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02120002 (2) 'CITY OF CUPERTINO 4 - xva " -ern nr. r•Atht r¢ BUILDING DIVISION PERMIT �CONTRAC:TORtINFORMAT,I x BUIg)0919@I9S0MERSET CT WONG WILSON T AND SUS3W S PERMITNO2120002 OWNBON&EWILSON T AND SUSAN S APPLTCATpNL9yR_PTY2002 PHONE: SANITARY NO. CONTROL NO. ARCHMI CVENGINEER: BUILDING PERMITINFO BLDG 0ELECT PLUMB MECH 0 0 Oo LICENSEDCOMAACnderproECLARATION Hl h Ihereby ion700f.fDivithat on34tensedunssandPisiovonsCode,and KITCHEN & BATI-I IDkNebhL with Section 100070(Division J of Ne Business end Professions Code,and my license is v, in full foreeand effect. 20x2 LicenseCw LK.4 OZF DateComrric ��If ARCHITECTS OECURATION If 1l�� I understand my plans shall be used as public records 3LL LicensedPmessional MAY 2 7 2003 ou41 OWNER-BUILDER DECLARATION �<E 1 hereby affirm shat 1 am exempt fmm Ne Contractor's License Law for the $30000 3600 following reason.(SeClut 7031.5,Business and Professions Cude:Any city or county 3 which requires a permit to convect,alter,Improve,demolish,or repair any structure RIM nimn Fzs< prior to its issuance,also mquires,the applicant for such pemlil to rile a signed statement £FO that he is licensed pursuant to the provisions of the CodracmrsLicenseLaw(Chapter 9 3�g961.ADo"13®A Valuation y (cammeneing with Section 70W)of Division 3 of the Business and Pmfwions Cole)or $ Wt he u exempt therefrom and the basis for the alleged exemption.Any violation of Section 7071.5 by any applicant for s Permit subjects the applicant o a Civil penalty ofpN N Occupancy Type not more Nan five hundred dollars(S500). 102 — PIERS I,uowvr of the progeny,or my employees with waguasHeir sole compevation, will do the work,and the ssrucmm ism intended or offered for We(Sec.706/,Business 183 UFER- And Profwlons Code:The Contractors License Law does not apply in an owner of Required Inspections property who builds or improves Hereon,and who does such work himselfor thmugh his 104 - REBAR awn employees,pmvided Hat such improvements arc not intended oroRered formle.If, 105 — ANCHOR BOLTS however,He building or improvement is sold within one year of completion,the owner. Wilder will have the burden of proving that he did not Wild or improve for purpose of 106 - SEWER & WATER asle'). 202 - UNDERFLOOR PLUMBING I,as owner of He Property.am exclusively convecting with licensed contractors to 2 0 3 - UNDERFLOOR MECHANICAL convect the project(Sec.7064,Edam.and Profwiom Code:)The Contracrori Li censglaw does not apply m an owner of properly who Wilda or improves discount.and 204 - UNDERFLOOR FRAME who contracts for such projects with a conuacmr(s)licensed pursuant to the Conmcmra 205 — UNDERFLOOR INSULATION XL ev ave. am exempt under Sec. ,B&P C for His mstan 301 - ROUGH PLUMBING ow r L1)IiSON d P-� m sag 302 - TUB & OR SHOWER WORKER'S COMPENSATION DECLARA 303 - ROUGH MECHANICAL 1 hereby affirm under penalty of perjury one of the following declarations: I have and will maintain a Cenificam of Consent o Ulf-insure for Workeb Compere 304 — ROUGH ELECTRICAL solion,u provided for by Section 3700 of He Labour Code.for the performance of the 3 05 - FRAME CIE,for which this parmlt is issued. 306 - HOLDOWNS 1 have and will maintain Worker's Compensation Insurance,as required by Section la of 37 307 - INSULATION 00 the bor Code,far He penormance of the work for which Hia permit is iasuW. My Workees Compensation Emma Cartier and Policy number are: 308 — SHEETROCK Cartier: PolicyNo.: 309 - EXTERIOR LATH CER' COMPENSAATEOF TISONINSURANCEPTION FROM ORKERS' 310 — INTERIOR LATH mous.[I.need not be completed lfthe pump is for one hundred dollars(SIM) 311 - SCRATCH COAT rA%, 313 - ROOF NAIL Icenify Hat in the r lithe work for which His permit is issued,lshall min 501 - FINAL ELECTRICAL ENERGY Amid Y.Cyperson' mann raou 1gbec m2>bject to Verkcri Compensation Laws or alxnmi .D 3 - 502 - FINAL PLUMBING ENERGY N ITOAPPLI IN th .efmrma In isCenificat of Exemption,youshou5 503 - FINAL MECHANICAL ENERGY 0 Z become subject to the orker's Compensation provisions o the labor Code.you must 504 - FINAL BUILDING ENERGY forthwith comply with such provisions or this permit he deemed revoked. ZR a CONSTRUCTION LENDING AGENCY 505 - FINAL ELECTRICAL n F kforwhaRrmHathercisacroswct30917,Cry.CgenryforHcperformenaruf 506 - GAS TEST x > HcwurkforwhichHisp mitisiuud(Sa.3097,Civ.C.) Lenders Name 507 - FINAL PLUMBING W 5z LndelsAddmu 508 - FINAL MECHANICAL J 0 1 certify Hat 1 have read this application and state that Bar above information is 509 - FINAL GRADE E4 torten.1 agree to comply with all city and county ordinances and state laws relating to 0 V buildingCovwction,and hereby amhoriarepresentatives ofthis city to enter upon the 5 FINAL PLANNING W show-puplionedprolanyforinspectionpurposes, 14 FIN I W RKS a (We)agree to save,indemnify and keep harmlcse the City of Cupertino against t7o incoiliu,jnce of the granting uind of this cswhich may in any way scene against City I ` C) a in wises,judgment, a the Granting expert es which Oft✓/ AP LIC UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT Issued by: Date S RCE GULATIONS. �'?'d Re-roofs Signsturt fApplicanV onsanur in HAZARDOUS MATE AIS ISCLOSURE Type of Roof Will f applicant or future Wilding occupan store or handle hanrdous masons] As defined by the Cupertino Municiryf Code.Chapter 9.12,and the Health and Safety Coda.oYcs Section 25532(,)? Mqo/ All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove emit haeardous air contaminants es lined by the Bay Area Air Quality Management District? p all new materials for inspection. ❑Ycs u I have read the havardous matenals requirements under Chapter 6.95 of the Califor. tie Health&S Iy Calc,Scc6wu2.WS.25533and255M.1undcrstaad Huifthc building docspm,.Onqlhp hate a tenenn,N it is my rupomibiliiy m nodfy He=upam or He mq7ms ichmustbcmetp rhounuaneeora irieteor ai—cy. Signature of Applicant Date Owner or authorixed agent D,te All roof coverings to be Class "B"or better OVER-BUILDER VERIFICATIO 1. (Check one) I or my immediate family(parent, spouse or i I d)•wNill-p i rfor. A. All the work authorized by this pe VV LS D • _ B. _ A portion of the work DE , 0 2 2002 C. _ None of the work By If B or C is checked,com Tete 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 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 and correct. I have read and understand the Owner-Builder Information(reverse side). Property Owner's Signature,/: D Date` 1y'> L- job Address:? 7 Permit# © fl Any changes tothe information provided on this form s aIl be submitted to the City of Cupertino Build Department. • City of Cupertino Building Dep artma CITY OF 10300 Torre Avet CUPEkTI �Ifl 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 recon{ 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 yonlrself 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 cornpensati� 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 retuned. Very truly yours, Building Department, City of Cupertino • Printed on Recycled Paper SAN% TY OF CUPERTINO Z ( Z ` - '�� Z CITY OF PET APPLICATION FORM CUPERTINO APN # 3� - 0 � 00 Date: Building Address: (03 ✓I SO+NUVV� er &T . Owner's Name: Phone#: VAN d WO(SS y,0j 2S tl21 Contractor: 0 to h-� License#: Contact: Phone#: *09- k b113 (�I� W I VON 974,0 f 6CUh -V Applicant/Contractor: g Permit Info: Bldg Elec ' Plumb Mech Job D scription: sidential: k, d_ 4-p,In 1,,,` �-Lv"oLgk Commercial: Sq.Ft. Floor Area: $/Sq.Ft.: Architect/Engineer: Valuation: �rn Type of Construction: Occupanc Ak Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances 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 Ener BUILDING BENERGYADD Ener Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Family Res MECHANICAL BNEWMULTI New Multi-family Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING 1 of3 APPROVED ANRDAN E WITH HE C ,,T un C 1PERT'No C ES I ANC ° 77 . A {IIsf:f1 T, ; set ,=ns and specifica ons MUST f� ;• t apt o,z :e jab of all time .nd it is un, \ / ` I; ,fu! to nc:,e any cheng4 alterations y spm= cy;:houi watte. e 1 fission from 1 : bur.,4ng Dept.. City C. C,1 ;rti= e,,e stamping of tfa pan ana pecificaHons ,N.`L RUI b* he; t� fermi 01 to be a ?� 1 opro a3 the voiatian of ny pro long V 1 mu as G.d,nance ae ;ta a aw_ DEC 0 2 2002 D By Cory 'y 0 DEC 0 r7}��''?��. APPROVED IN ACCORDANCE ITH THEN CES CUPERTf, COD AND S DATE SIGNED S un This set of is is and specifications MUS d it i be kept on they lob chafngesen or alterations lawful to make any permission from on same without written p 1 the building Dept.. City of Cupertino. The stamping of this plan and specifications SHALL NOT be held to permit or toobcion e an approval of 0 d nfanee or Staten of yLaw. \ / ,f anv City oma ��11