05070144 (2) CITY OF CUPEXHNO "b6 h
nU1LDINC DIVISION PERMIT WNTRACTE)R INFORMATION,f;.
as ,as ,Yf�._ .Ji x, .S, red•
1LBUILDING ADDRESS: SUSAN GAUTHIER PERMITNO.05070144
10714 CARVER DRIVE
0NER'S NAME: PERMIT ISSUE DATE
SUSAN GAUTHIER07/25/2005
PHONE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
tion LICENSED CONTRACTOR'S DECLARATION Job Description
4 U I bereby affirm that I am liaised under previsions of Chapter 9(commencing M'
with Section 7")of Division 3 of the Business and Professions Code.and my license is II P.N I yy k".m ry��
I.- inmumreaandeffam REMOVE EXISTING"aPANEL_\i,-'j REPLACE WITH 220 AMP
p jAZ Licenm Class Lic.Y Y 4w Ij
=Fp Dau Contractor
"s ARCHRELTS DECLARATION
< 1 understand my plans shall Ire used as public records
Ju. lO/ l.U9U
apG Licensed Prefcssional
5 OWNER-BUILDER DECLARATION'
zoo berthy alum that 1 1. exempt from Nr Contrfeewas Cou Any c law for the
5 m O following mason.(Branton]oJL5,Business and ere,dean¢Codr:Any city ns county lryVsl) n n9
m vs which myuses a promo also re construct,alter,improve,demolish,or repair any twment �T $2200
-iy pathos tsiensedp pursuant
the tMvision of for CchPermit m Olaasigned
aw(Chtemcm
YFo< (comae hansedpurmant7W)ofDiviansnfdmcamanes nianxavwfchaptar9. Sq.FL Floor Area H Valuation
(commencing with Section 10607 ofDivisionJ o(dre Bulinus and Professions Cndc)Ur
i $ Nat he is ezampt therefrom and the haste far the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty Of AP14 Tqr Occupancy Type
not mom Nan firs hundred dollars(S500).
❑I.as,owner of Ne property,or my employees with wages as their sale compensation,
will do the we*,and Ne muco m is not intended or offered for axle(Sec.RAW,Business
and Professions Code:The Contractor's License law dors not apply to an owner of Required Inspections
property who builds or improves thereon,and who doessuch work himmlf orthrough his
Own cmplayrsn,provided that such improsemeno are not intended ora@red bursae.If.
howcvar,the building or improvement is said within one year of completion.the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
1,as owner of de prop rtY,am exclusively contracting with licensed conatewm to
coniwct Use project(Sec.7044,Business and Profecians Code:)The Contractor's Li
come law does not apply to an owner of property who builds or imp caws Nemon.and
who contracts for such projects with a contraetor(s)licensed pursuanuo are Contractor's
License Lasv. I ... .. r ,. .. __
ED l amexemptunder Sec. B&P C far this moon � - - � �
nc%11 A/�-f}--A� ♦ 1 Q Dau ZV'10 .. ..
' ""WORKER'S COMPENSATION DECLARATION "" """ —"_"'"'
I hereby album Under penalty of perjury One of the following dalasatiOme
❑I have and will maintain a Certificate of Cots ret to self-insure for Worker's Compcm
cation,as provided for by Section 3700 of the labor Code,for the performance of the -
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Code,for Ne Performance of tM work for which Nis permit is issued.
My Worker's Compensation Insurance artier and Policy number art:
Cartier. Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This aratinn need not be completed ifthe permit is for one hundred dollars(SIB))
ter Itis.)
I canifv that in the performance of tie work far which this permit is issued,l shall not
employ any person in any manor t owmcxubjcct to NC Workers Comperemon
Laws of Cabfin a,,Date
Applicant-5�,,1L�y
NOTICE TO APPLICANT:IL after making this Ccniricam of Exemption,you should
become subject to the Worker'a ComPensation provisions of the IaMr Code,you at
0 forthwith comply with such provisions orthis Permit shall W deemed revoked.
'P O CONSTRUCTION LENDING AGENCY '
Phereby affirm dot there is a cormmction lending agency far the performena of
a: the work far which Nis permit is issued(Sec.ID9'1.Civ.C.)
{L7 Q Lender's Nanta
z Lender's Address
U Q 1 reify that 1 hast mad this application and sure that tbe above information is
f-' cortccL I agree to comply with all city and county ordinances and sure laws relating to
0 building concoction.and hereby autharim representatives of this city to rnur Upon the
} G ahavcmentioned property for impaction purports.
(Wo)agree to save,indemnify and keep harmless the City of Cupcnino against
FN liabilities,judgments.Cosa and expenses which may in any way scene,against said City
U in consequence of the Granting Is permit.
'—' APPLICANT UNDERSTAN AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
51g1\µYp,CEA,/REGULATION
Re-roofs
Signature of ApplianVC.r MMmr Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant Store or handle havardaus material
u defined by Or,Cupcnino Municipal Code,Chapter 9,11,and the Hralth and Safety
.Seetian z55n(a)" All roofs shall be inspected riot to an roofing material being❑Yea �No P P Y g g installed.
Will the applicant or future building occupant use equipment or&Vices which If a roof is installed without first obtaining an inspection,I agree to remove
cart hazardous air contaminants as defacd by the Bay Area Air Quality Managamcnt all new materials for inspection.
District'
p Ycs U-
I have read the hazardous m rials requirements under Chapter 6.95 of the Califon
nice Health&Safety Code,116 Was .2111 and 15534.10nderscM that if Me Minding
J n t<urtcntiy bac a renanL Na ia my responsiM1ility as notify tbe occupant of the
myu, am I,.hichmumbe m ' r tmsuanter I CerOfwauab the apaney. Signature of Applicant Date
Owner m authorirW agentZ Dare All roof coverings to be Class"B"or better
CITY OF CUPERTINO
m 1 of 1 PERMIT RECEIPT OPERATOR: kiersaw
COPY # 3
Sec: Twp: Rug: Sub: Elk: Lot:
APN . . . . . . . . : 37532011.00
DATE ISSUED. . . . . . . : 07/25/2005
RECEIPT #. . . . . . . . . : 30493
REFERENCE ID # . . . : 05070144
SITE ADDRESS . . . . . : 10714 CARVER DRIVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : SUSAN GAUTHIER
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : SUSAN GAUTHIER
CONTRACTOR LIC # *OWNER*
COMPANY . . . . . . . . . . : SUSAN GAUTHIER
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
• TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
BENERGY PERMIT FEE 83 .16 39.92 0.00 39.92 0.00
BELEC200 METERS 1.00 29.43 0.00 29.43 0.00
BPERMFEE VALUATION 2, 200.00 83.16 0.00 83.16 0.00
EPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
BSEISMICRE VALUATION 2,200.00 0.50 0.00 0.50 0.00
TOTAL PERMIT 191.38 0.00 191.38 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ __-------__-------
OTHER 191.38 M/C
TOTAL RECEIPT 191.38
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY
505 FINAL ELECTRICAL
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
r3u� �le�fY i C_ 3-z8 A Ld.w &vie_
$ri in S Sa—iaCIa-rr Ccs 9LI1Ug7_ c-10 51ec is
® 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/Pirm Address/City Phone Number Type of work to be
erformed
.....................................................................................................................................................................................
I declare under penalty of perjury that the bove is true and correct. I have read and understand the
Owner-Builder Informatio everse side).
Property Owner's Signature. Date:
CO/roe" �
OHO`�OJob Address: O r1Permit# 114 L)
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
it
City of Cupertino Building Departmeno
' I CITY OF 10300 Torre Avenue
C V P E Q T I N O Phone: (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 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
0��-0H-+
'� - CITY OF CUPERTINO
CITY 0' PERMIT APPLICATION FORM
e CUPEVINO
APN# Date:
3� - 3A- 01 I 9I2-�/or
Building Address: Mailing Address (if different from building address):
1O1Iy LarVe.r fir. (gyp. cam, gsO1y
Owner's Name: Phone #:
�.tso, GcLvc"AIe✓ `I0tS 82-9 - -111g3
Contractor: License #:
3W Eleci nc. qq11-ogZ Q- -10
Contact: pp Phone: - 1032— Cupertino Business License#:
'Df IanEllr-\gS Fax: 94(F- 1o3U
Building Permit Info: r2vv10Ve- ek151-u. q pneI — rr-ploce- w- 1� Zzo Aup
Bldg ❑ Elect 3- Plumb ❑ Mech ❑
Job Description:
Residential [9 Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Project: Occupancy Group:
'Z ZOO
Type of Co struction: Please check this box if the project is a
Cye-C, r-( c- l second-storyaddition: ❑
Pro'ect Size: Standard d Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> I OOK 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 <= IOOOA ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
/ BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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C - CITY OF CUPERTINO
°F PERMIT APPLICATION FORM
CUPERTINO
Quantity 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
BOVERTRAE 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 Stom-/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 Reins ection Fee BUILDING
BREMACOVER A/C Unit> 10,000 clip MECHANICAL
BREMAiRHAN 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
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ammv, CITY OF CUPERTINO
CITY OF PERMIT APPLICATION.FORM
CUPERTINO
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
BSVvgM 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 Change BUILDING
•
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