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05060073YY�ZZO RCUCZ ^sG �z pp .q U a0 N yEn CO ,ISE! 'Zt i CITY OF CUPERTINO�,' BUILDING DIVISION PERMIT CONTRtiCTOR,INFURMATION ^ >s, e inr rep{ x a 0'. si :aN'i'�% 'v4.Yao$ .+u^�:#iaae BUILDING ADDRESS: 08 WATERPORT) CLIFFORD COUEY PERMIT NCO 5060073 OWNER'S NAME: PERMIT ISSUE DATE CLIFFORD COUEY 7608 WATERFORD 06/13/2005 ONE: SANITARY NO. CONTROL NO. ARCHI]BC (ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION IionbyY)of that Iem licensed umkrpmvtsionsofChapmr9(commencing Job Description with Section ]OMI) of Division 3 of the Business and Pro(cuions Code. and my license b infaRto. adflal. REMOVE (E) FIREPLACE, & Dalense Clw Lie.« Dam Con ADD OUTLETS (4) ARCHf1EDSCLCr5 DECLARATION 1 undersand my PWo W11 be oval u public memds Licensed Professional OWNER -BUILDER DECLARATION I hereby of on that 1 em exempt from doe Contractor's License Law for the �� following mason. (Section Ria 1.5, Business and professions Code: Any city or aunty which requires a as ennalNm, Mter. hnpmw, demolish. or repair any smrctuu 6 Format prior In its Issuance, also requires the, aplicant far such Permit to role a signed statement that he ie licensed Punuanl to Ne Provisions of the Contractors License Law (Charter 9 fn. _ Sq. Ft. Floor Area.� Valuati($1700 (commencing with Section 70001 M Division 3 of the Busincatod Pronasions Com) or " 7 a that he is exempt therefroand ave, bait for the alleged exemption. Any viohtion of m ti. Sudan 7031.5 by any applicants for a permit subjeeu the appllanl an a civil Penalty of gpN;Nuinber 4/� ®� Occupancy e p y Typ not mom than fiw hundred dollars MOD). , 3 6 6 P4!0'3 0 Y 0,0 ❑I,uowarafthe pmpatYormy employees with wgauthebule compensstion, vlr�R _ will do the work, and the auumure is not amended or eflued for ask (Su.]044, Bomiiv^(S Code: Connotation. and Profession Coe Connotation Littaowner of taw deal not apply m an ownof z1' 4� ..,.Requiredjnspections property who bulldsu lmprovea tereun, and whodousuch work himselfortluough his 4i V awn employees, provided thusuch improvements am atlnmMed oraRered faael%B, j however. the Wilding or Improvement is sold within am you of completion, the owar- Wilder will low the burden of proving that Ire did not Wild or Improve for purpose of aam). ❑ 1, as owner of env property, am exclusively coaectol, with I cased carruuan in construct the pmJnn (Sec. 7014, Business and Professions Code:) The Consumes U. ce law doss not apply m an owner of property.who Wilda or improves Income. and. wh carnets for such pmjecu with a eonusemr(s) licensed pursuant m the Conuanoes L emu Law. l am ear under In, B&PCfar thi rea� ewer`it/e / "� Dem ) 3 0 WORK 'S COMPENSATION DECLARATION I hereby alnrm under penally of perjury as of the following declanaau: I haw and will maintain a Cenifino ofconsentto self-mmre for Workees Compeo- sedan, u provided for by Sutton 3700 of ere labor Cade, for ere Performance of ere wart for which this permit Is issued. ' O 1 have and will maintain Worker's Compensation Insurance, u required by Studios - 3700of the labor Code, for the performance cruse work forwhich this permit is issu d. My Worker's Carepensatian Nmnnce carrier and Policy number art: ' Canner. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE , (This section aced notbeeampleted if the permit Is free= hundred dollars [SIM) or less.) I ceNfy Not In the performance of the work for which this permit Is Issued, I shall not ' c nlD. ma0ar mW'mjleaubject to am Workeri Campenanon" �' laws of Oa _h wee Calif Applicant /—I— NOTICE TOhP .ICXN1:-If, efd4jilaking this CenlOcale of Exemption, you mould become abjat m the WO Mr's Compensation provisions of gr' labor Cade, you muse forthwith comply with such provisions or this peatt Mall be domed rested. CONSTRUCTION LENDING AGENCY 1 hereby afErm stet then is a construction lending agency for the Performance of _ Mae work for which MIS peau is Wood (Sec. 3091. Civ. C.) Landow Nae ' Lender's Address I unity don I haw mad this application sed sok that the above information is Goan. l sine m comply with all city and county ordinances and rote [am misting to Wilding construction. and hereby euthariu repmaentniwa of this city m now upon the amilode entivaA Property for inspection which es (We) same to ave. indemnify ad kap hocks, the City of Cupertino against onW calls and .peaces; which may in any way ucmc aaainaluid City may incama,itnce ramling of APPLICANT UNDEof the RSTANDS ANDWILLWILL COMPLY WITH ALL NON -POINT Issued by: Date X/3' 22S" SOURCE REGUL��yorr+IS. C�1� Re -roofs Siaawre of AppliannContracmr Data HAZARDOUSMA EIRIALSDISCLOSURE Type of Roof the applicant or room Wilding coupon pare or handle taxation material definedbyereCupertimeMan' 'pal Cade. Chapter 9.12. and ate Health and Safety le. sectien 25x32(.)1 m.NoAll roofs shall be inspected to any roofing being installed. idhWill 0yes prior material If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future Wilding Occupant use equipment or devious which hazardous air contsminx; dcfiad by the Bay Area Air Quality Management all new materials for Inspection. District?❑Yes No I have mad the husrdousmaerlalsrequirements under Chapmr6.95 of arc Califon. ole Health & SafetyCodc. Sections 25505:35533 ami 25534.1 understand thulfthe Wilding , dors not current) haw e e m tit ism poalollty m notify de occupant of she Y t,. reyviremcntawhich m melprirmi aafacenifiama,Occopercy. `' �_ �' l�yo� Signature of Applicant - Date All roof coverings to be Class "B" or better Owner or amhorived agent Dom *COF �UPEkTINO C, 9 Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: �60.r PERMIT # d o6dr6-? OWNER'S NAME: C_0t_ PHONE # GENERAL CONTRACTOR: F FAX # I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information Owner/Contrac Signature 6 -i3 -OS-- Date 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 42 Owner/Contrac Signature 6 -i3 -OS-- Date OWNER -BUILDER VERIFICATION 1. (Check one) I or/ 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. 9 Persor/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 (rev e side ✓ Property Owner's Signature: l Date: J Job Address:.h L,c a t// o r)�— ` Permit # Any changes to the information Provided on this form shall be submitted to the City of Cuyertino Build DeRartment. Dear Property Owner. City of Cupertino Building Department 10300 Torre Avenue 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 nailer 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 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 an Racycied Paper aco CUPERTINO CITY OF CUPERTINO 62-(-66,1-673 PERMIT APPLICATION FORM APN # 36i' l L' 00/ Date: J uIC- J BuildingAddress- Mailing Address (if different from building address): Dln <- Owner's Name: Phone #: Contractor: / C License #: Contact: Phone: Wolf Fax: Cupertino Business License#: Building Permit Info: Bldg Z Elect E Plumb ❑ Mech ❑ Job Description/6--v. Mc --.S- A :ref Residential ,;, rjce ;e- 0"tlu Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: •? o c) 00 Occupancy Group: Type of Construction: Please check this box if the project is a second-sto addition: 11Project Size: Standard El Large ❑ El • QuantityFee 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 BINVESTIGA Investigation fee BUILDING 1 of 3�%�— CUPEkTINO *I CITY OF CUPERTINO PERMIT APPLICATION FORM 2of3 Ouantitv I Fee 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 BOVERTWE 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 BPINIBRCEP 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 BREN 4AIRHAN 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 Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2of3 CITY OF CUPERTINO 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 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-Fam PLANNING PLLONGRNGR Planning Long Range Residential PLANNING ZADDCHG Address Chane BUILDING 3 of 3 1 J •