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06020160 (2) CITY OF CUPERTINO r^" +^?w ;sPk"•e �` ^' BUILDING DIVISION PERMIT s CONTRACTOR INFORMATIQN A' BUTLOINGADDRUS: JOHN KOEPPEN PERMMNo.06020160 10150 PHAR LAP DR OWNER'S NAME: PERMIT ISSUE DATE JOHN KOEPPEN 02/27/2006 NE: SANITARY NO. CONTROL NO. ARCHITECT/ GINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MEC" �0, LICENSED CONTRACTOR'S DECLARATION Job Descri f�}}wrsrr U I kmby E of iuts�ws I am f1 B under ditfets of Clique,, 9(commencing p�f��MAL Ns� with Seeman', of DivisionJofIk Budnmotl Profhssiov Code,eM myliceveu LE® -M in full forte antl enett REPLACE WATER HEATER j gj? License Class Lic.N n�n Dow Contractor I=£°j ARCHITECTS DECLARATION �1 C 1 and.oil my plans slue W sued u public records MAR ` 7 2006 JyU k Gln Licensed Professorial atIam OWNER-BUILDER DECLARATION ����� I hereby .(Seto Nm 1 1. exempt from Ik Comnmm',License taw for the my p O fallowing tomo..(SRtiM]Ion son r,Business and noc.temov Cale:Any city s..my $ which myuim,a pcuio rc rims the applicant improv,hsuch Permith,Fie a sig any mmctum Q _Z j, prior m its i licensed puralssuant mq0 the thovisio sof for Contractor's In mense,Law snmmcm < that cingwJpunusmroNcpmvisiovofNeCommnessaJuvclaw(Ckpmr9 Sq.Ft. Floor Area Valuation y�$ (Comm(mmmncing with Section]OW)of DivisianJnflk Burners and Pmfmiov Code)or " Nat Ice k cumtherefrom and therefroand me bum for thm alleged exemption.My violation of 3 OR Section 7031.5 by any applicant for a p.it subjects the applicant to a civil penalty of ......Na low,hundred aolkm($!5OQ. er Occupancy Type ❑Las wnmofthepmputy,or my employees with"gum Neirsoleeompensadon, will do re work,and Ne ire Come secs License ace do Itoeek(Sec.]014,weer of and arty wh bon Code:]Tm Contracrors Llano law dove not apply if rt owner or Required Inspections man who buildsvided tat suus chicon.andwho amdatdoc"uchwork himself d!for Weugh his own employces,provided Nal such improwmw t art not intended mplinirnd for owner. Wild qNe building or impmwmentisoldwithinov Weldofimp.l on.thep..f Wilder w'll kw Ik Wrdrn of proving Nan k did nor build m imProu fm purpose of akJ. u Cove,of Ne property,em eatlusitecly convecting with licensed convectors to .cw,the pmject(Sec.7004.Business and Proressiau Cake)The Convacroes Li. antic taw does not apply to an owner of property who Wilds or improver hereon,and. who contracts for such pmjecm with a contractor(s)licensed pursuant to he Comossues License Law. ❑lame sunder ee .B&P C forth,moon Ow Da�'� \ ORKEWS COMPENSATION DECLARATION 1 hereby a10rm under penalty of perjury one of tk following dechrstions: 1 haw and will maintain a Certimwm of Covent to self-ivu,for Workces Compen. anion,m prevented for by Section 3]00 of Ne Labour Code,for me performance of mm work for which Nis Permit is issued. ❑I have and will maintain Worker's Compensation Insurance,as required by Section 37M of the labor Cade,forme performance of the work for which Nu Permit is issued. My Workers Compensation Ivunme carrier and Policy number am: Cartier. Policy No.: CERTIFICATE OF MEMMON FROM WORKERS' COMPENSATION INSURANCE (This scedu need net W completed ifft Permit is forme,hundred dollars($100) Cor les() 1 certify Not in Nc perfnenc o work for which this permit u issued,I,hall not employ any'pension/'ss((anyin come subject m the Workons Compensation Laws of California`B.y "3 �,� . Applicant / _ NOTICE TO APP ANT:If,after making this Cenimom of Esempdon,you should becomes ecomsubject)d Ne Worker's Compensation provisions of the labor Code,you mus, .J O forthwith N with comply with such nineiini eis l erW mmm mi,that dcced ked. Z` CONSTRUCTION LENDING AGENCY I hereby affirm that mess its emuwcsinn lending agrncy fm tk perfumnace of C' Ne work for which this N.it is issued(Sec.3097,Ci,C.) V]0 lender's Name 6. •i Z Urdch Addmv u,Q 1 ttnee that pass read this city and county aM sue thin Ne aWw information u (T. F building I agree to comply with all city om rounry ntatim of ans,um sews miming e pLu abovengconswctiro.cent hcmbyamhonpuroreunu,ivss of this city mentor upon the C[1 above-mentioned judgments. property for inspection which may F 0. (We)agree m ave,indemnify and kap hmmless ce City of Cupertino i gaivt rp incoitieajudgments.costs add eapevesmit. may in any wyeceme againm said City Liz in eonuqune Nu granting of this permit. �_�� a^' APP D STAN AND WILL COMPLY WITH ALL NON-POINT Issued by: di Date -ate SOUR R U ONS "27"G6 Re-roofs S of lion on or - Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will,he applicant or form Wilding occupant mom at handle hvallous material as defined by Ile Cupertino Munic al Code.Chapter 9.13•and rex Health and Safety 'joilEarea.Section 3ss32(a)T ❑Y00 j©Nu All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future Wilding occupant use equipment or devicu which If a roof is installed without first obtaining an inspection,I agree to remove it huardir s air contimmin Ca syr fm.cd by Ne Bay Arta Air Quality Managcmen, all new materials for inspection. ❑Ycs ❑Nu I have read the haa,d.usmmenids requirements undc,ouipmr695 of me Calif.,. nu Hullh&SafetyCodo.Scctiau25505.25533 and 35530.1 udcutand thmifine Wilding does trot carte a not,that' is my responsibility to nosy mm oxmpor Of me requimine hi m at tomuanaer.CemrcateC, neer. Signature of Applicant Date 7 owner 56L6mivasenn 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 3below. 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 vc - cta vaaaacu 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: ose�,- Date: Z -Z -7-O6 Job Address: /0/15 L ACA a DIC 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 Department ' I pCII ROF A' 10300 Torre Avenu C V f E TIN Phone: (408)777-322 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 compensat or* 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 Recyded Paper CITY OF CUPERTINO T"PS WATER NEATER d �od � 5 l CUPEkTINO PERMIT APPLICATION FORM APN# 3 Z / 3 Date: 6 f n � Building Address: UI ti Owner's Name: Phone #: ja u 2 7 Contractor: Phone: License#: Contact: Phone: Cupertino Business License#: Building Permit Info: -6,525� 5 G h4olo, Bldg ❑ Elect Ga' Plumb.O' Mech CT, Job Description: Residenti Commercial ❑ Cost of Project: • Strapped On Platform ❑ Bonded ❑ New Location ❑ Re lacemee-� Qty. if Applicable Fee ID Fee Description Fee Group BPWHEATER Water Heater/Vent BUILDING PPERMITFEE Plumbing Permit Issuance PLUMBING BENERGY Energy BUILDING BUSLIC Business License BUILDING 333