06090140 (2) CITY OF CUPERTINO "w '• s R
BUILDING DIVISION PERMIT ' CONTRACTOR INFORMATION` -
BUILDING ADDRESS: RICHARD FREEMAN PERMIT NO-06090140
10189 S TANTAU AVE
OWNER'S NAME: PERMIT ISSUE DATE
RICHARD FREEMAN 09/18/2006
14 Ir ONE: SANITARY NO. CONTROL NO.
ARCHrtECfIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Op Lm that IDCONnRd underSDECLARATION - Job Description
i 1 ionhereby70 affirm that 1 am n¢nxM under provision of Chapter 9(commencing
]j.w wiNSecuon7IX10)of Division3af Ne Business and Professions Code.and.1 license is
awn infull[a=and effect. REPLACE GAS HEATER 2 SIDED
�l2i Lt..Class I.M.N
=t„a Date Cenrrazwr
s£ ARCHITECTS DECLARATION
>W U 1 understand my plans shall he used a public records
'u.ponal
ts Licensed Professi
5 OWNER-BUILDER DECLARATION
gm 1 hereby airliner Nat I am exempt from the Contractor's Liccnw law for the
COD following Mason.(Section 7(n I.6.Business and Prefecsiou Critic:My city or county
$ which¢quin,s a permit m conuvet,alcor,improve,demolish,art repair any slmowrc $700
_Z< poor to its issuance.also require the applicant for such permit to Bic asigned s iumem
that he u licensed pursuant Bic prevision of the Conraor's Liceruc Law Valuation
(Chapter 9 Sq.Ft. Floor Area
u�$ (canmemingwiOSecd.n70D0)nf Mi ion3ofthe BusinmmdProfession Code)or
Nat he is exempt therefrom and the basis for the alleged e¢mption.Any violation of
Section 7031.5 by airy applicant for a permit subjecu the applicant to a civil penalty of r Occupancy Type
net mom Nan five hundred dollars(SM.
❑1,as owner of use pmpany,or my employc s with wages as their sale compensation,
will da the work.and beawnum is not intended or offered for safefsec.7014,Becomes Required Inspections
and anywhiobu Cade:The Canvazwr's Line Law dos rot apply lf an owner us q P
propertylobe builds i improvech improvements
vedwM rmssmhwmk himulfor Waugh hu
own employee,proWded Natsuchnt is
with am not intended aidetir.forsale If.
however,the building or improvement u sold within one year of c prove far
ore ownuf
builder will have de burden of proving Nat he did cos WiW a improve far purya¢of
ate.)
as owner of the property,.B exclusively connecting with:)The
contractors t.
c.constLa the es ton (Sec.7044,Business and property
who
Cade:)The es banson.Lid
case ntr doe sot apply a an owner of property who bullas art ant as ds corem.and
who contracts far such prejecu with a conuuwrts)li¢nxd pursuant w W Conuuwls
License Law.
❑I am exempt undo ce B k P C far this Hawn
Owner j/Z[4 ,�
WORKER'S COMPENSATION DECLARATION
I thereby affirm under perulty of perjury neve of the following declarations
I have and will maintain a Certificate of Consent w self-insure far Worker's Compen-
sation,a provided for by Section 3700 of W labor Code,far the perfom mance of Ne
work far which this permit is issued.
❑I have and will maintain Worker's Comperm ion Insurance,as visioned by Section
3700 of the labor Cade,for Ne performance of Ne work for which one permit is issued
My Worker's Compensation Incummea carrier and Policy number are:
Cartier. Poli,No.:
CERTIFICATE of EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This scrim need not be completed lithe Permit is fa one hundred dollars($100)
or ICU.)
1 ccnify that in the,performance of Nc work for which this permit u Lssmd.1 shall not
employ any pawn in any manner so as to become subject to tM Work<ri Compcn inion
lawsca Cali �y
NOTAppliCEa ¢¢tea er /
NOTICE TO�Po ther.WfTaf,after mahm pr Certificatensof of FLaw io d you shoos
became subject to the Workeh Compcwtion previsions of dm lalpr Code,you most
.JO forthwith with such provisions.,,his permiuharevoked,
ll be deemed
'Z "' CONMUCnON LENDING AGENCY
H .�., I hereby drum than Nen,is a eonnmctinn lending agca,for be performam:c of
ra dm work fur which this permit is issued(Sec.3097,Civ.C.)
lender's Name
.7 z Lcml Addous
U O 1 certify Nat 1 have read Nis application cord sew that the above information is
correct.I agree w comply with all city and county ordinances and sum laws mlating to
�U building concoction.and hereby authariae.prescmmins of his city locator upon the
alwao-mentioned ia.property furl,., n purposes.
H a (We)agree to save,indemnify and keep ha ralaas the City of Cupenlno against
y in
of
and capcnsemit. may in any way accrue agaieasaid City
U z A APPLICANT
pf Ne granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC GULATIONanS.
--r - Re-roofs
srgnw o�pen✓C
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dm applicant or furan,building occupanraare or handle hammou.m urrial
u defined by Oe Cupertino Municipal Cade.Chapter 9.11,and the Health and Safety
Code.Sections 25532(a)7 All roofs shall be inspected prior to an roofing material beim
❑tics p p y g g installed.
Will the applicant or fun.building occas nt use If a roof is installed without first obtainingan inspection,I agree to remove
W c.Air Qui or rk''ccs which g
cmh hvardnn air cmuminanu u dcfimd by the Bay Arta Air Quality Management all new materials for inspection.
Distdctl �
❑Yes ❑No
I have Mad Or haardawsmamrials requi.menu under Chapter 6.95of ule Califor.
riaHealth&Safety Cade,sectors 25515.25533 and 75534.1 unditmed all building
doss of dy hem a¢rant.Nat it u my..possibility to notify Ove occupant of the
nee taw'hmu =' erwissuameef.eencrveamefoccu Signature of Applicant Date
yr,' /�/��y1�}Md
o ne�hariv.e s ms m �� - � � All roof coverings to be Class "B" or better
CITY OF CUPERTINO
gem 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 37507026 . 00
DATE ISSUED. . . . . . . : 09/18/2006
RECEIPT # . . . . . . . . . : 36101
REFERENCE ID # . . . : 06090140
SITE ADDRESS . . . . . : 10189 S TANTAU AVE
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER RICHARD FREEMAN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : RICHARD FREEMAN
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : RICHARD FREEMAN
ADDRESS
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . :
*FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- --------- - ---------- ---------- ------ ---- ------ ----
BREMFURN NO UNIT 1 . 00 14 . 31 0 . 00 14 . 31 0 . 00
BENERGY PERMIT FEE 1 . 00 34 . 86 0 . 00 34 . 86 0 . 00
BSEISMICRE VALUATION 700 . 00 0 . 50 0 . 00 0 . 50 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
MPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
------- - - - ---- -- -- - - ---------- -- --------
TOTAL PERMIT 164 . 78 0 . 00 164 . 78 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
------- - -- ------- ------- ----- ---- - -------------
CHECK 164 . 78 7159
TOTAL RECEIPT 164 . 78
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-- -------- _____
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL
•
Community Development
�F 10300 Torre Avenue
+ i Cupertino CA 95014
Telephone(408) 777-3228
CITY Of Fax(408)777-3333
4§UPER,TINO
Building Department
JOB ADDRESS: PERMIT#
1101 f 49 - u �, �1c7JGfu^
OWNER'S NAME: , �f_ PHONE # ,k 2 r- 2 1 2 o
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors: l 8/0%
r
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
r�
Owner/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
G(1 i31iilG4
3. _ 1 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 slide).
Property Owner's Signature: Date: Uj .f IO A
Job Address: I D 19 9 .(', �R Alfl—Au AV i= Permit#
Curio,th.%, 0,q _ q roil
Any changes to the informatiWn vrovided on this form shall be submitted to the City of Cupertino Build
Department.
•
is
City of Cupertino Building Department
CITY OF 10300 Torre AvenuEe
C U P S kT I NO Phone: (408)777-3228
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 costa) 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 cavy 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
CITY OF CUPERTINO Woqol
FURNACE/AC
•CUPEROF
TINO PERMIT APPLICATION FORM
APN # 3-FD-� 0 Date g D
Building Address:
D A _ D/
0rr's am e: Phone#:
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect Plumb IJ Mech
Job Dription:
71,e-P(-ACP- e zq-E2 _ S S D
Residential Commercial ❑
For Residential Installations:
Attic ❑ 1" floor 2nd floor❑
Adhere to min set back requirement[]
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) El
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project:00 Type of Construction: Occu ancyyoup:
D
Strapped ❑ On Platform ❑ Bonded LT Sq.Ft. Floor Area:
New Location ❑ Replacement E9`
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 efm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 elm MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BPGAS Gas Piping System Fee PLUMBING
BUSLIC Business License BUILDING