05030095 (4) CITY OF CUPERTINOsw �-^• ' �''^�t
BUILDING DIVISION pE T CONTRACT0AANF0 „ Tl�la
s A%�xiV Z7m.-'r a: S, ?„mss*.--Ab uYh�xe
BUILDING ADDRESS: PEAM "NO05030095 NO05O3OO95
OWNER'S NAME: PERMIT LOVE DATE
NB SANITARY O. C OLNO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION
to F I heeby afriem that 1 W licensed under provisions of Chapter 9(commencing ®® Job�gDeseTtfl�s}G1(�
U ucf with Sedan RK10)af Disision7ol Ne Husinessand Professions Code.and my license is �'® B /� � G r4
6
iin ren come a,td erre. KITCHEN REMODEL ��iCs■IYf/"��C R■16451
License Clm tic.a
F❑ Dem Cminu or
',f' ARCHfTECI-S DECLARATION
< qq J/2
I undersand my plans shall he used as public rtxurdsu �% A°i �J �QO[5
&,t; Licensed Pon(ummnal
3
OWNER-BUILDER DE Ce CeATme ON
f I hereby.mem than 1 am exempt from de GaIONrS License Law fns the
G o following mason.(Section?031.5,Business and Profecdons Code:Any city or county IN
B which mquims a permit to construct alar,improve,dcmalish.or repair any structureiy prim he ler issuance.atm requires applical for such permit to rile a signed suamw
< 1hatW is iiccnad Purmanua Nc provisions of Nc Contnnor's lJana law(ChapCer9 Sq.Ft.Floor Area Valuation
�$ (cmnmencingwiNScNon?B00)of M; ion3aftMBusie and Pmressima CM)w
_ dat be u exempt therefrea and the basis fsr the allegcd exemption.Any violation of
Section 7071.5 by arty appliont for a permit sabjau the applicant to a civil penalty of 3]l�B�E3'bm47ePO 0 Occupancy
not more Nan Ove hundred dollar(sem} P y Type
❑1,as owner of the property,ar my employees;with wages as their sole compena0on,
will do the work.and the me.u notaetWW or offered forsak,(Sec.?W4.Business
and Rafessions Code:The Commm es Liame,Law does not apply to an owner of Required Inspections
property who buildserrimproves h mon,and who dorssuch workhimselferr through his
own employees,provided that such impmvemena art not intended oranead fmsals.If.
however,the building or improvement is mid within one year of eemplmon.the owmr.
Wilder will have the border of proving that M did not Wild or improve for purpose of
:i..
.as owner of the property,am eaclounclY contracting with Hansed comernama a
wn the ptayem(Sec.]Ossa.Business aM Professions Code:)The Conustors U.
a Ism dors not apply a an owner of property who Wilds or;mprows dmaon,and
contracts fm such projects with.c.=mr(s)licensed porswm to the Conteaelors
nse Ism.
am exempt under Sm. B di P C for Niser ! s4— 2 Dass 3-4-oS
ORKER'S COMPENSATION DECLARATION
1 hereby amrm under penally of perjury Me of the following decla rations:
ha w aM will mairam•Cen;Ocate ofoonsem anself-ita re for workers Campco,
as provided for by Section 37M of the labor,Cod.,for Ne performance of the
work for which this permit is issued.
❑1 hast ad will maintain Worker's Compensation Insurance,as required by Schon
37m of Ne Labor Code.Ire Ne pcdmmuice of the work for which this permit a issued.
My Wa lms.Conjuration Insurance cans.and Policy number art:
Cartier. Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This Mi need nothe emmpletrd if the permit is forone hundred do0=(elm)
nr les.)
I cerdfv Nal in 1W performance or the.,it for which this Permit is issued,I Mall nu
employ any person in any mannerm a m bccorye subject to the Workess'Compensation
LiWsar Califon;a.WWe —
APPiicant ICA .s.r.-+v
IjOTICE TO ct to me A : r after m ;ng n p Ceni0coa of Exemption,you should
become subject to it Warn pro Compensation provisions err the tabor Code,you mtut
Oforthwith comply with such provisions w Nu permit shall ho stamN rcvnk.d.
i
CONSTRUCTION LENDING AGENCY
t 1 hereby amren the,edea is a construction lending agency for the performance of
' the work fur which Nu permit it;issued(Sm.3W7.Civ.C.)
1 0 Landers plan
iZ Lender's Address
I 1 certify that 1 hast mast this appl;estion and aura the the.hove mrome.u.is
cowcc Jaguar in comply with all city and county on insncea ad some laws mating to
j building construction.and hereby authodm mpmmmliwS of Na city a enter upon tad
In .bow-menudgm property for iexpeNon puquvs _
G (Wc).gess to ase,indemnify ad kap barmlea the City of Cupertino agwmt
In lubinconcesuence, rthecostsang expenses which may in aY wyacme against said Ciry
Iz APPLI ANT NDERaling of this permit
'-� APPLICANT UNDERSTA
SOURCE ULATION
DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
TgcR
lnr i - s'""� 3—4I Re-roofs
Sigholum of AionuConuamar Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tad appliant m future bNltling arupat core or haltlk harudow maaeial
M declined by ft Cupertino Municipal Code.Chapter 9.12,and she Health and Safety
Calc,Section 25572(.)7
[:]Y. IgNo All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant.equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
C haardnes air aonaminsnns as refined by N.Bay Area Air Quality Management all new materials for inspection.
aim?
❑Yes 1p�u
1 hove read the hvarecus materials requirements under Chapter 6.95 of the Califor-
nuHeal”SafmyCotic.Scctimts25505.25533 wM 25534.I UMrrmmN the it the Wilding
does not currently how a enma Nat it u my rcryme ihility to..or,ft umupat or N.
ecyuitc�Cnts h Tl prima;.ram..arac.edB.,e 3-err'e-P .7 Signature of Applicant Date
I N
Owner m,n oriredagent G oD,tr I 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
n,
F-0-&K265-2-5- 04 - 94/ 962 85 Gat> P
Jo1e CA- S -2.0 32
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
S 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: 12-63 N Pkk 17-7 'DR Permit# O O 9 S/
GopozT/N0, C/- a's-6 /�4
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
•
City of Cupertino Building Department
CITY OF 10300 Torre Avenu
C O P E kT I A I O Phone: (408)777-3
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 compensatione
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.
professing to be contractors is to secure n owner-builder
A frequent practice of unlicensed persons
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 Pape,
CITY OF CUPERTA
ITY OF PERMIT APPLICATION FORM
CUPEII;TINO
APN# 3 I G — 3 S — 01 j Date: h 490J, 2-00S
Build* Address: Mailing Address (if different from building address):
I9-V63 ML;;,-kRITT 1K GUPekpoo C/�- 95-0i
Owner's Name: Phone#:
SAT-)" EfUin1G TPuST L,,/2-/O) - D� _�S3 —C)
Contractor: License #:
l
Contact, Phone: Cupertino Business License#:
{SI N SI A-MA) Fax: /- c4q 253oS9�'
Building Permit Info:
Bldg Elect Plumb a Mech 12�
Job Description: kgta -P &
Residential Is CVUAkt:eri L# O,V G ih ek7A Commercial ❑ "Y7
Sq.Ft. Floor Area: $/Sq.Ft.:
)D$ S -
Cost of Project: Occupancy Group:
Type of Construction: —M Please check this box if the project is a
—"� second-storyaddition: El
Size: Standard X Large ❑ Major El
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> IOOK 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
BCONSTAXB 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
1 of ����
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' �SID�sNIIAL OV-4—E-A-S-11 P�ROJEC—T COE;Tz
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. CUPEkTINO s ` 4_
Assessor's Parcel Number: �J 5 - C l )
Name ofowner. S VI LC wl/111 G- TR 01 T
Project address. 6 3 EP P I I 7-(fy c) Cwt
Contact person. V C P N S t+M i Phone. 402 - Z�J0 5 :S-
Fax.
Net square footage of lot. /6 oo
Existin g Proposed
Square footage: First floor:
Second floor: I illi f ���� fit II
Garage:
TOTAL:
Are there at least two 10 foot by 20 foot clear spaces inside the garage? N
• Is privacy protection planting required for the project? Y
On what floor(s) is work being done? p
Brief description of work. /� . C (i ti L ti G�-t.rZ
Ep < -S cn /Z � N �t L,U
Ike h
�c
Code editi s: 2001 CBC (Y -N)2001 CFC (Y- N)2001 CMC (Y-N)
2001 CPC (Y-N)2001 NEC (Y -N) APPROVED
IN ACCORDANCE WITH THE CRY tF i
CUPERTINO CODES AND ORDIWJd(;F$
Effective 11/1/02 DATE OJ —
i
SIG
(� ✓1�2 1�Q7
/Q0 w ^ This set c, y ry, ur• MUST be
1 Kcpt on t, aro+1 v, unlawhll to
W ✓ h��� . 12ke any r.. ua a ,uF,n:iata on same
.f.IhoU1 ': iii ^•.is=^nr• trom dieOUndine
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' no.
C� Z��7tiC C • �1v 1 l yar ane. cpgdlicatimts
RECEIVE U U 'ALL cs er,n.l m to o0 an
,.:-tat of the violation of any provism of
MAR20U5 _.;, nr nnnrs or 3.&,law
Plan Review Process Work Book Page-8-Revised 4/28/04
home Design • draftplan1 • Thursday, March 03, 2005
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APPROvF-® OF
IN ACCORDANCE wRH THE Offy
OUPERTINO COUES AND ORD mce3
DATE
SIGNED
Thte Set C; I`s .int .VOOI' n"n, MUST tm
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—pt 00 ti^ 10h 8t 111 lines ,,no It t= unlawfW to ,
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lake any cn„nut
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:houl ' m:, 'e ion from he
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Slc': `- 9t 'hl.- PIAn And S9efAft90f18
-'RLL t:Ul Je t"� '.o pd,,ttii of to no an
,val ot the vlolat,on of any aovlsans d
n,P'00 id Stnto Law
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