04020013 (2) , if CPPY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION �'-
BUILDINGADDRESS: RAYMOND lit �MONICA CHONG a PERMIT ND040200I3
OW NER'S NAME: PERMIT ISSUE DATE
9'12
NL:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
.076 LICENSED CONTRACTORS DECLARATION
m 1 hereby affirm that I am Hamed ander pmvixl.m.f Chapmr v Uomm ming Job DOSCrIp[IO❑
a< with Secsinn 70M)of0ivixion 3 of the Busincxs and Professions Code,and my license is
< in full fame and effect. REPLACE WALL FURNACE C gAy�
�1 License Class Lica ■ '�I1��®
nF,p Dam Conuacur
gayARCHITECTS DECLARATION
/
I understand my plans shall W used es public rceoNs
=d6 FEB 1 9 2009
is LLa Licensed Pmfesxiond
5 OWNER-BUILDER DECLARATION
CommiON
.�0 0 I hereby maso ,(Seth that 11. exempt from Inc Contorts Co :Any cense Law for the BUILDING
p p following reason,Permit
t ]construct.
Bulinus and Professions Cole:Any city Or county
K$vs which requires a permit tomiuims the
nim[improve.demolish,or moth any statement`-< prion.its issmnce,also myuires the applieam for such Permit axignedstammem .
m that be,is licensedpursuanttomepmvisiomofdWContractor'slimasclaw(Cnaptcr9 Sq.Ft. Floor Area Valuation
xFp (commencing with Section 7")of Division S of,h Business and Proressions Code)or
e. $ that he is exempt tnertfrom and that basis for the alleged exemption.Any violation of
Section 703 1.5 by any applicant for a permit subjecta the applicant to a civil penalty of 3-Mil" Occupancy Type
not mom than five hundred dollars(5500).
1,as owner of the property,or my employees with wages as dlcir sole combination,
will do use work and the sracture is not intended or offend for sale(Sec.7044,Business
Cork: -
and Professions Co :The Chromium's License as e Law donot apply to an owner of Required Inspections
pmpeny who builds or improns thereon,and who doessuch workhimself or drmugh his
n employees,provided that uch improvements are not intended or offered far sale.It,
however.the building or improvement is cold within oto you of completion,one owner.
builder will base the human of proving that M did not Wild or imprs for puryon of
sada.).
0 1,as Owner of the property,am exclusively contracting with licensed conb¢mrs to
consume,the pmjem(Sec.7044.Business and Professions Code:)The COnmacmrs Li.
cents Low d.not apply to In pWa,pf property he Wilda m imp Msexi thereon. it
In contracts for such projects with acontrutnist licensed pursuant to the Contractor's
u rase Law.
1 a
em In under Sec. .B&PC for Nis mason
l t
Own
WORKER'S COMPENS' (DECLARA�T�I''ON"",�fs
1 hereby aRrm an&,penalty of pe arc of Bre fOlIA-7 y—tions:
I bas and will maintain a Certificate of Canute to self.insure for Worke's Compen-
snit.,u provided for by Section 51W of the Labor Code,for the pesfomupce of the
work for which this permit is issued.
Fj I Ns and will maintain Worker's Compensation Insurance,as seyuired by Section
5700 of me Labor Code,for th performance of Bre work for Which this permit is issued.
My Worker's Compensation Insurmce carrier and Policy number am:
Cartier: Policy No.;
CERTIFICATE OF EKEM PFION FROM WORKERS'
COMPENSATION INSURANCE
mads senior need he,W camplmed if the r .it is Ran.hundmddallars(SIM)
to lexa)
I examfy ma,i the parromun m of me Work for which oris permit is issued.l shall no,
employanyR ynrih Sasomomssub' t to the wimboo Campensadon
laws of Cal' to -
Appli n
NOT
APPLICANT:If,aRcr making his Cc t c of Exemption,you should
bmo a eject m the Worker's Ccon,mation pro rich, f the IaMm Code,you must
.,O forthwith comply with such provisions or Nis per it sh Wdcemed revoked.
Z� CONSTRUCTION LENDING AGENCY
1-. I hereby affirm that theme is a construction lending agency for the ierformanm of
[( r7 the work for which this permit is issued(Sm.5097,Civ.C.)
W Q (vender's Name
1 lender's Address
U O 1 certify that I hs rtad Brix application and sure than IW above information is
W F correct.I agree to comply wit all city and county ordinances and stale laws mlatingto
0 U building construction,and hereby whorive mpremntxtives Of this city memmrupom But
r W shave-memipned p.,,,y for inspection purposes.
f—'C (Ws,)agrte to save.indemnify and keep harmlpas th City of Cupertino against
rat liabili,iea,judgments.eosts and expenses which may in any way seems,againasaid City x
U Z in mosayuemc or the granting of for permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
REGULATIONS.
Re-roofs
Signature of ApplicanVConvm,or D m
HAZARDOUS MA 1 LS DISCLOSURE Type of Roof
Will me applicant ser future buil ng cupamsomeorhandleharardousmamdal
as defncd by,he Cupenino Municipal Chapter 9.12,and the Health and Safety -
CWe,Ss,mion25552(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yas
Will the applicant or fwum building occupant esu equipment or devicca whim If a roof is installed without first obtaining an inspection,I agree to remove
i,hvardnus air contaminants as defined by the Bay Area Air Quality Management . all new materials for Inspection.
iuriet7
❑Yea IANu
I have mail he beraidsws mistrials myuirements under Chapter 6.95 of the Califor.
ria Health&Safny Cada.Sections 25505,25555 mJ25554.I understand that lith Wilding
does no,currently has a mnanc that it is my maponsihility an nntity the eawpont of me
entswnipn thou k puprmstl seance Or certificamtr(kp cy,� - Signature of Applicant Date
caner or..Ih.n cd agent Dam
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. 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.
Person/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 (reverse side).
Property Owner's Signature:\���/` Date:
Job Address: S�
(dJ`/y OftR/�eNe. — —" rvermit# D�D�t9 n
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
01M
City of Cupertino Building Department
CITY OF 10300 Torre Avenues
C O P E kT I N 0 Phone: (408) 77-3pM
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
Printad on Recycled Paper
CITY OF CUPERTINO
FURNACE/AC
UPEIIiTINO PERMIT APPLICATION FORM
41 APN # S'- 7— �) Date:
Building Address:
0�2 C�Fi/i/.f0/1/ Cis/ e5�a7FIt",o I ?s—Ol�/—
Owner's Name: �DN,o � ! �c"�o � Pho
/27 D N�/i4- uh� A✓
Contractor: Phone: License #:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech
Job Description
Residential ❑ Commercial ❑
For Residential Inst ations:
Attic ❑ I" floor M 2nd floor❑
Adhere to min set back requirement❑
7For Commercial Installations:
eplacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation PlanningApproval Re uired ❑
Cost of Project: Type of Construction: Occupancy group:
Strapped ❑ On Platform ❑ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement El
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Ener BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elee Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License UILDING
7 2 3�