03110125 (2) CITY OF CUPEWI'INO •, ' ' v im` 'r 4* �+'¢ ' " ''"r`--" -
BUILDINGDIVISIONPTRMIT WNIRACTORINFQRMA1,WN:,,'' -
Bu1LDINGADDRESS: DARRELL KETTNER PERMITNG)3110125
190 LYNTON CT
OWNER'S NAME: PERMIT LSSUE DATE
RRELL KETTNER 11/20/2003
NE: SANITARY N0, CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
O O O O
IOp LICENSED CONTRACTORS
OECons of CON Job Description
I Wmny affirm shat l am licensed under and
Proton of Crede, 9(commencing P
with Semion 7(Nllpo(Division 3 of the Business and Professldna Code.and my license is
in roll force arrear. NEW GAS LINE SWITCHqz License lms Lic.a
Dam Contractor FI
NA
LE®
ARCHITECTS DECLARATION ��3g
f U Iunderstandmyplans shallWused apublicrecords C 4 2OOJ
Ltt; Licensed Profcatonalj vs DEC
3 OWNER-BUILDER DECLARATION
<y 1 hereby affirm that 1 am exempt foam the Contractors License Law for the BUILDING
O D following reason.(Second 71131.5,Bvslneae and Professions Codec: ■Y■:Any city or county
C
2 8� which mquire5 a permit m c.nsudc,.arm,,Improve,demNish,nr repair any swnuoa $300
d�< Poono its iauonce,also requires the applicant rorsuch Permit m late signed Statement
�th Nat he is licensed pursuant in the provision,of the Contractor's License Law(Chapter 9 Sq.Fl. Floor Area Valuation
(commencing with Section WWI of Division 3 of the Business and Professions Code)or.
$
that he is exempt therefrom and the basis(or the alleged exemption.Any violation of
- Section 7031.5 by any applicant for a permit ubjects Ne applicant o a civil Penalty of
not more Nen five hundred dollars($500). ¢ Occupancy Type
❑1.as,owner of the propeny,or my employees with wages as their sole compensation,
will do the work,and Ne swnum is not intended or offered for sale(Sec.7044,Business
and Professions Code:That COm uctOh License Law docs not apply to an owner of Required Inspections
property who builds or improves thercon,and who does Such work himselforNmugh his -
own employees,provided Net such improvements are not intended oroRered for isle.If.
however.the building or improvement is sold within one year of completion,Ne owner
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
❑ h as owner of the pmpeny,em exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li. -,
cerise Law does not apply to an owner of property who Wilds or but prows thereon,and
who contracts for such projects with a conuantor(s)licensed pursuant to the Camnctar's -
Liceme
❑lama underSa. .B 6 P C for Nis on
wner Dam
WORKER'S COMPENSATION DEC1wtJkgO1
Ihereby affirm under Penalty of perjury one of dielfabonding dechostioa:
I have and will maintain a Certificate of Cament m self-imam for Workers Comped.
scion,a provided for by Section 37M of the Labor Code,for the performance of Ne
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of she Labor Code.forth,performance or the work for which this Permit is Trines.
My Workers Compensation Insurance crier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ITIS section need not W completed lithe Permit B for one hundred dollars(1100)
or less.)
I ceniry that' the pc ormeuc of the work for which this Permit is issued.l shall not
employ any ma manncrmusNMrvmwtbjud the Worked Compensation
Laws o(CHif a //// yY
Applin)
NOT OAFWCANT.If,after75akfof this enificte 0r'Exemption,you Mould
Weome Subject to the Worker's Compensation previsions of Ne labor Code,you must
0 forthwith comply with Such provisions or this Permit shell W deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
1 hemhy affirm Net Vert is construction lending agency for the performance of
the work for which this permit is issued(See,3097.CN,C.)
V]Q Lumber's Name
=z Leader's AJdreas
U Q I=.try Nat I have read his application and satic that the above information la
Ig. torten.I agree to comply with all city and county ordinsues and sum laws relating in - ---
Q Wilding construction.and hereby suthorm,representatives or this city to enter upon the
W above-mentioned property for impection Purposes.
gy Wc)agree m save,indcmmfy and keep harmless the City of Cupertino against p
to 1 ride ddgm,mta,Cosa andeapcnsoa which may in any way accuc against said City
V Z neomeq eaceofthe gmaimsor Nis permit.
APPLIC NT.UNDERST 0A WILL COMPLY WITH ALL NON-POINT Issued by: Date
URC REGULA
Re-roofs
Signaturcof Applicant/Con oar Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum Wilding mcupsntsmr,or handl,lou,,) a masedal
a defined by the Cupenimo Municipal Code,Chapter 9.13,and the Health and Safety
due,Section 15s3xa)7 All roofs shall be inspected prior to an roofing material beim installed.
❑Yee No P P Y g g
Will the applicm o mwm diving dcedpamt ore equipment or devices wM,g 'If a roof is installed without first obtaining an inspection,I agree to remove
I WMWOus atr contaminants u rincJ by the Bay Area Air Quality Management all new materials for inspection.
Vicl7
❑Yca
Aa mad the haaaNnus materials requirements under Charm,G95 ofthe Califon
nix mlNg: safely Ceda Seetio�9�ukrsmM that if the Wilding
J net cu rely hoc a moam notifytMaxuparlefNetobirnmdae ,anraedp y. Signa[ureofApplicant Date
.O run aumorived agent D
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. L11- -m-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 willutilize 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.
PersorVFirm Address/City Phone Number Type of work to be
_performed
.....................................................................................................................................................................................
I declare under penalty of parevers
he above is true and correct. I have read and understand the
Owner-Builder Informatione).
Property Owner's Signah> /� / Dat -11126103
job Addrpss_ �o/Qn ✓ -1� nOUR 7' Permit# 6 U/
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
• Department.
CITY OF CUPERTINO o3 I / o I 'L S
PERMIT .APPLICATION FORM
CUPERTINO
APN # -2 Date:
7
--3 a o
Building Address:
20190 ,(
Owner's Name D }2 4n /C en Phi`168 ^ 'O�
Contract o : License#:° U eell e �'
Contact: Cupertino Business License#:
Build�i Permit Info:
BI'dgElect El /Plumb Mech E]
Job Description:
Residential ❑ omm ial
Sq.Ft. Floor Area: S/Sq.Ft.:
Cost of Project: Occupancy Grou
Type of Construction:
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler>500K to 1M Btu MECHANICAL
BBOILER4 Boiler> IM 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
BMITIGATC Comm. Housing Mit. Fee BUILDING
MW
13 er
1of3
&jmCITY OF CUPERTINO
CITY OF: PERMIT APPLICATION FORM
CU kT NO
Quantity Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family Res BUILDING
BOVERTIME 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 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 Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm 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 Mise Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
2 of 3