03030118 Y CITY OF CUPERTINO '�
u BUILDING DIVISION PERMIT Z, TNOT.iMATQN, :
OUILOING ADDRESS: PERMITNO.
BATCHELOR FAMILY TRUST
oWNe FEW,
PAW
7N SANITARY iftOL NO.
ARCHITECIZENGINEER: BUILDING PERMIT INFO
O ELECT
PLUMB MECH
O
�00 LICENSED CONTRACrOR'S DECLARATION
1 hereby+frim that]am hound under provWans of Chapter 9(cemmencing Job Description
with Secdon]000)of Dheulon Sof the Bualnessand Profe sdans Cade,and my licca is
inmufmce.adercea ELECT FIXTURE/OUTLET UPGRADE
Llce—Cl.—Lm.N
3 De¢
ARCHITECTS CConon DECLARATION
o 1 understand my pian chit be used as public records
35,' Licensed Professional
OWNER-BUILDER DECLARATION
0 f I hereby.(Sere Nat 11. cutely from the Contrrs Ce License c Law for the
02 following reason. erten i 7 o stn Business and Profession Caor::Any city or County
$ which requires a Issuance Alto to cannmcL alte0Improve,demean t or rcpnir any atement
_ Se tammlmccmod ,alsun to the the applicant of for FerLERSU.esianedmtemant
ggg < (commncing witpunuamion 7WO of inl dehe Busmen and PoulLaw(ChapnrY Sq.Ft.Floor Area V IOn
(commencing Is exe wW Sensfrom and
the
bsiDivision r or the al Busmen and on.Any vi Coide)ladon of $1��
that M k campy therofrom and the beck it dm alleged pplica to Any l pension of
Seaton 7071.3 by any applicant dolly fors permit ab)eeu the applkat ro a civil penalty of 6R!r iY1l
not move than five hundred dailw(S30D). � 3 0�7:L 4 V V§eT 0 0 Occupancy Type
1,u owneroTDe Property or my employes with wages as their sole ampmarmho,
will do the werk,md flumuctues knot handed m offend beside(Sec.7D44,Bwa
utl304 - ROUGH l �Eda'Rll; btimns
and Pmfwlons Code:The Contravenes Littre Law does not apply in an owner of
pmperty who builds orimpmves mercon,and who doeuwhwmk himalfor through his 501 - FINAL ELECTRICALI ENERGY
own employees,provided that uch improvements am not intended ororcered forsale.Ir. u—^ i
however.rte building or Improvement is sold within one year of completion,the owner- 505 — FIN EBECTRI'CA
builder will have the bund..of proving that he did at build or improve for purpose of I' t 1 �,
Cale.).
❑1,as owner of the propcay,am esclusively contracting with licensed contrams at
eeawa thed project(See.]a4,Business of and Pmfaalons Code:)The Comrclofa LI-
«w Vw doer not apply m ts owner of property who sed p or Improves nonan.and,
who se Lacon faraueh projects with econtncta(Olicensed Punwnynrte Contrunofa
License Law.
am ca odes Sec. ,BkPC for mi non
w•
O r Oban
O0.KER'S COMPENSATION DECLARATI
I hereby aiRne under penalty of perjury oa of the followi Iwtioa:
In end w01 nainuin•CeNOCam.f Cansentmulf-Insurefor WoskehCompen-
ion,u provided fm by Satlon 3]00 of the ubor Cade,(m rte pcaannamx of me
work for which this Permit is Issued.
I have and will maintain Wakeh Compewdon Insurance,u required by Section
37o0of me labor Code,ter ma peaormmce of the work(m whkh this permit issued.
My Worker's Compensation Insurance Cartier and Policy number w:
Cartier: Policy No.:
CERTIFICATE of EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This mcdon meed not beeomplctod ifthe permit is foroa handed!dalw(f I00)
err lass.)
1 teNfy Na in rte perfmmsnce of the work For which this Farrah Is issued,l Mall not
employ aner
Try thin yen ssl b co subject that Worken'Compewdon
Law of Cali(orn
App 1i rat ,,��.aapr011
NOTE APPLICA W:If,after making this Ccdllkat.of ExempOon,you Shashi
he am bject n me Worker's Compensation provision of IM labor Code,you must
.J Z. Tote rally with such provisions Or this permiahall be darned Coked,
OCONSTRUCTION LENDING AGENCY
[—t I hereby aRnn that mere is a construction lending agency for the performance of
a.> the work for which tela permit is Wued(ger.3097,Civ.C.)
Q Lender'.Nam.
7 Z Lender's Address
U Q 1 unify that I have mad this application and sun that me above InfomNU.is
I4 !+. correct.1 agree in Comply with It oily and county osdinancn and sun kw mbting to
0[U^ building construction,and hereby aumoda represenudves of this city to ether upon the
W ahove•mcn0oned property for Inspection purposes.
(We)agree to save,indemnify and kap hapless the City of Cupertino apron
CAA Ikbill0u,judgments,coca and expense which may in my Cay acne against sad City
C) in consequence of the gra ming of this permit.
APPLICA UNDERSTANDS AND WILL rPWLY WITH ALL NON-POINT Issued by: Date Ve:5�7X
SOUR ULATIONS.
= d =_41%197/6 3 Re-roofs
silkrc of7i HAZARDOUS MATERIALS OfOUCOCIRCLor I type of Roof
Will the
,applicant or future building occupant atom or handle haardow material
as dc0ned by the Cupertino Municipal Cada,Chapter 9.11,and the Health ad Safety
Cod., E es 3ss33DI7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes `�No
Will the aPpncam of future building Compete use equipment or aeries which If a roof is installed without first obtaining an inspection,I agree to remove
it hayMous air conuminanu u dc0ad by me Bay Arts Air QUWty Management all new materials for inspection.
arid?
❑Yu WN.
1 have mad meh azoloussmmaterials requirements underchalkr6.95ofteCalifor-
RmHcalthAS.fmyCudc,Saduns15505.35533md25534.1undcramndmatifmc building
dna not tly hew a nnm4 that It mY res Ibillty to badly the occupant or the
uln whichmustMmet sou an of y Signature of Applicant Date
war ur thomr4 egem a em
All roof coverings to be Class "B"or better
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family(parent,spouse or child)will perform:
A. JL All the work authorized by this permit PFM@212003 B. A ortion of the work C. _ None of the workIf B or C is checked,com lete 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
performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information( erse side).
Property Owners Suture: 4te: 2 O 3
Job Address: /O 3!PZ 17 ICks tALeKC b Z! V Permit#
AU changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
CITY OF City of Cupertino Building Departmeel
C U PEI�TI NO Phone:
Torre Avon
one: (408) 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.
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 compensatioi
contributions.
There may be financial risks for you if you do not cavy 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