03110081 CITY OF CUPF,RTINO '+. "' t• "�
BUILDING DIVISION PERMIT 6 CONTRACT6kAN ORMATIO
w rA xA Mme. 1ZK ._.�
BU,(LDING ADDRESS: PERMIT NO0 3 110 0 8 1
7
OWNER'S NAME: PERMIT ISSUE DATE
MESH & BEENA MENON 11/17/2003
NE: SANITARY NO. CONTROL NO.
ARCHITECrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
G7 0 0
+oo LICENSED CONTRACTOR'S DECLARATION I]Ob Description
Fu❑ 1 hereby art,.that I we limucd under provisions Of Chapter 9(commencing P
ZW with Section 700)uf Division3of to Busmcas arm Polksmons Code,and my license is
j n< infuBrorceandeffect. REPLACE WATER HEATER
z License Class see.g
J o Data Connector
fARCHITECT'S DECLARATION
1 understand my plans shall W used as public records
got' Lice.od Profevional
3 OWNER-BUILDER DECLARATION
<E 1 hereby.(firm that 1 L cBcmpt from the fessions Ca License Law for me
00 following mama. etch t 703 LS,Business and Profession Code:Any ally or wunre,
$� which rcyviru a permit m construct,alms,improve,Jemnluh,or rtpair any mmctum , � _\ $600
�< pout in issuance,also requims the applicant for such permiuo file a sign..srstemem
2 O
that he is licensed Punuam to the provisions of the Contractor's License lsw(Chaper9 SG;,;f''t. Floor Area ] �� Valuation
3 $ (commencing with Section 7")of Division 3 of the Business and Pmdmasinns Codc)or j
Nn he Bsemp
et feerefrom and the Ensu for the,alleged Gumption.Any violation of f
Section 7031.5 by am applicant for a Permit subjects me applicant a civil penalty ofIC / (OCC pansy Type
not more man five hundred dollars(SSW). - ,.
❑ I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,end me centum is not intended or offered farad.(Sac.7W.Busincu
and Professions Code:The Conan tory License Law dao not apply m an owner of a red S CtlOnS !
property who builds or improves thereon.and who does such work himself or through his
Own employees,provided that such improvements am not intended or.fferad formle.If.
however,the building or improvement is sold within one yew of completion.the invest.
builder will have the burden of proving that he did not Wild or improve for purpose of
,ve�yl.,).
G..h as Owner of he mopany,am exclwivcly contracting wife licensed contractor a
as
the project(Sec.7014,Business and Professions Code:)The Contractor's Lh
cense law does not apply to an owner of property who Wilds or improves themed.and,
who contracts for such pmjecb with a contrutor(s)licensed pursuant o the Comramri
License Law.
❑lam.10",under Sec, B&PSC to, his�rea�soa
as r7,7 Bt 4� Q QDI't- Dal. I�
WORKERS OM ENSATIONOECLARA4I
I hereby aRnm under penalty of perjury one Of me following declunions:
�- I have and will maintain•Certlficare of Consent re self-inswefor Workers Compcn-
asion,.provided for by Section 7700 of he IsWr Code,for do,peRonexe of the
walk for which this permit a issued.
❑I have and will maintain Worker's Compensation Insurance,u required by Section
3700 of me labor Code,for the performmce,of the work far which this permit u issued.
My We
Compensation Insurance smother and Pettey number art:
Center: Policy No.:
CERTIFICATE OF EKEMPrTON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the Permit is for one hundred dallier(SIM)
or less.)
1 certify that in the Performance of thc work for which his permit is issued.I shall nm
employ any pecan in any mannersai u w section,subject to the Wolkcri Coduar atlon
Laws of California,Dam
Applicants
NOTICE TO APPLICANT:If.after making Nis Ccntf¢am of Exemption,you should
became subject to the Worker's Compensation provisions of the labor Code,you must
.,O forthwith comply with such provisions or this former shall W deemed revoked.
z^ CONSTRUCTION LENDING AGENCY
I hereby nlrum that mea in eo.uuNon lending agency fur he performa vof
'x M the work for which this permit Is issued(Sec.3M7,Civ.C.)
�W 0 Lender's Name
5 Z Lendeh Add.
U Q I certify hat I have read his application and made that the above Information is
caner.I agree to comply with all city and county ordinances and more laws relating to
0 Wilding Construction,and hereby authorise«prcantatives of his city to enter upon the
W above-memioded progeny for!.Mon..purposes /I
�'gy (We)agroe to ave,indemnify end keep hwss he mleCity of Cupertino against ll
fn Imbl lilies,judgments.costs and expenses which may in any way accrue against said City
U Z, in consequence of he granting of his permit.
APP ANT UNDER
ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU REGULATI0�1$,
--411-11-03 Re-roofs
` igmum ofAPPlicaNA2ARGOLISMATERIALS DISCLOSURE Date Type of Roof
Will the appltc...or
future building occupmt sore or handle haandaus mamrim
as dented by IW Cupertino Municipal Code.Chapter 9.11.and he Health and Safety
ode.SeNnn13532(a)7 All roofs shall be inspected prior to an roofing material bei. Installed.
❑voce � P P � Y g g �
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
7mq.�
hrrardnu air cmeaminants u defined by d o Bay Area Air Quality Management all new materials for inspection.
icl?
❑Yes
I have mad me huarthws materialsreyuiremcnu under Chapter 6.95 of the Califon
ealth&Safety Code,Sectors;25505.25533 and 25534.I understand mw if its Wilding
net cunmly haw tens r. at It is my rcmponsihiliry w nmil'y the occupant of dte
nuwhichmu dorw isuseccofa Ccrdficate Oroccu�^cyA-0J Signature of Applicant Date
sur amhmirad agents cmc All roof coverings to be Class "B"or better
1
CITY OF CUPERTINO
WATER HEATER 23 11 v "
�CUPERTINO PERMIT APPLICATION FORM
APN# ),'2- Date: 4 - 14 - D 3
J
Building Address: R57 VEAWIE-CT CUP EA7 I Na GA 4SQ f 4-
Owner's
Owner's Name: Phone#:
P,4 ml=-S-8 f}ND Q FcNA MSN°N .
Contractor: -�- Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech ❑
Job Description: \
Residential ❑ Comme dal
Cost of Project: 09
Strapped n Platform El Bonded
New Location ❑ Re laceme
Qty. if
AppliAle, Fee ID Fee Description Fee Group
BPWHEATER Water Heater/Vent BUILDING
PPERMrrFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
-2, 3,3 -
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. _ 1 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 Signature: Date:
Job Address: M/216/ Permit# D3112D81
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
i
Department.
City of Cupertino Building Departm
4CITYF 10300 Torre Aven
CUPERTINO '° `4°$'�73
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 compensatioe.
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