08060070 (2) CITY OF CUPERTINOa *roes� •x „»k,Y
BUILDING-DIVISION PERMIT �.cC01�ITRAC^roTOI2�INi`�f}RNI.ATION :
PERMr NO
BURTgcbT%"6AKLEAF PL HELMHOLD DENNIS L AND MONA 08060070
OWNER'S NAME: PERNM ISSUE DATE
HELMHOLD DENNIS L AND MONA L 10058 OAKLEAF PL - 06/09/2008
NE: SANITARY NO. CONTR01.NO.
ARCHITEC iENGINEER: BUILDING PERMrr INFO
BLDG ELECT' PLUMB MECH
l� O O D
u o p LICENSED CONTRACTOR'S DECLARATION ,
u gI hereby alarm that 1 am licensed under provisions of Chapmr Y(commencing Job Description
with Section7000)OfDiAsl 3 cribs Businm and Pon[ecsieesCode,andmyliecoscis RE-RF WDSHKS TO COMP SHNGLSASPHLT. APPLY PRES TL
in full farce and strut
= LieenacClass Lc.g ASPHLT SHNGLSCLS A 40SQ
=rC Dam Contractor
e uuyss ARCH171ECfS DECLARATION
y s< I understand my plans Mali be used u Public meeNs
ayu
b G H Lictmsed Prefcssioml
i5 OWNER-BUILDER DECLARATION
�2 1 hereby affirm Nal I am exempt from Ne Contractors License Law for the
E p o following moon.(Section 7031.5,Business and protections Code:Any city of county
which requires a pemiit to csmsuucL alum.improve.demolish,or repair any su etme
_2 y prior to its issuance.also mquira rhe applicant for such Permit to rile a signed summcm
E O
that he is licensed pursuant to the provisions of Ne Contractors Litems Law(Chapter 9 Sq.Ft. Floor Area Valuation
$ (commencing with section 70DO)of Division 3ofthe Business and Professions Code)tic $8800
y .. Net he is exempt therefrom and the basis for the alleged exemption.Any violation of
section 7031.5 by arty applicant for a Permit subjecu the applicanno a civil penalty ofNumber Occas
not mom than fin hundred dollars(Ss09). 32618061 Occupancy Type
❑L,u awnm of the pmperty,m my employees with wage u emir mle compewdon,
will do dos work,and the ammture u notimmtided oroffaed fertile(Som.7W,Business
and Professions Cede:The Contraction's License Law does rot apply to an owner of Required Inspections
property who bui Ids a Emissions dmrmn,and wha does such work himsel f or through his
awn employees.poo ded our inch impronmenu are not intended moRcrtd fonts U.
howenr,the building or impronmarm is cold within om year of completion,the owner-
builder N0 Nn dm burden of proving that he did rot Wild or impmn for purpose of
axle.).
�K1:u own.of the property,am exelusinly convening with licenced conoacu rs ni
coestwn Ne project(Sec 7Wd,Businm and Pretei hour,Cade:)The Corm icmrs Li-
cense law dura not apply b an owner of i mpeny who builds or improws Neuron,and,
who contracts for such projeeb with a comoscu(s)licensed punt usillas Convenors
L law.
C3em sac I mor St .8 a P for this..on
Owne,
WORKEEts COMPENSATION DECI.ARAT N
PF 1 hereby aff im under Mostly of pejury arm of the following declarations,
❑1 han and will reainWn a Ce+tifiom ofC..at mrelf inm c for Wurkeh Com,.-
Issues.u pmvided for by section 3700 of the labor Code.for the Performance of the
wart for which this Permit is issued.
❑I bun and will maintain Workers Compensation Insurance,u required by section -
MY W-11 a Labor Cade fes I.peRarmmeer and
emrk for which this permit u l.ad
My Workers Compensation bssurara esrtiar and Policy number arc:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
C@issoctlon recd wl he completed if Ne permit Is furrow hundred dollars(SIW)
or Ice)
I anify mol in the perfoononce of Ne}' k for hi this
emit b issued.I shell not
employs ype any manncrxo ario 1, Z; J-ct wiM Waft..Comperiummo
Laws of f. /
NOMCFl
NOTICE TO A CANT:ILfatmr looting this Certifies he o emption,you should
become subject b NS Work.',Compensation provuloua of the Labor Cod,you muss
.,z forthwith eamp1Y with such pmvitioru ar this permit me]be doomed raked,
Z O CONSTRUCTION LENDING AGENCY
04 affirm thatI herby that there it.ea committed.lendingagecy for the perforearr f
Ci� tiro work for which Nis permit is i.ued(Sex.3097,Civ.C.)
a Q Lenders Name
D z Lenders Address
U O I cuufy Nal I Mn rood this application and sum the the soon information is
F correct.l agree to comply with all city and mumy or linenen and sum laws relating to
. building compunction,and hereby"theatre mpromifil nS of Nie city to cnw upon 0th
t�U
W abovcmenuonedgmems,porc costs
for ie pcNes whichpurrims
LL (We)agree to an,indemnify,and Jump hared,.Is City of Cupertino against
In liebilities,Judgmcnu,teats and expenses which may in ony way accrue vg last.id City
U z mc nuc of the granting of this rmir.
AP off UNDERSTANDS iP 'LL MPLY WITH' LA L ON-POINT Issued by: Dale
UR EGULA ONS/
e-roofs
Signature a App rnoyJ�Con Da
/JIAZAi OUS MATERIALS DISCWSU Type of Roof
Will the applicant or future Wilding ecmpmt store a Ie hauNaes muaiad
u defined by Ne Cupertino Municipal Code,Chapter 9.17,and the Hohh and Safety
Code,section 25573(x)?
❑yes CIN. All roofs shall be inspected prior to any roofing material being installed.
Will the applicam m future building omrpanr use equipment or de,ias which If a roof is installed without first obtaining an inspection,I agree to remove
.moil havardnus sic conuminents as defrmd by the Bay Area Air Quality Management
❑Yes 1-new materials For inspection.
Oisuict7
�.No n/ ^
Ihonroad Code Sections
mamrialsr,quiremenls der cep 6.9 of
ni HLUN&$arctyCode,Smuau25505.2$577and 4.1 cid d K •Wildin G y
nOle n
an m.M4 that 11la yrot htll bn I'y c .,of
kq.ten<ru i con met r u 'flu/
Signature of Applicant e
owner act wad agent All roof coverings to be Class'%Q”or better
CITY OF CUPERTINO
• 2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32618061 . 00
DATE ISSUED. . . . . . '. : 06/09/2008"
RECEIPT #. . . . . . . . . : BS000005051
REFERENCE ID # . . . : 08060070
SITE ADDRESS . . . . . : 10058 OAKLEAF PL
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : HELMHOLD DENNIS L AND MONA L
ADDRESS 10058 OAKLEAF PL
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1107
RECEIVED FROM . . . . : MONA L HELMHOLD
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY HELMHOLD DENNIS L AND MONA L
ADDRESS . . . . . . . . . . : 10058 OAKLEAF PL
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1107
TELEPHONE . . . . . . . . :
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
-------- ---------- ------ ---------- - ---------- ---------- ----------
1BSEISMICR VALUATION 8, 800 . 00 - 0:: 90 0 . 00 0 . 90 0 . 00
1REROOFRES SQ FEET 40 . 00 520 . 00 0 . 00 520 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 520 . 90 0 . 00 520 . 90 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 520 . 90 AMEX
---------------
TOTAL RECEIPT 520 . 90
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
1 FNo 0 0 7D
' CITY OF CUPERTINO
REROOF
CITY OF
*CUPERTINO PERMIT APPLICATION
APN # 3.2 6 / n o ( / 0 o
Building Address: d
oos 4 0 Qk I-eet F 14 c,.e_,
Owner's Name: Phone #:
vr0(_ /mho WDS-) 996-/g¢/
Contractor: Phone #:
6CU./l Fax #:
Cupertino Business License #: Contractor License #:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ .Built-Up roof
❑ Asphalt Shingles V Asphalt Shingles
a/ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other (Specify)
Number of existing coverings j ❑ Provide I.C.B.O. Report#
q� To be Removed ❑ Provide Mfgr. Installation Specs.
Job Description: k(yf rvcow- OOA S O, C,001f01t7
�41�vy Shc.c iv�Jr - Rpl°�� �Pr� ia�t� o a1 - O'wSdsB s(�ctic oS u� s e.�T-�Coo�
Rs�hal►" Shin/�/�,5•
Residential Commercial El
Green Building: Please complete relevant portion of the Confirmed with Planning Dept. if
Green Building Checklist & attach it to the there are any restrictions: ❑
application or if applicable, include in plan
set & the sheet index. / S 0 C54--
Valuation:
®O
• I Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy:
Z
Signature
' CITY OF CUPERTINO
k= REROOF
CITY OF
CUPERTINO FEE SCHEDULE
Number of Fee ID Fee Description Fee Permit Type
Squares Group
1REROOFCOM Re-roof Commercial B 1COMMLROOF
1BSEISMICO Seismic Commercial B
1REROOFRES Re-roof Residential B 1SFDWLR00F
/ 1BSEISMICRE Seismic Residential B
1RER00FMRES Re-roofMulti-FamilyB 1MFDWLROOF
• 1BSEISMICRE Seismic Residential B
1BUSLIC Business License B
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
• Telephone: (408)777-3228
Fax: (408)777-3333
Building Department
Subject: Re-roofing policy for the City of Cupertino
1. Prior to permit issuance,you must agree to comply with 1997 UBC Standards
and manufacturers specifications on re-roofing.
2. New roof coverings shall not be applied without first obtaining all inspection
and written approval from the building inspector. A final inspection and
approval shall be obtained from the building inspector when the re-roofing
is completed.
3. All roofs shall be inspected prior to any roofing installation.
4. To receive a final sign off from the City, the following steps are
required:
1) Pre-inspection and/or tear off approval.
2) In-progress inspection approval.
3) Final inspection approval.
a) Spark arrester installation.
• 5. If plywood is installed, a plywood nail inspection is required.
6. Any roofing which is applied without first obtaining an inspection,
will require the removal of all new material down to the sheathing,
so a proper City inspection can be performed.
7. NOTE: If you call for a plywood nail inspection and the job is not ready,
you will be charged a re-inspection fee of$176.18. The re-inspection fee must
be paid before another inspection can be scheduled
IMPORTANT:
1. Flat roofs must have a minimum of 1/4" per foot slope and demonstrate
that there is no ponding.
2. An I.C.B.O. report is required to be on the job site at the time on inspection.
I understand and will comply with the above stated policy on re-roofing.
Homeowner's Name: I�DY10� JJl�ce110 /b/__O(
Job Site Address: LO o ss Q�c -ea F &AC,,O—
T
Roofing Company Name: // 11JJ
Applicant's Signature: r DatzZ-
• Greg Casteel
Building Official
Revised 11/2/04
Green Building Plan Check
Index of Green Building Points/Categories
A. Category Example of an Index or Table of Green Plan Sheet or Page Points
Building Points Categories that must be
shown and referenced on the Project
Plans See below
B. Site 9. Install H.E. Irrigation, (details/spec)' L-1 2 points
11. Permeable Paving, Note L-1 2 points
C. Foundation 1. Use 15 % Flyash Concrete, (note) S-1 5 points
D. Structural 3. Uses Wood I-Joist, (See Spec.) S-2 2 points
5. Use Truss with heels, (detail) S-2 2 points
6. B. OSB Sheathing, detail S-2 2 points
E. Ext. Finish 1. Composite Decking, (Note/Spec.) A-3 2 points
4. B. Fiber Cement Siding, (Note/Spec, A-4 2 points
F. Plumbing 1. Insulate all H.W. pipes, (Note/Spec.) P-1 2 points
5. Tankless W.H., (Note/Spec.) A-2 2 points
11. A 2500 Gal. Tank, (Note/Spec L-1 10 points
G. Electrical 4. E. Ceiling Fans, (Note/Spec.) A-3 4 points
H. Appliances 1. Energy Star Dishwasher, (Note/Spec.) A-3 1 point
3. Energy Star Refrigerator, (Note/Spec. A-3 1oint
P. Other 1. List Green Features on Plans A-1 1 point
TOTAL POINTS 40 points
•
•
Plan Review Process Work Book Page-12-Revised 3/25/08
Green Points Rating System for Remodeling Projects
• Due to the diversity of remodeling project types,assigning a'total points'value to a project to be considered environmentally friendly is
not feasible.However,25 measures have been highlighted to signify that every effort should be made to incorporate them into your
projects. These items have been chosen based upon their impact on the environment and the health of the home in coordination with
ease of implementation and relative low cost. These measures can be used as a starting point for'greening'your project.
.Srte
1.Recycle Job Site Construction&Demolition Waste
65%=1 point;75%= 2 points;80%=4 points up to 4 Resource pts 0
2.Salvage Reusable Building Materials 4 Resource pts y=yes 0
3.Remodel for Mixed Use,Adaptive Reuse,and
Historic Preservation 4 Resource pts y--yes 0
4.Protect Native Soil 2 Resource pts y--yes 0
5.Minimize Disruption of Existing Plants&Trees 1 Resource pt Y--yes 0
6.Implement Construction Site Stormwater Practices 2 Resource pts y=yes 0
7.Protect Water Quality with Landscape Design 2 Resource pts y=yes 0
8.Design Resource-Efficient Landscapes and Gardens 4 Resource pts y=yes 0
9.Reuse Materials/Use Recycled Content Materials
for Landscape Areas 2 Resource pts y=yes 0
10.Install High-Efficiency Irrigation Systems 2 Resource pts y--yes 0
11.Provide for On-Site Water Catchment/Retention 2 Resource pts y=yes 0
MEWB.Foundation
• 1.Incorporate Recycled Flyash in Concrete
25%Recycled Flyash=2 points;Add 1 point for every 10%
increase of Flyash,up to 5 points up to 5 Resource pts 0
2.Use Recycled Content Aggregate 2 Resource pts y=yes p
3.Insulate Foundation/Slab before backfill 3 Energy pts y=yes _ 0
1 1 1
C.Structural Frame
1.Substitute Solid Sawn Lumber with Engineered Lumber_ 3 Resource pts y=yes 0
2.Use FSC Certified Wood for framing
(For every 10%of FSC lumber used=2 points,up to 10) up to 10 Resource pts. 0
3.Use Wood kJoists for Floors and Ceilings 2 Resource pts y=yes 0
4.Use Web Floor Trusses 2 Resource pts Y=yes 0
5.Design Energy Heels on Trusses 6'or more 2 Energy pts y=yes 0
6.Use Finger-Jointed Studs for Vertical Applications 2 Resource pts y--yes 0
7.Use Engineered Studs for Vertical Applications 2 Resource pts y=yes 0
8.Use Recycled Content Steel Studs for Interior Framing 2 Resource pts y=yes 0
9.Use Structural Insulated Panels(SIPS)
a.Floors 3 Energy pts y=yes 0
b.Wall 3 Ener is
9Y P )'=Yes D
c.Roof
3 Energy pts y=yes 0
10.Apply Advanced Framing Techniques 4 Resource pis y=yes 0
11.Use Reclaimed Lumber for Non Structural Applications 3 Resource pts y=yes 0
Of Use 058
• a.Subfloors 1 Resource pt y=yes p
b.Sheathing
_ 1 Resource pt y=yes p
1 ! 1
D.Extenor inis
!1 Use Sustainable Decking Materials { •
a.Recycled content ( 3,Resource pts y=yes 0
b.FSC Certified Wood 3 Resource pts y--yes 0
2.Use Treated Wood That Does Not Contain Chromiurn/Arsenic 1 IAQMealth pt . y--yes 0
3.Install House Wrap under Siding` _--� 1 IAQ/Health pt y=yes 0 p
4.Use Fiber-Cement Siding Materials 1 Resource pt y=yes D
1 1 1
E.Plumbing
1-Install Water Heater Jacket 1 Energy pt y=yes 0
2.Insulate Hot and Cold Water Pipes 2 Energy pts y=yes 0
3.Retrofit all Faucets and Showerheads with Flow Reducers
a.Faucets(1 point each,up to 2 points) Up to 2 Resource pts. 0
b.Showerheads(1 point each,up to 2 points) Up to 2 Resource pts. 0
4.Replace Toilesl with Ultra-Low Flush Toilets
(1 point each,up to 3 points) _ Up to 3 Resource pts. 0
5.Install Chlorine Filler on Showerhead 1 IAQ/Health pt y--yes 0
6.Convert Gas to Tankless Water Heater 4 Energy pts y=yes 0
7.Install Water Filtration Units at Faucets
(2 points each,up to 4 points) Up to 4 IAQ/Health pts. 0
B.install On-Demand Hot Water Circulation Pump 4 Resource pts y=yes 0
__
r- uecrncar
F.Install Compact Fluorescent Light Bulbs(CFLs)
(6 bulbs=2 points,10 bulbs=3 points,12 bulbs=4 points) 1 Up to 4 Energy pts. D •
2.Install IC-AT Recessed Fixtures with CFLs(1 point each,up to
5 points) Up to 5 Energy pts. 0
3.Install Lighting Controls(1 point per fixture,up to 4 points) Up to 4 Energy pts. 0
4.Install High Efficiency Ceiling Fans with CFLs
(1 point each,up to 4 points) Up to 4 Energy pts. 0
1 1 1
G.Appliances
FInstall Energy Star Dishwasher 1 Energy pt y=yes 0
2.Install Washing Machine with Water and Energy
(Conservation Features 1 Energy pt y=yes 0
13.Install Energy Star Refrigerator 1 Energy pt y=yes 0
[.Install Built-In Recycling Center _ _ 3 Resource pis Y--Yes 0
H.Insulation
1.Upgrade Insulation to Exceed Title 24 Requirements
a.Walls 2 Energy pts y=yes 0
b.Ceilings 2 Energy pts Y_-Yes 0
2.Install Floor Insulation war Crawl Space 4 Energy pts Y--yes 0
3.Install Recycled-Content,Fiberglass Insulation with 1
No Added Formaldehyde i 3 IAQ/Health pts y=yes 0
4.Use Advanced Infiltration Reduction Practices 2 Energy pts Y_-Yes 0
5.Use Cellulose Insulation
a.Walls 4 Resource pts y=yes0 •
b.Ceilings 4 Resource pts y=yes 0
6.Alternative Insulation Products(Cotton,spray-foam)
a.Walls 4 Resource pts y=yes 0
D.uenings 4 Resource pts y=yes 0
1 1
t.'Winaows
• t.Install Energy-Efficient Windows '.
a.Double-Paned 1 Energy pt y=yes 0
b,Low-Emissivity(Low-E) 2 Energy pis Y--yes 0
c.Low.Conductivity Frames i 2 Energy pts y=yes 0
2.1lnstall Low Heat Transmission Glazing 1 Energy of y=yes 0
1 11
J.Heating Ventilation and Air Conditioning
1.Use Dud Mastic on All Duct Joints — 2 Energy pts y=yes 0
P.Install Ductwork within Conditioned Space 3 Energy pts y=yes 0
3.Vent Range Hood to the Outside 1 IAQ/Health pt y--yes 0
4.Clean all Ducts Before Occupancy 2 IAQ/Health pts y=yes 7
0
5.Install Solar Attic Fan 2 Energy pts y=yes 0
6.Install Attic Ventilation Systems 1 Energy of y=yes 0
7.Install Whole House Fan 4 Energy pts y=yes 0
8.Install Sealed Combustion Units
a.Furnaces 3 IAQ/Health pts y=yes 0
b.Water Heaters 3 IAQ/Health pts y=yes 0
9.Replace Wall-Mounted Electric and Gas Heaters with
Through-the-Wall Heat Pumps 3 Energy pts y=yes 0
10.Install 13 SEEM 1 EER or higher AC with a TXV 3 Energy pts y=yes 0
11.Install AC with Non-HCFC Refrigerants 2 Resource pts
y=yes 0
12.Install 90%Annual Fuel Utilization Efficiency(AFUE)Furnace 2 Energy pts y=yes 0
• 13.Retrofit Wood Burning Fireplaces
a.Install EPA certified wood stoves/inserts 1 IAQ/Health pt y=yes 0
b. Install/Replace Dampers 1 Energy pt y=yes 0
c.Install Airtight Doors 1 Energy pt y=yes 0
14.Install Zoned,Hydronic Radiant Heating 3 Energy pts y=yes 0
15,Install High Efficiency Filter 4 IAQ/Health pis y=yes 0
16.Install Heat Recovery Ventilation Unit(HRV) 5 IAQ/Health pis y=yes 0
17.Install Separate Garage Exhaust Fan 3 IAQ/Health pts y--yes 0
1 1 1
K.Renewable Energy and Roofing
1.Pre-Plumb for Solar Water Heating 4 Energy p1s y=yes 0
2.Install Solar Water Heating System 10 Energy pts y=yes 0
3.Pre-Wire for Future Photovoltaic(PV)Installation 4 Energy pts Y--yes 0
4.Install Photovoltaic(PV)System
(1.2 kw=6 points,2.4 kw=12 points,3.6 kw=18 points) _ Up to 1 B Energy pts 0
i6.Seled Safe and Durable Roofing Materials 1 Resource pt y=yes 0
7 Install Radiant Barrier v 3 Energy pts y=yes p
1 1
L.Natural Heating and Cooling
1.Incorporate Passive Solar Heating 5 Energy pts y=Yes 0
2.Install Overhangs or Awnings over South Facing Windows 3 Energy pts y=yes p
3.Plant Deciduous Trees on the West and South Sides 3 Energy pts y=yes p
• I 1 1
RAPUT Resources Energy [AD/Health i
M.Indoor Air Qua ity and Finishes
1.7 se 116;AD VOC Paint_ _ _ _ 1 IAQMealth pts y=yes 0 •
2.Use Low VOCI Water-Based Wood Finishes 2 IAQMealth pts y=yes 0
rr3.Use Low/No VOC Adhesives 3 IAQMea th pts y=yes 0
I�� - d----- - - ----- - -
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQMealth pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAO/Hsalth pts y=yes 0
Seal all Exposed Particleboard or MDF _ _-�, 41AQ/Health pts y--yes 0
6.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Tim 1 Resource pts y=yes 0
10.Install Whole House Vacuum System 3 IAO/Health pts y--yes 0
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring B Resource pts y=yes 0
2.Use-Rapidly Renawabla Floodng Materials _ _ 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y--yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
{ { 1
Total Points 1 1401 1301 57 •
Total Points Project Received: 0 0 0
GdaWprogslgreenbuil3ngguidellneslremodelerslgreenpoin!stnal212.04proteMed.xk
v� 0 0-7 c)
r
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)
ContractorAddress/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 a correct. I have read-and understand the
Owner-Builder Informati n (reverse side).
Property Owner's Signature: Da
/GO�+c� Gt,,�f�
Job Address: -- Per 't#
1�. s'zY
Any changes to the reformation provided on this form shall submitted to the City of Cupertino Build
• Department.
CITY OF City of Cupertino Building Departmeno
10300 Torre Avenue
CU P E 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
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
WUPERTINO
Building De artment
JOBDDRESS: PERMIT #
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OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: F #
I am not using any subcontractors: Ou ll (��
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum / Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
,
Tile
er/Contractor Signature ale