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04060105 (2) CITY OF CUPERTINO f! gym,"�7"j ( r°'�" y'4 BUILDING DIVISION PERT "�1�!I�"^^"""^ ^' BUILDING ADDRESS: PERMITNOID4 0 6 010 5 10465 ORANGE OWNER'S NAME: PERMIT ISSUE DATE KIMBERLY PAGE NE: SANITARY N0. CONTROL N0. ' ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH p 0 0 0 0 Y00 LICENSED CONTRACTOR'S DECLARATION lob Descrl G bu 1 thereby aM.Net I w limrtud under previsions of Chapter 9(commencing P dA Na® �Jt� �� i1rSection 70010 of Division 3 of Ne Business and Precocious Code,end my license is `W�J,brsa ��y inmOforenandeffect UPGRADE ELECT. SERVICE 5 Z License Clot Lie.# ZDan Contractor JUN 1 2004 ARCHITECT'S DECLARATION 1 understand my plans shall W mud as public memos Licensed Professional 3 OWNER-BUILDER DECLARATION BUILDING 0I I hereby affirm on I am exempt Imre the Conirns,Cc License Law for the i O O following soma.(Suction 7mrser,Business and Professions Code:Any oily or County +�$� which requires a permit w cnnswcl,circa improve,demolish,or repair any swnum Fly prior to its issuance,aim requires the applimnt for such permit to file a signed sutemcnt Gthat he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq.F[. Floor Area Valuation M $ (commencing with Section 7000)of Division 3 or the Business and Professions Code)or Wit W Is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by arty applicant for a permit subjects the applicanuo a civil penally of `.A'PIhI4`Ii3�7befO O Occupancy Type not mom Nan five hundred dollars(ML D 1,as owner ofUu property.a my emplDycea with wages as ftiTmle compensation, will do the work and theswaum isnot intended oroffered forsale(Sec.7W,Business and Professions Cade:The Convector's License law docs trot apply he an owner of Required Inspections propertywho buildsorimproves thereon,endwho doessuch work himself Orth nigh his own employees,provided that such Imprownestu eR not intended oro@red forst,If. however.the building or improvement is mid within one year of completion,the owner. builder will have the burden of proving that W did not Wild or improve for purpose of sain ❑1.as owner of the property,em exclusively connecting with licensed convmwm to convect the project(Sec.7004.Business end proftssions Code:)The Conuacmr's U. Cane law docs not apply to an Owner of property who Wilds or improves thereon,and whocomraces f im.bpmje ami tlrazlots)licensedpursuetntodu Conwctofa License Law. actout mod e. ,B&PCfmthiaaumn O n0 a KER' PENSATIONDECLARAAI 1 hereby afore under penalty of perjury one of the following decimations: 1 have and will maintain a Certificate of Consent to self-insure for Workcr'sCompen- sation,an provided for by Section 3700 of the Labor Code.for the performance of the work for which thio permit is issued. ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the labor Code,for the perfermmce of the work for which this permit is issued. My Worke's Compensation Insurance carie and Policy number am: Cartier. Policy No.: ' CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (chis section need nor W comploud if the remit is forms hundred dollars($100) less.) 1 certify Nati Jhecpp�prformyynce of the work for which this permit is issued.I shall not t employ any ninlatt3/matlm az to Wcame subjecuo the Workers'Campenation Laws of Calif APPIic t NOTIC fs, making this Certificate of Exemption,you should hero a ct t the Wo k r SAC ompensation provisions of the Labor Code,you..at Oconhwith care with such previsions or Nis Ferrell shell W tloemctl revoked. i CONSTRUCTION LENDING AGENCY [—t 4 I Wreby affirm that thcre is aconmuction lending agcttcy for the performance of ' Rt r7 the work for which this permit is issued(Sec.3097,Civ.C.) QImdur',Name z Lender's Address U O 1 certify that I have mad this application and stale that die above Inf.on.tim,is IL.H comet 1 agree to comply with all city and county ordinances and sun laws relating to DU building Conswetion,and hereby milb.dm mpreaemtows of thio city in enter upon the Lt7 shove-mentioned property for inspection purposes. a (We)agree to save,indemnify and keep hamlets the City of Cupertino against V;O�� r/I Iiabilitia,judgmcnn,coati and expenses which may in anyway accrue against mid City / e ganung of this permit.STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date NS. b`u Re-roofs vCmuracmr Date HAZARDOUS MATERIALS DISCLOSUREType of Roof Will the applicant or future Wilding occupant store or handle haysedous material defined by the Cupertino Municipal Code.Chapter 9.12,anti the Health and Safety de,Section 25532(.)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes Nowin Nc applicant tar idem building=open(use equipment or devices whichIf a roof is installed without first obtaining an inspection,I agree[o remove lt havamnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? t/ Dyna L{Nu I hero mad the homeless materialsrequiremenuunderChapurG95ofNeCalifor- nia HcalN c Code, c6on25505,25533md25534.1undcamndthatiflhc Wilding does not mind he a Nat it is my responihility m notily Um occupant of me requirements no us 'orwicuanec OracerdfcauoryxmPercy. Signature of Applicant Date W ,m m l2 Dam All roof coverings to be Class"Bt'or better a Community Development J 10300 Torre Avenue ry Telephone(408) 777-3228 CITY OF Fax(408) 777-3333 �UPEkTINO Building Department JOB ADDRESS: U �S ✓� PERMIT # OWNER'S NAME: C ,u PHONE # GENERAL CONTRACTOR: / I am not using any subcontractors: 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 l r/Contractor Signature Date 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 I ENE T! 'ua pa—formed 3. _ I will utilize unlicensed person(s) other than my immediate family to perforce'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. PeFirm Address/City Phone Number Type of work to be erformed .......................................................:...................................................................................... I declare under penalty of perjury the above is true and correct. I have read and understand the Owner-Builder Information(rev se s' e). / - Property Owner's Signature: / Date: 6 Job Address: Permit# Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. i City of Cupertino Building Departsent CITY OF 10300 Torre Avenu C U P E RT I N O Phone: (408)777- 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 r' CITY OF CUPERTINO CUPEI�TINO PERMIT APPLICATION FORM N# { Date: Buildinggddres : Mailing Address (it dif rent from uilding address): Owner' ame: I Phone#: Contractor:/� License#: P\ I— � re Lk r/ Contact,;, �(`JJ,, l I& Fhaonax. v� 777 7� Cupertino Business License#: Building Permit Info: Bldg ❑ Elect ❑ Plumb ❑ Mech ❑ Job Description: Residential Elv4— ��oa M 1) C (\'''�P-��ee vL ommercial ❑ Sq.Ft. Floor Area: I $/Sq.Ft.: Cost of Project: 6-06 DD Occupancy Group: Type of Construction. Please check this box if the project is a second-storyaddition: El ro'ect Size: Standard ❑ Lar e ❑ Ma'or ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> I OOK 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 BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax–Resi/Mobile BUILDING BELEC1000 Elec 600V <= IOOOA ELECTRICAL BELEC1001 Elec 600V> IOOOA ELECTRICAL . BELEC200 Elec Svcs 600V<=200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING 1 of 3 r CITY OF CUPERTINO CUPE or PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING 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 BPINIERCEP 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 rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING Ah 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 cfin MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREM 3USWAY 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 Misc Apparatus ELECTRICAL BREMNRAPP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 5 j CITY OF CUPERTINO = CUPEkTINO PERMIT APPLICATION FORM QuantityFee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL i BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING i BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection BUILDING BSWiM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp 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 3 of 3