06010001 CITY OF CUPERTINO +
BUILDING DIVISION PERMIT CONTRACTOR`tINFORMATION.
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BUILDINGADDRESS: DAVID KOPELS PERMIT NOU6010001
958 WRRTT.YNN WY
OWNER'S NAME: PERMIT ISSUE DATE
Alk DAVID KOPELS 01/02/2006
NE: SANITARY NO, CONTROL NO.
7ARCHITECT]ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSEDCONTRd underSDECons ATION
ofCapIionI AJ)of Nat1amftheBdunderndP000uorCWpmr9(mmmens;is Job Description
Section]Ogl)nf Diviuon3of NC Busine antl Profcuians Codq and myliccns ixuromeandertttLWATER SUPPLY LINE-METER TO BLDGCommemr SHUTOFF VALVE ARCHITECTS DECLARATION rl t vTt D
yd C< 1 undersuml my plans shall W used As public meads
guy Licensed Pnslessionel7006
O OWNER-BUILDER DECLARATION v+ L
<� 1 hemby affirm that I am exempt from the Contractors License Law for the
y00 following mason.(Section 7031.5,Business and Prefesslom Code:Any city or county •��yy r� gyp/ PLL!{I��� ,g{f �a +
.$4, which requires a Permit to censorial.Atte(,improve,demolish,or Rpair any sm ctuR i +�\ �}�try !1\\5 t1
zy pror us its issuance,also roplims the applicant for such penning file a signed statement
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that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valoa[io '500
(commencing with Section 7")of Division 3 of the Business and Professions Code)or
that be is exempt themrmm and the Ensu for the 01cgetl exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of APN Number Occupancy Type
not more than five hundred dox(s500). 35927016 . 00
P Y YP
❑1.u owner of the property,or my employees with wage in their sule compensation,
will do the work and the structure At not intended or offered for sale(Sec.7064,Business
and Professions Code:The Contractors License Law does not apply in an owner of Required Inspections
prepeny w by builds or improm thereon.and who does such work himself or through his
Own employees,provided that well improvements are not intended oro@red for sale.IL
however,the building or improvement is sold within one year of completion.the owner-
builder will have the burden or proving that he did not Wild or improve for puryose of
sale.)..
—
L�faf.es owner of Ne propen,am exclusively controlling with flamed Contractors he
contract she prides,(Sec.7044.Business and Phimudou Cotler)The Contractor's W-
oeue Law does not apply m an owner of propeny.who Wilds or improves thcmon.and.
who contracts for such projects with aconrmuo(s)licensed pursuant to the Contractor's
Uletic Law.
01am eaem ticr tt./ ,B&P C for this uson
Owner iCI"7 Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Mrs.tY of perjury,one of the following declarations:
I hoe:and will maintain a Carol of Conant in self-insure for Wodme3 Cmnpen.
on,u provided for by Smdon 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insulation,u required by Section
lion,
of the La Wr Code,for the performance of the work forwhich this permit is issued.
My Worker's Compensation Inwnnce carrier and Policy number arc:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thusection need no,Inc completed if ilan permit is for one hundred dollars(SIM)
or less.)
1 certify that in the perform.."of the work for which this permit is isucd.I shall no,
employ any person in anym nerve ;bo me eosin Workers'Compensation
Laws of Caiilpmia.Da¢ � �1 L
NOTICE
Applicant L1 ACA Ttif
NOTICE TOAPn the boor: CompensAfter ation
thisCertificateof Exemption,you.youshould
mot
become subject y the such
Comp-1 this emviaions of Ne Labor Code,you mule(
.J O foMwith comply with such pmvitiom or this permit shall be tlamcd mvotetl.
z h CONSTRUCTION LENDING AGENCY
rIhereby affirm that then is a consuuction lending agency for the performance of
C the work for which this permit is issad(Ss..309'1,Civ.C.)
{S] LendcrS Name
= z Lender's Addax
U C) I minify that 1 have tad this application and sum that the above information u
LL Corect l ago to comply with all city and county ordinances and sou laws relating 10
O[, building construction.and hereby authodrz opreaman;ves Of this city in oma upon on
[A above-m,judgments.
udg tlproperty for inspection purposes
H 6 (we)Agra he save,indemnify and keep hatmless the City of Cupenino against
z IiaConses.ryce of th.eostsang of this
may in Any way acerin against said City
V z in eoxwquencc of the granting of Nis Permit.
^ APPLIC T UUNDDEERSTAN S AND WILL COMPLY WITH ALL NONE. OINr Issued by: Date
i ' _A
frrO��t Re-roofs
75ignamm of AppLcaMCommClor Dau
HAZARDOUS MATERIALS DISCLOSURE�— Type of Roof
Will On applicant or future Wilding occupant atom or handle hanrdous materiel
u defined is the Cupertino Municipal Code.Chapter 9.13.and the,Health and Safety
role.Sc o.y.zss33(,)? All roofs shall be inspected nor to an roofing material being❑Yes �� P P Y g ginstalled.
Will thea applicant of future building Occupant use equipment If a roof is installed without first obtaining an inspection,I agree to remove
nn 6 pan a proem art Marta which g P
it hxvardous air canuminants u dcfiad by the cry Area Air Quality Management all new materials for inspection.
WCR
❑Ycs
1 have read the harsrduu mvaialsmyvimments under CluPmr 6.95of the Califor-
Hcalth&SafctYCade,Sceliou 25515,35533 W25534.IundersmtW thatifthc buildingdocs not c y have a mnana Net it u my mspounuelity m notify the axcupaot f Ne
minim n4 ; �jAsgainrrousuaneenfacemficamor(kypaneyO6 Signature of Applicant Date
nia
7Owner orantn�d s��T �, D,m All roof coverings to be Class "B"or better
uwNEK-15UILUhK VtrKIkIt:A11VN
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
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(rev ide
Property Ownels Signatare '� Date: 041.0 D
Job Address: 9S8 (/GST1✓irW 9yl�+ 4,ermit#
�O/VAny chanes to the information provided on this form shalt be L tted to the City of Cupertino Build
Department.
City of Cupertino Building Department
Torre CITY OF Phone:°(4W)77777A
CUPEkTINO
Dear Property Owner.
An application for a building pernnit has been submitted m your name fisting yourself as the builder of
the property improvements specified
For your protection you should be aware that as owner4milder you are the responsible party of record
on such a permit Building permits are not required to be signed by property omeone other wners than they arourself,you
personally performing their own work. if your work is being performed by y
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 1b 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$700 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 ation
security taxes,workers compensation insurance,disability insurance costs,and unemployment en p
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 workerscompensation insurance.
For more specific information about your obligations under federal law,contact the Internal Revenue
the U S.Small Business Administration). For more specific information about your
Service (and if you wish
obligations under state law,contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended fol sale,property owners who are nosed contractors are
t licensed allow 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.
Inforanaon about licensed contractors may bd obtained by contacting the Contractors State License
Board in your connn unity or at 1020 N Street,SaQamier tO,California 95814
Please complete and return the enrlosed owne?builder verification form so that-we can confirm that
you are aware of these matters. The b4dmg,penmt:will not:be'Mme uintil the verification is returned
Very truly yours
Building Department,
City of Cupertino
PrhiWd W R&CYCW PaW
CITY OF CUPERTINO
lu RREPIPE/SEWERS/MAIN SERVICE
: CITYOF
CUPEkTINO PERMIT APPLICATION FORM
APN # 02 �/ Q)t
Building Addr ss:
. 9 G 0n4ZZ/41yOwner's N e- Phone#-
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Contractor: Pho e License #:
/Jer- fag V' % 3009
Co ct: Phone: Cupertino Business License#:
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Building Permit Info: —/
Bldg El Elect El Plumb C9
Job Descri
i^ o E� �
Residential Commercial ❑
Cost of Proje ,(-
nl ,
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
/ PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Repi e of Fixtures PLUMBING
BPFIXTURE Pblg. Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING