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02100182 (4) CITY OF CUPERTINO - - - • ' - BUILDING DIVISION PE _ IT CONTRACTOR IN_60 TION: Bul9P&g19P12EsgLORENCE DR DYCKMAN TERRY A AND BRENDA PE3MITN92100182 owgYr_sItM4AN TERRY A AND BRENDA J APPLICATIPOSN BYBT12002 ONE: SANITARYNO./ / CONTROL NO. ARCHITEC(ENGINEER: BUILDING PERMIT INFO ocZ BO ELO PLUMB O �!00 LICENSED CONTRACTOR'S DECLARATION rchap ��� ion7 mNatlamlicenmdunder provuionsorCbap rY(rommeaing KITCHEN REMODEILo M$ t G<i in fu Scorce 0)(1)of Division Sof Nc Busmcsamd Pmfcssinne Code.Mdmylianacis in roll tote,ane cffcu F'R? Licence Class TSD 7 OZ F O Dale Contractor �F=wty ARCHITECTS DECLARATION o a041I understand my plan 041 u used ramie mcnrtls `D /rLLo Licensed Professional OW NEM BUILDER DECLARATION El"6ya 1herebyaffirm NalI1. exemptfromNc Contractor's :Any,Lew for the $25000 a u r a whfollich masores a Permit t 703 LS.Bounces imp Professions Crude:Any city or county %m ut which requires a porton re pomace,alar.improv,demolish,or repair any uncimm _zi priormiucensed e.also pursuant the applicant for such Contractor's Pilose Law(Cha mem ESG what Wislicenmdpursuanttothe provision oftWContmnor'xLiccrveLew(CM1npmrY 3$6Bt5IF7fid-aA@0 Valuation z� (commencing with Section 7")a1 Pivision 3 of tM Businax and Profession Cade)or a 3$ that he is exempt Iheafrom and Ne:basis for Ne alleged esemption.Any violation of Swoon 7031.3 by any applicant for a permit subjects the applicant to a civil Penaltyof not more Nen five hundred dollars(SS(KIL PNN - Occupancy Type 102 - PIERS ❑6uOwner of the property,or re 1. employees wit wages r Ilk(See cW.Business will da the woh.and the structure is not intended or offered(orsak(Sec.7040,Business and Profession Code:The Comaxnors License Law does net apply In an owner of 104 - REBAR Required Inspections property who builds or improves thereon.and who doessuch work himadfori miSh his own employees.prodded that Man Improvements art not intended clattered tarsale.If. 105 - ANCHOR BOLTS however.the building or improvement is sold within one year of completion.the owner. builder will ban the burden of proving that he did not Wild or improve for purpose of 106 - SEWER & WATER calk.). 202 - UNDERFLOOR PLUMBING ❑LuOwner ofthe property,.70,1 ,Bexclusively convecting with:)Theetlourecu 's to 203 - UNDERFLOOR MECHANICAL convect Ne project(Sec.70W,Business and contracting Cotler)The Contaacmr's Lia ceras,Ltw dors trot apply to an owner or propcny who Wads Or improv dAmon.and 204 - UNDERFLOOR FRAME �&who contractsfor such project,with a ecommelons)licensed pmMMt to the Convectors 205 - UNDERFLOOR INSULATION Am Law. Ialn=•=septanynse�� Ba PCtor s 301 - ROUGH PLUMBING o er /ii �— DO 302 - TUB & OR SHOWER oscoMPENsnnoND N 303 - ROUGH MECHANICAL W I reby afrm under penalty or perjury one of I Bowing declarations: 3O4 - ROUGH ELECTRICAL Iaw hand will maintain a Cenificau of Consent m self-insure for Workers Comfort- 304 — FRAME ration,As provided for by Section 3700 of NW Ne Iar Code,for Ne performance of Ne work for which this permit is lattice. 306 - HOEDOWNS 1 have and will maintain Worker's Compensation Insurance,as required by Section 3 O 7 — INSULATION J700 of the Isbor Code,for Ne performance of the work for which Nis Permit is issued. My Worker's Compenadon lnurana carrier and Policy number are: 308 — SHEETROCK carrier: Policy RO 309 - EXTERIOR LATH CERTIFICATE OF EXEMPTIONNFFROM WORKERS' COMPENSATION INSURANCE 310 - INTERIOR LATH Crhissdction need not W completed tribe parmil is phone hundnddnRars u IM) 311 - SCRATCH COAT 11lolr) 313 - ROOF NAIL 1certify Nat in abs, ro ce of the war for wub is Aid 501 - FINAL ELECTRICAL ENERGY employ any person i octet es 6 troth Workers Compenation Isws of alifomia.Da �'^ m� 502 FINAL PLUMBING ENERGY Ap tic N 10APPLI NT. L rmrmakingthisCemficateofE,criphan,youshould 503 - FINAL MECHANICAL ENERGY become subject to the Worker's Compensation previsions of the Labor Code,you must 0 RmthwithcomplywithsuchprovisionsorthispamittailWdeemedmvnkca. 504 - FINAL BUILDING ENERGY Z h CONSTRUCTION LENDING AGENCY 505 - FINAL ELECTRICAL FIherebyAffirm that there isaconstrneuonlending agency for NcPerformance of 506 - GAS TEST a > the work for which this Permit isissued(Sec.3091.Civ.C.) Lendcri Name 507 - FINAL PLUMBING a Q :::) z Gender's 508 - FINAL MECHANICAL U O 1 anify that I haw read this apPlication and sole that the above information is 509 - F I NAL .GRADE ly �^ COtral.l ague Ice comply with all city and county ordinances and state laws relating to o.C, U Movengconuuctiomantl hereby Auhomin reprtsenutiv of this city m enter upon ire 5 FINAL PLANNING W above-menuoned Propertycosts for inpecde&purposes 14 F I N a (We)agreetosav=,indemnifyandkeepharmlesstheCityofCupertinoagainst LIC W RK tq liabiliues,judgmenu,costs end expenn which may in any way ettrue agaiw said City U Z in conrgoenec of the granting of this permit. / APPLICANT UN RSTAN S AND WILL COMPLY WI L NON-POINT Issued b : Date 6 SOURCE REG ON \ y J 1 noun of icaMCOnrecon Re-roofs Dare HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will Ne applicant or future building occupant store or handle hvardous material As defined by the Cupenino Municipal Code.Chapter 9.L2.and the Hallo And Safety code.sectiea 25532(a)7 ❑res All roofs shall be inspected prior to any roofing material being installed. Will the applicant Or rot rt Wilding occupant me equipment or&vice,which If a roof is installed without first obtaining an inspection, I agree to remove it hazardous air conuminanu a dc0ned by the Bay Area Air Quality Management all new materials for inspection. District( ❑Y �No I have read Ne WmW ousmamdalsmquimmenu underCW por6.93 of the Glifor- niaHUIN&Safcay Catic,Section LSSOs,z3331 am125534.1 unticrsland thoif Nc Wilding does not eumend ve a vnant, it is my resproatility to notify the occupant of the requiremcnuw m.Wm orwiuuanec ofa CeniOcallof ey. Signature of Applicant Date Owner or no rizeda col alc All roof coverings to be Class "B"or better OWNER-BUILDER VERIFIC40ION 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 v LS U LS D If B or C is checked,complete 2 or 3 below. U 2 8 2002 By 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 (reverse sid ). Property Owners Signature�1 ° Z11 Job Address: O,LC F0 � r7.✓cr2 Permit# V 0 79 Any changes to the information Provided on this form shall be submitted to the City of Cupertino Build Department. • 1 N. CITY OF City of Cupertino Building Depart p 10300 Torre Ave* C U PE TIN 0 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 compensati• 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 iri 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 Pape, au-InCITY OF CUPERTINO d Z CUP TYOFFINO PERMIT APPLICATION FORM APN# Date: �? Building Address: f- V O L o/LZ.✓c-op, Owner's Name: Phone#: Contractor: License#: . C�C3Us�iGyt— Contact: Phone#: Applicant/Contra�� Fax #: Buil in Permit Info: Bld Elect lumb Mech Description: Residential: Sq.Ft. Floor Area: /Sq.Ft.: Architect/Engineer: Valuation: Type of Construction: Occupancy G up uanti Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX hid/Off/Comm/Quasi BUILDING BCONSTAX13Q Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax—Resi/Mobile BUILDING BELEC1000 Elec 600V<= 1000A ELECTRICAL BELEC1001 Elec 600V> I060 ELECTRICAL BELEC200 Elec Svcs 600V<=200A ELECTRICAL BENERGY Ener BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investi ation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Famil Res MECHANICAL BNEWMULTI New Multi-famil Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING I of3 go 2-, l °�2 - 79' 'Ea * CITY OF CUPERT O • CUPCITY OF EkTINO PERMIT APPLICATION FORM uanti Fee ID Fee Description Fee Grou BNUMULTI New Multi-family Res PLUMBING BOVERTIME Ins ection 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 R i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain &Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfrn MECHANICAL BREMAIRHAN A/C Units<= 10,000 cfm MECHANICAL BREMAPPLI A liance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Li htin Fixtures ELECTRICAL BREMFURN RelocationofFurnace MECHANICAL BREMFURNOV Relo Furnace> l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc A azatus ELECTRICAL BREMNRAPP Rem Non-Res A liance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/A azatus ELECTRICAL BREMRECEPT Rc 9, Switch & Outlets ELECTRICAL BREMRELOCA RelocationofHood MECHANICAL BREMREPALT Re air/Alter Heatin MECHANICAL BREMRESAPP Remodel Res A liance ELECTRICAL BREMSIGNAD Rmdl Si s Add Branch ELECTRICAL BREMSIGNS Remodel Sin ,Maz uee ELECTRICAL BREMTHEATR Theatrical Li tin Fix ELECTRICAL 2 of 3 CITY OF CUPERTINO CUPEkT CITINO PERMIT APPLICATION FORM I�T u Fee ID Fee Description Fee Group BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSF&2FAM Single & 2 Family BUILDING BSFNA Single Family New Add BUILDING BSPECIAL Special Insection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Ternp 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 ZADDCHG Address Chane BUILDING 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> 1.75 M Btu MECHANICAL 3of3 ' � � � Ile I fi. . ` . - . .. . � � 4 � O / ! \7i227#$ $ƒ � &a £a2 2 . . . -rte>p �s �.^_..... .fxsrvc ktP•uwr�1 � Ca x 3 c co i ILA •*I I�I I M � /�\ � a dCo o © r `A � w • � � a roe . —/rAw f 64-a% 000uw Ali Z✓ PAI_ r .a o BTREEFJcJ+o r aL✓o.au C.t_ C L,044W"Pris Rw+sco ea—Pu ois cm -ruo e-A V'/ sch6 oic's t�c+e- »s-oaa• —.a C .�W L�y PHONE -+� - (•I�'� �J4��14.1 GSb-�pry,-JTo4 QPOWN mu0tr, .w G+A yy P!D�, /..+n��Op0 ' w D. ._f._.'_._'_T_"_ by � j{/ '. �8". 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