04010121 (2) CITY OF CUPERTINO K :i
BUILDING DIVISION PERMIT CONTRAq,0R,`INk0RMATI0N ',
BU ILDING ADDRESS: ARIK DONDE PERMIT"04010121
OW NER'S NAME: PERMIT MUE DATE
ARIK DONDE 11 .12 6"2"
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINCER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
:OO LICENSED CONTRACnderpDECLARATION lob Description
nm❑ 1 hereby afnrm Net 1 am licenxd under provisions of Chapter 9(commencing p
ota in fhSCCrceadd0)nf Division Sof NCHusinca and Profcssinns Codc,antl myiiccnse is ,..p I,Va«®
o°' inmO,Class erre`f UPGRADE ELECTRICAL SERVIC
]'a? Licenac Chis Lic.M
"2p Dam GOaEC FEB 1 2 2004
ARCHITECTS DECLARATION
g I understand my pi
ars shall IncIncused a public«enNs
o'uuLicenud Pmfcsaionel BUILDING
OWNER-BUILDER DECLARATION
C M 0 1 hereby arfrm on 11. exempt from the Contractor's o License Lew for the
i.p O following«arta.herrn t W13s r Business and Professions Code:Any city nr county
5$ which rets iss a a pnmic re construct,the,alter.improve,demolish,or e a signed ,Nruau«
priormisiensedpalso uantto«a lhevisiapposof for such Connector's License
Nese signed
that he is licenced pursuant In the previsions of NC Contrac«r's License law(Chapter .S Ft. Floor Area
$ o p P q• Valuation
No
$ (coOut he is examwith Section700(dand the
Division r the al eged cess andexempt POreson.Any
alion or
y
Outheis 31.5 b therefrom and Ne harm for be alleged the exemption.Any l pennon of •�w�a��.Ts�s.A
Section than five
buryapplicant for aPermit subjects the applicantmacivil penalty of 3 s" 4TJ0"Qr00 Occu araC Type
net more Nen rim hundred donors(5500). p y yp
0 1,a owner of the property,or my employees with wages as their sole compensation,
will do the work,and the awetuse,is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's Liccue law does not apply to an owner of Required Inspections
property who builds or impraves thereon,and who does such work himself or through his -
Own employees,provided Nat such improvements are not Intended or offered for Sale.It.
however.the building or improvement is Sold within one year of completion,the owner.
builder will have the burden of proving Net he did not build or improve for purpose of
Side.).
❑1,as owner of the pm,mEy,am exclusively contracting with licensed convectors I.
construct the project(lee.7044,Business and Profusions Code:)The Contractor's U.
cense Law docs not apply to an owner of property who builds or improve the«on,and -
Lho contracts for such projects with a convactor(s)licensed pursuant to the Contractor's
6d.law.
,I um exempt er Sac. ,B&P C for this noon -
Data 2G•DY
WORKER'SC ENSATION DEC RATION "
I hereby aRum under penalty of perjury on following declarations:
I have and will maintain a Certificate of Covent to self-insum for Workers Compere
S
u provided for by Section 3700 of Ne Labor Code.for Ne performance of the -
work for which thin permit is issued.
❑I have end will maimain Worker.Compensation Insurmea,u required by Section
3700 of the Labor Code,for the performance of Ne work for which this Permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carrier: Policy Ni:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSU RANCE
(This sectirm need not he completed it the permit is Our one hundred dollars ISIG])
.,jam)
I certify meti h ormance of the work for which this permit is iuuetl.1 shall not
I mploy any ray manna mina become subjectm the Worker.Compensation
V o(Celiforyryie.Date
AP am /
ba C TO APn the Workers LIf Conemaking Nisvisins of of Exemption,youshould -
bert uomp Ip it uchoCaons or
Provisions Oal of themed revoked,you must "
.JO forthwith comply with such Provisions or this permiuheli he dccmctl mvnkcd.
'Z`" CONSTRUCTION LENDING AGENCY
[•+ work
by which affirm that them isaed(Sce.construction lending Ch, agency for the performance of
W the work for which this permit is issued(Sec.J09],Civ.C.)
WA Lenders Name
z Lender's Address
J C) I minify that 1 have«ad this application and mate That Ne shove information is
fkn P: correct.I agree to comply with all city and county ordinances and stale laws totaling to
O V building conawetom,and hereby mthmiserep««ntatives of this city to enter upon the
aehovcme judgri propcnyfor
and
depenies purpose.
(We)agree to saw,indemnify and keep harxnlea the City of Cupertino against'
aN.w fA liebioOq,ju nee of
Of this expenses which may inany way accrue egainsssaid City
A consequence of the grmcing nr this permit. •O ([J
^ APPLICANT ULAjPbS _ DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 7—
SOUR EGULATI `/\/p
.O�/ Re-roofs
«ofA,licmV usecor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant more or handle h Som ous material
as defined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
,dMik-do.so Yea, xa)+ �3 All roofs shall be inspected prior to any roofing material being installed,
Yca gMo
Will the applicant or future building occupant ate equipment ordevim which If a roof is installed without first obtaining an inspection,I agree to remove
ut`tW7,ardnus air conraminann dcrincd by the Bay Area Air Quality Management all new materials for inspection.
O Yes No
1 have«ml the ha artlrms materials mquimmenv under Chapter6.95 of the Califory
nib Health&SafetyCade,teed..25915,25533md25534.11nJc ndthatif Ocbuilding
docs not currently haw a tenem,Nae it «sponsihilicy to nodl'Y the Occcurrent of the
require ten mbar aiaaaance nrac oras 9'n� Uf,Signature of Applicant - Date
r
Ow
or
D„e All roof coverings to be Class "B” or better
OWNER- UILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform
A. All the work authorized by this permit
B. portion of the work j��i CEIVE
C. _ None of the work
JAN l 4
If B or C is checked,co m Tete 2 or 3 below.
2. A state licensed contractor will be hired to do: r
A. _ All of the work
B. A portion of the work (complete sectio ow)
Contractor Address/City, Phone # State License # Type of work to
c�c cu vauacu
• 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(reve €sdga
Property Owners Signature: Date:
Job Address: 7'3 -,3 Permit#61
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 Avenue
C' I D[kT I A I O 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 vourself 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 forst so that we can confirm that
you are aware of these matters. The building permit will riot be issued until the verification is returned.
Very truly yours,
Building Department,
City of Cupertino
Printed an Recycled Paper
lawCITY OF CUPERTINO
CUPEt�TINO PERMIT APPLICATION FORMIr
APN# �b Date: I
Building Address
Owner's Nam Phone
Contract4- License#:
Contact: Cupertino Business License#:
ringPe it Info:
Elect Plumb ❑ Mech E3
ob e hp on:
p /
R ential Lam✓ ' G� comer
Sq.Ft. Floor Area: $ Sq.Ft.:
Cost of Project; . � Occupancy u
Type of Construction: v� Ir/
�ITD p
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERl Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K 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<= 1000A ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
2, 7
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a - CITY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPERTINO
AF-Quantity Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE PbIg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Cbeck 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 rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
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 Chn MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Fumace> I OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BRE OLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
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ifl,as
CITY OF CUPERTINO '
CUP TY OF O PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMRECEPT Rc tl Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Sips, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
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 Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
BMISCELL Building Misc Fees BUILDING
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