars($100)
or less.)
I certify that in the performance of the work for which thio omit h fined.l shall not
employ any person in manners oto beco a 6je eWc h_Co retention
Laws of Califamia.
ApFll.w
NOTICE TO APPL7 ! .If, ter eking this Cent ere of E ,xemptio ou should
become subject to the W.hcr's IensWon provisions of the Labor Code,you mug
rJ O fonhwith comply with such provisions or this permit shall be deemed revoked.
ti tiCONSTRUCTION LENDING AGENCY
[-� Ihereby affirm that them Is a construction lending agency for the performance of
the work for which esu permit is issued(Sec.3097,Civ.C.)
W Q Lenders Name
] z Lenders Andrea,
IJ Q I certify that I have read this application and sou that the&Ww Information u
W F correct.l agree to comply wit all city and county anlinances and sate law mating to
Q V building convection,and hereby authorize representatives of this city to enter upon the
W shove-mentiond property far inspection purposes.
(We)agree to now,indemnify and keep harmless the City of Cupertino against
y liabilities,Judgment,costs and narcoses which may In any way&come against old City
fJ in consequence of the&renting of thin permit.
APPLICANT LINGERS 7A OS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date If 2 U-6,r`
SOURCE RE �// ^'
Signature plican Con Aver z oi�Td^� Re-roofs y 'l
DOUDow
S MATERIALS DISCLOSURE Type of Roof
Will be applicant or futum building occupant arae or handle huardou material
As defined by the Cupertino Municipal Code,Chapter 9.13.and Me Health and Safety
otic,Section 35533(.)? All roofs shall be inspected prior to any roofing material being installed.
❑tion ❑No
win the appnant.r,morebonding«aapant saeegaipmant.rdeMees- I "If a roof is,installed without first obtaining an inspection,I agree to remove
it he,mous air conuminsnts u defined by the Bay Area Air Quality Management all new materials for inspection.
ania7
❑Yea ❑No -
I how mad the huardsau materialamquiremenu under Chapurd.95 ofthc Califor.
nia Halt&SafctyCadc,Sumiau 35505,35533 and 35534.1 understand thatlltle Wilding
dace not currently how a tempt.that it is my msponsihilit miry the occupent or the
rcyulrcmcnts ' amus metpnor I seance C of aPancy. Signature of Applicant Date
Owner or an arized a Dae All roof coverings to be Class "B" or better
.— . .. a i : • n 1. ..
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
UPEkTINO
Building Department
JOB ADDRESS: PERMIT#
—1 ZSOro r03S
OWNER'S NAME: PHONE # V,75r�7
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: �tg— "`
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
kO d N
caner/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—Erfo.u,ed
d 2
• 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 Signature: K U/G1X f/� Date:
Job Address: �W Id I r �s� `C Permit#
Any changes to the information provided on this fora shall be submitted to the City of Cupertino Build
Department.
City of Cupertino Building Department
CITY40 10300 Torre Avenu
CU PEf�TINO Phone: (408)777-3
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 Califorriia 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 anemployer,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
aclo
CITY OF CUPERTINOCUfTINO PERMIT APPLICATION FORM
Ask
N# /O Date: r—
Buildin dr ss: G Mailing Address (if different from building address):
Owner's ame:
O
Contractor: License
Contact: Phone: Cupertino Business License#:
Fax:
Building Permit Info:
Bldg ❑ Elect (3 p Plumb ❑ Mech ❑
Job Description:
Residential ❑ L Commercial ❑
Sq.Ft. Floor Area: q.Ft.:
Cost of Project: Occupancy Group:
Type of Construction: Please check this box if the project is a
second-story addition:
ro'ect Size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
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
Ak BINVESTIGA Investigation fee / ^ BUILDING
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r
CITY OF CUPERTINO
PERMIT APPLICATION FORM
' PEI�
CUTINO
-Quantity Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMNIE 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 InstaWAlter 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
BREMA KHAN• 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 Rcpt], 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
CUPEI�TINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Sigris, Marquee ELECTRICAL
BREMTHEATR Theatrical Lielting 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 Ternp 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.
PLLONGRNGC Planning LR Comme/Multi-Faro PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Chane BUILDING
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