03050037 (2) crrY or curraT[lvo
BUILDING DIVISION PERMIT TOWINFORMATION51.
BUILDING ADDRESS: PERMIT NO„3 0 5 0 0 3 7
FITS NAME: PERMIT ISSUE DATE
P ONE: SANITARYNO. 2 CONTROL NO.
ARCHITECryENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O O
±op LICENSED CONTRACTOR'S DECLARATION
�miE 1 hereby affirm that 1 am rammed under provisions of chapter 9 moe menemg Job Description �s1��
<G wiN Section Rgl(pof Division 3of NC Business and Professions Code,and my liccnsc is ��®
< in full force and effect.
1gjE License Class Lic.0 TENANT IMPROVEMENT -
eaE� Date Contractor DEC gg 2003
EC 1 a7 ARCHITECTS DECLARATION - L
C i U 1 understand my PIam.Call be uxd as public rtenNs
`o1 LicensedPndcssional �' �'��
�1 5 OWNER-BUILDER DECLARATION ■`D
20 0 1 hereby affirm on 1 am exempt from Nro Csecons o Any c Law rut Nc
p O which
followingMason.Permian 703L3.Business and Profession Code:Any city of mousy
$ whim requires n permit to construct.the almh improve,demolh remarked
or repair any statement
thathe its issuance.Clsurequires thcaiionso(the Con Petor's fiensele a Lnedetammem
F (Commiscing edpunuamh0k))o(the visionofortheBdinessandProd ssunChapwr9ode)or Sy. Ft. Floor Area Valuation
++ (Commencing is exempth Section70k))and o(Division do,
Business pion.Any Violation
or
Na(he ts exempt Ncmfmm and Ne basis for Ne alleged exemption.Any violation of 31621090 . 00
Section 1031.5 byby applicant for a pc.it,.bj,,u the applicant to a civil penalty of APNNumber Occupancy
no(more Nan five hundred doll...n!R)0). pane y Type
❑1.as owner of the fropeny,or my employees with wage,u Neir sale emopenadon,
will do the work,and the suvaure is not intended or offered for Sete(Sec.7044,Holiness
and Professions Code:The Contractor's License law dolt ons apply in an owner of 102 - PIERS
d Inspections
property who builds or improve,Nescreon,and who dosuch work himselfm through his
Own employees,provided chat uch improvements are not intended oroffered for sale.If. 103 — UFER
however,the building or improvement is sold within one year of completion,Ne ownerry
builder will have the burden of proving Na(he did not build of improve for purpox of 104 - REBAR
sail.' 105 - ANCHOR BOLTS
conns,a nwncr fl ct pro.704f+m exclusively mesand
contracting wild limned rnnlnmnr,i.
construct the pmjen(Sec.]IN4,Bu.iness and Profession Code:)The Conmeari u. 10 — SEWER & WATER
cense law does not apply to an owner or property who wilds or improves demon,and, 202 — UNDERFLOOR PLUMBING
whocondacufor,uchprojecu withac d .,(I)Ummaid pumuem to the Contractor,
License Law. 203 - UNDERFLOOR MECHANICAL
❑tem eaemp(unde ,B&PCfn Ni mason 204 - UNDERFLOOR FRAME
ION 0 205 - UNDERFLOOR INSULATION
WORKE ' �1PENYt P OEC ATION
trmunder penalty of pejury one of the following declsfoions; 301 — ROUGH PLUMBING
❑I have and will maintain a Ccnificate of Consent m self-usure for Wortrr's Comfort. 302 — TUB & OR SHOWER
ration,as provided for by section 3]00 of the labor Code,for the performance of(he 303 - ROUGH MECHANICAL
work for which this fermi(I.issued.
❑I have and will maintain Worker's Compensation Insurance,n required by section 304 - ROUGH ELECTRICAL
7]W ofthe labor Code,for Ne performance of the work for which this permit is issued. 305 — FRAME
My Workers Compensation Insurance carrier and Policy number am:Policy NO.: 306 — HOEDOWNS
Carrier, CERTIFICATE OFEXEMPIONFROM WORKERS' 307 - INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
or ossa.This section nem notes completed vibe rcrdis is for one hundred dolars(HINE 309 — EXTERIOR LATH
I Caniry that in the performance of too work for which Nis Permit is issued,l man not 310 — INTERIOR LATH
employ any person in any manner m m to become subject o the Worked Cnmpenaion 311 — SCRATCH COAT
Lawsca California.Data
Applicant _ 313 - ROOF NAIL
Law.
NOTICE TO APPLICANT:If.alter making this CCN(Ieate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become Comply
the women Compensation permit hal of DO,LaborfCore.you nun 502 - FINAL PLUMBING ENERGY
�,2 become object
wits such er'sCmensatinpermil shallbedccm boli COE,
?C CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
I hereby affirm that there is a conmuc(inn lending agency for the Performance of 504 - FINAL BUILDING ENERGY
zCI thework101 nthis p mit i.ia d(srd5091.civ.ca 505 - FINAL ELECTRICAL
JJ Q LenderssName
�z Lender's A°°� 506 - GAS TEST
j 0 1 merry that 1 have rad this application and stoic that the above information it 5 0 7 - FINAL PLUMBING
y comet.1 agree to comply with all city and county ordinances and state laws relating to
7V building conweion,and hereby authmire mprommebms or this city to enter upon the FIN MECHA(NG' L
1 anave-mentioned property for inspection purpoms.
ti (We)+gree m save,indemnify and keep handless the City of Cupcnino egaims O 9 FI �!
h liabilities,judgmcna,costs an ich may in any way acc=against said City
J in comm to
of the rgW� ng of this per il. 5 APPLICANT U ERSTANDS AND U , MPLY WITH ALL NON-POINT Issued by:5 ORKS Date
0 CE RE ATIONS. Z4 e/
Sig arc or APPlican racer Died e Re-roofs
AZARDO MATERIALS DISCLOSURE Type of Roof
Ne applicant of future building occupant store or handle haadmous material
indefined by the Cosentino Municipal Code.Chapter 9.12.and the Health and Safety
.rection 35513(x)?
❑Yes WN. All roofs shall be inspected prior to any roofing material being installed.
Will Ihcopplicamor ruwmbuildingoccuponluxcyuipmcnlcrdcviccs which If a roof is installed without first obtaining an inspection,I agree to remove
c I ho.mous Cir comami ants ss defined by the Bay Arca Air Quality Management all new materials for inspection.
Dinric,?
❑Yes `991Nu ..
Ihavcfair Nc hatmmaw T Is requirements under Charter 6.95efthe Califor-
nisHcaW/kssfey Sec(ions2550 25533md25534.1nndcrsandthwirthCbuilding
Jnr not cement}} ox a anent,No its y omihility m i ndly ded occupent of Ne
requirement hichmusthedi pnor moa enlncateofOcc
upan9 Signature of Applicant Date
Ml 0
Own e ,mwneed „e 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 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
c. Ge ��o-rut c , p sio 4si �� '1 13 LFLe
Q3µ6 i i
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
.....................................................................................................................................................................................
r
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(reverse si
Property Owner's Signature: Date:
Job Address: Lin j2LO-,-1� , CSA Permit# a 3o!� 007
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
City of Cupertino Building Departm
' I CITY Of 10300 Torre Aven
CVPERTINO Phone: 408 777-3
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 compensatio
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 US. 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
CITY OF CUPERTINO
m 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng : Sub: Blk: Lot :
APN . . . . . . . . . 31621090 . 00
DATE ISSUED. . . . . . . : 08/19/2003
RECEIPT # . . . . . . . . . : 22829
REFERENCE ID # . . . : 03050037
SITE ADDRESS . . . . . : 19997 STEVENS CREEK BLVD
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : .VERDE T CAFE (ROSAN LO)
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : DENNY UNG
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . :
EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
------ - ------------- ---------- ---------- ---------- ---------- - ---------
BENERGY PERMIT FEE 380 . 00 114 . 00 114 . 00 0 . 00 0 . 00
BPERMFEE VALUATION 35, 000 . 00 380 . 00 380 . 00 0 . 00 0 . 00
BPFIXTURE UNITS 6 . 00 49 . 98 49 . 98 0 . 00 0 . 00
BPLANCHK PERMIT FEE 380 . 00 323 . 00 323 . 00 0 . 00 0 . 00
BPSEWAGE UNITS 1 . 00 62 . 16 62 . 16 0 . 00 0 . 00
BPSEWER SEWER SYSTEM 1 . 00 19 . 98 19 . 98 0 . 00 0 . 00
BPTRAP NO OF TRAPS 1 . 00 8 . 33 8 . 33 0 . 00 0 . 00
BPVENT UNITS 1 . 00 8 . 33 8 . 33 0 . 00 0 . 00
BPWATER UNIT 1 . 00 8 . 33 8 . 33 0 . 00 0 . 00
BPWHEATER PER HEATER 1 . 00 9 . 99 9 . 99 0 . 00 0 . 00
BELEC200 METERS 1 . 00 22 . 20 22 . 20 0 . 00 0 . 00
BPWSVCS WATER SERVICE 1 . 00 8 . 33 8 . 33 0 . 00 0 . 00
PPERMITFEE FLAT RATE 1 . 00 35 . 52 35 . 52 0 . 00 0 . 00
BREMAPPLI NO OFAPPLIANC 7 . 00 42 . 77 42 . 77 0 . 00 0 . 00
BREMFIXT NO. FIXTURES 17 . 00 18 . 87 18 . 870 . 00 0 . 00
BREMFURN NO UNIT 1 . 00 12 . 21 12 . 21 0 . 00 0 . 00
BREMPOWER POWER UNITS 1 . 00 44 . 40 44 .40 0 . 00 0 . 00
BREMRECEPT NO. OUTLETS 20 . 00 22 . 20 22 . 20 0 . 00 0 . 00
BREMVENFAN NO UNITS 10 . 00 96 . 62 96 . 62 0 . 00 0 . 00
BREMVENSYS NO UNITS 1 . 00 8 . 33 8 . 33 0 . 00 0 . 00
BSEISMICOM VALUATION 35, 000 . 00 7 . 35 7 . 35 0 . 00 0 . 00
BUSLIC FLAT RATE 1 . 00 100 . 00 0 . 00 100 . 00 0 . 00
EPERMITFEE FLAT RATE 1 . 00 35 . 52 35 . 52 0 . 00 0 . 00
MITFEE FLAT RATE 1 . 00 35 . 52 35 . 52 0 . 00 0 . 00
---------- ---------- ---------- ----------
L PERMIT 1473 . 94 1373 . 94 100 . 00 0 . 00
R
tHOD OF PAYMENT AMOUNT NUMBER
CITY OF CUPERTINO
m 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp : Rng: Sub: Blk: Lot :
APN . . . . . . . . . 31621090 . 00
DATE ISSUED. . . . . . . : 08/19/2003
RECEIPT # . . . . . . . . . : 22829
REFERENCE ID # . . . : 03050037
SITE ADDRESS . . . . . : 19997 STEVENS CREEK BLVD
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER VERDE T CAFE (ROSAN LO)
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : DENNY UNG
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
,TELEPHONE . . . . . . . . :
E ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- - - ----- ------------ --------------- - --
CASH 100 . 00
TOTAL RECEIPT 100 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
--101--- FOUNDATION ==102-== PIERS=====__________________
103 UFER 104 REBAR
105 ANCHOR BOLTS 106 SEWER & WATER
202 UNDERFLOOR PLUMBING 203 UNDERFLOOR MECHANICAL
204 UNDERFLOOR FRAME 205 UNDERFLOOR INSULATION
301 ROUGH PLUMBING 302 TUB & OR SHOWER
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
305 FRAME 306 HOLDOWNS
307 INSULATION 308 SHEETROCK
309 EXTERIOR LATH 310 INTERIOR LATH
311 SCRATCH COAT 313 ROOF NAIL
501 FINAL ELECTRICAL ENERGY 502 FINAL PLUMBING ENERGY
503 FINAL MECHANICAL ENERGY 504 FINAL BUILDING ENERGY
505 FINAL ELECTRICAL 506 GAS TEST
507 FINAL PLUMBING 508 FINAL MECHANICAL
509 FINAL GRADE 510 FINAL PLANNING
14 FINAL PUBLIC WORKS