03090102 (2) CI'T'Y OF CUPERTINO rte"`` * �•h# � a" ''
BUILDING DIVISION
PERM CO URACTOWINFORMA'�N -�;
BUILDING ADDRESS: LORI KIMBALL PERMITN'03090102
OWNER'S&S TANTAU AVE 10279 S TANTAU AVE PERMIT ISSUE DATE
PHONE: SANITARY NO, CONTROL NO,
H17ECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I� t�
loo LICENSED CONTRACTOR'S DECLARATION
`wF ehereby0 at r."f that I am licensed under provisions ofsCock, 9 my licancing Job Description
`ea�f with Scnian 7(g111)of Division Sof NC BminusaM Prorcuiuns Crdc.and myliccnsc is �`e
in full farce and ellen. P�NALED
j,? LfailkCwas Lic.N STUCCO (E) HOUSE
p Dam Cummmar
ARCHITECTS DECLARATION
f6
I understand my plans shall w reed a public tensed, SEP 2 2 2003
ca.
Licensed Professional
OWNER-BUILDER DECLARATION
W q 1 hereby,Item that I em exempt from the Contractors ;Any c Lew for the BUILDING
p o following meson.(Sian Section](131.5.exempt
and heftricasionsContras Code:Any city w toothy
5 which requires a permit in construct.also,improve,demolish,or repair any suunum
-ii prior to its Issuance,also requires the applicant for such permit to file a signed statement
-r< that he is licensed pursuant to him provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation -
`1-•(commencing with Section 7000)of Division 3 of the B usiness and Prorceinna C"de)or
that he is exempt Barefoot and Be basis for the alleged exemption.Any violation or 37508006 . 00
Section 7031.5 by any applicant for apannit subjects the applicant to a civil rarely of .AFN Number . .. OQQII Type
not more than five hundred dollars(S500L -- ' - - - Occupancy yp ---- -
�1,u owner of,fie property,ar my employs with wages u stir arta campenaodnn, T�
will do the work,and the structure,is not intended or offered for sale(See 7W,Business - WJcRWed Inspections
and Profession,Code:The ConuaclarY License Law does not apply to an owner of
property who build,or improves thereon,and who doessuch work himselfor through his 102 — PIERS
own employees,provided that such improvements are not intended orafered forsale.If, 103 - UFER
however,the building or improvement is sold within ran yerr of comple ion,the owner-
buildcr .will ban the burden of proving Nat he did not wild or improve for purpose of 10 4 — REBAR
ole.).
1,as owner of the property,am exclusively contracting with licensed contractors m 10 5 — ANCHOR BOLTS .
construct the project(Sec.7o44.Business and Prnfessioas Code:)The Contractor's Li. 106 - SEWER & WATER
cense Law does not apply to anowner of progeny who Wilds orImproves domain,and, 2O2 — UNDERFLOOR PLUMBING
who contracts for such projects with a canmaor0um
l licensed pursuant tee Conctor's
tACe"
B&PCrnr mice..on 203 — UNDERFLOOR MECHANICAL
91 maze t n Sec. ,
S17-0) 204 — UNDERFLOOR FRAME
o \ ORKE0.'SCOMPEN'ATIONDECLA to 205 — UNDERFLOOR INSULATION
herchy oRimt under penalty or perjury"noofthe "nmving declarations: 301 — ROUGH PLUMBING
avzand win mainuita Cinifieamafconseruoself-imam forworketscumpcn- 302 — TUB & OR SHOWER
u provided for by Section 3700 of the tabor Code,for Ne performance of the 303 - ROUGH MECHANICAL
for which vis permit is issued.
❑_I base and will maintain Worker's Compensation Wunna,u required by Section 304 - ROUGH ELECTRICAL
non or the tabor Code,for be para mance of the wart for which Ibis permit is issued. 3 05 - FRAME
My Worker's Compensation Insurance prier and Policy number ave: 3O6 - HOEDOWNS
Carver: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS' 307 - INSULATION
COMPENSATION INSURANCE 308 — SHEETROCK
or IcsW(Thisscctitm need not he completed if the permit is for one hundred dollm(St00) 309 — EXTERIOR LATH
1 certify,Net in the performance of the work for which this Permit is issued.I snail not 310 - INTERIOR LATH
Lawrofa�n"p�peJr�posng�o"ao3"��C.m;7n
as with the Workeri Compensation 311 — SCRATCH COAT
Ar Tea.Y- LLle/KA 313 — ROOF NAIL
N .fP ICAA '.aCam".. rExcmp,ion.you
shnuld 501 — FINAL ELECTRICAL ENERGY
bcc�jccl m the Worm pmvisiom of the tabor Code,you mush
>0 mahwithComply whhsuch provisions orthis Permit shall Is,deemed ranked. 502 — FINAL PLUMBING ENERGY
zrn CONSTRUCIONLENDING AGENCY 503 - FINAL MECHANICAL ENERGY
I hereby affrm that there is riaruction lending agency for the perfarmance of 504 — FINAL BUILDING ENERGY
Y. > the work for which this permit is issued Sue.3097,Co,C.)
s7 q Leader',Name 505 — FINAL ELECTRICAL
�z nder'sAddmu 506 — GAS TEST
;)0 I cavity that 1 have read this application anal show that Be above information is 507 — FINAL PLUMBING
J. coven.1 agree to comply with all city and county ordinances and stemm
laws missing
TrUV building construction,and hereby authorise representatives of this city mcnwr upon the 4INMEC CAL
ah"vcmcmiuncdpropertyion,and for iby au ionpurepres.
0. (We)agree m vase,indemnify and keep hanmleu the City of Cupertino against 0 9 r
rA liabilities.judgment.casts an xpntn which may in any way acrneagainn ssid City 5 NG I
J z in ernuyuenec of the gamin of,hi,permit. /
APPLICANT UNDERSTA DS AND WILL COMPLY WIT^H ALL NON-POINT Issued by:5 C WORKS Date
SOURC EGULATI
V Re-roofs
Si t e r IF a 0 tractor Data
HAZARDOUS MATERIALS DISCLOSU Type of Roof
Will the applicant ser fuss building occupmtuom or handle hvallous material
as fined by the Cupertino Municipal Code.Chapwr 9.13,and the Health and Safety
Code, 25532(.)?
0y. All roofs shall be inspected prior to any roofing material being installed.
❑Ya u
Will the applicant r future wilding eccupan,use equipment or dcvica which If a roof is installed without first obtaining an inspection,I agree to remove
mit h l.o nus air cavum amu as defned by the Bay Arta Air Quality Management all new materials for inspection.
rm,7
❑Yci yl nhy
I have mad the hareolourm�atcrials requircrecnt under Chapter 6.95 of the Calif x.
pia Healthf&C'n
ecdmu25N15,35533.d25534.lunde.md Nmirft¢ ilding
d cutenant,Net it is my mapomihility to omit,the t¢cup.,of me
re ire nM et prion"issuance Ora cordncal,�e(Oc cy. Signature of Applicant Date
n oramn rivcdage., /�l e All roof coverings to be Class "B" or better
- SUBMIT (.
#1
�ppRov cccr on
1N PCCOADPNCE WAN
GUP.ERtt RECEIVED
ZEMoSt SEP 15 2003
OP and spdicaiand 1t is oa
SIGN set of P' ob at aU hme os: attetakla BY: �i�
Sh�s t 1 es taml�
chanB m�ssion
oe KeF� make any
dtten Pec
1o` same wd Dot.,CAI of 8�sp�b�r�
oe badd�n�geo khts pian et os.to viuooa LJt 1
he stamp a held to 4 t any pco � �.✓11
jpAN NOo t e 4tolaaoof Staff 1 (40
s� L�
appsolla Ord1nance �7
Cr`�y�
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aOTOFCTY OF CUPERTINO*
CUPEI,TINO PERMIT APPLICATION FORM
N# L� OV Date:
Building Addres :
Owner's Name: /^/ / / hone #:
S �7
Contractor: r ' p License#:
• Contac . / . /r tl�, ,^ Cupertino Business License#:
Buil n ermit Info:
BI g Elect ❑ Plumb ech ❑
Job scription: GGA
Residential ❑ C erci 1
Sq.Ft. Floor Area: q. t.:
Cost of Project: i Occupancy Group:
Type of Construction:
uantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> IOOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILERS Boiler> 1.75MBtu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
13CONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V <= IOOOA ELECTRICAL
BELEC1001 Elec 600V > IOOOA 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
z3/ 3
1 of 3
x-33 7,6
TPERMIT
OITY OF CUPERTINO
APPLICATION FORM
PE TI
CU NO
Quantity Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-FarnU Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMIv1 New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family Res BUILDING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check 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 HeaterNent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 clip MECHANICAL
BREMAIRHAN A/C Units <= 10,000 clip MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BRENMXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Fumace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
2 of 3
40
WITY OF CUPERTINOO
MY OF PERMIT APPLICATION FORM
CUPEII;TINO
Quantity Fee ID Fee Description Fee Group
BREMPOWER Power Device/Apparatus ELECTRICAL
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 Signs, 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 s foot PLUMBING
ZADDCHG Address Chane BUILDING
•
3 of 3
OTWER-BUILDER VERIFICAT#
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
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 bove is true and correct. I have read and understand the
Owner-Builder Information ( verse side)
Properly Owner sSignature: AJ - `LN Date:
Job Address: /V 7� S . I Ct`(V7q U Permit#
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 0, 10300 Torre Avenue
C U P E TI NO 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 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 d or county. The are also required b law to put their license number on all
city tY Y q Y
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 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,
Cary of Cupertino
Printed on Recycled Paper