03110091 (4) 'CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTnR�INF.ORMATIGIN '
BUILDING ADDRESS: PERMIT N003110091
'957 VERNIE
ER'S NAME: PERMIT E15UE DATE
MESH & BEEBA MENON 11/18/2003
NE: - SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�Op LICENSED CONTRACTOR'S DECLARATION
I ZC 1 hereby affirm that 1 am licensed under provisions or Chapter 9(commencing Jeb,Deseription.
w wildScmion]fXlO)ofDivision3oftheBusincssandProfcssionsCnde,entlmyliccnseis `�_j_�7
3t Zia,
in full force and effect. ADD BATHROOM
License Class Loc.N J -
�Fp Datc TS DECr
qq 7W ARCHITECTS DECLARATION
)au lunderstand my plans shall Mused as public records
s�� Licensed Professional
5 < OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from Am Contractor's License Law for the
.M0 following reason.(Section 703 1.5,Business and Professions Code:Any city or county
3$ which requires a permit to construct,alter,improve,dcmnlish.Or repair any structure 88000
-iy prior as its issuance,also requires the applicant for such Permit to rile a signed suument
2 < that he is licensed pursuant o the provisions of the Contractors License Law(Chapter 9 Sq. Ft. Floor Area Valuation
2�0 (commencing with Section 71100)of Division 3 of the Business and Professions Code)or
$ that he is exempt themfrom and We basis for We alleged exemption.Any violation of
Section]031.5 by any applicant for a permit subjects the applicant to a civil Penalty of µ'8e700 Occupancy Type
not more than rive hundred douars(5500). P Y YP
0 I,as owner of the pmpeny,or my employees with wages as their sole compensation,
will do the work,and me structure is not intended or offered forml.(Sec.7044,Business
and Professions Codd:The Commerce's License Law docs not apply to an no,of Required Inspections
property who build&or improves thereon,and who does such work himself orthrough his
man employees,provided that such improvements are not intended oroRerdd intuit.If,
however,are building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving chat he did not build or improve for purpose of
salcJ.
❑1,as owner of the property,am exclusively contracting wild licensed contractors to
conswet the project(Sec.7044,Business and Professions Code:)The Conlrazmr'a Li.
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuanuo Be Contractor's
License Law.
❑Ismlander IS B&P C for this..an
el eluw� pate //-i8-e3
137MWORKERS COMPENSATION DECt.sK ATION
I hereby affirm under Penally of perjury one of me following declarations:
have and will maintain a Cenificale of Consent to self-insure for Worker's Compcm
n,as provided for by Section 3]00 of the Labor Catle.for to performance of the
for which this permit is issued.
have and will maintain Workers Compensation Insurance,as required by Section
of me Labor Code,for the performance of the work for which this Ponan is issud.
Wmkere Compensation Insurance carrier and Policy number,arc:
Cartier: Polity Na.:
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not Meompleted if tM Permit is for one hundred dolls o(1X1)
or loss.) -
I eci ify met in the performance of the work for which this permit is issued.1 shall not
employ any person many manner so ax A Mcome subject,.the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Ceniliwm of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you must
.,z forthwith comply with such provisions or this Permit shall bb deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
j—t I hereby affirm that there is aconstruction lending agency for the Performance of
me work per which this pmmil is issued(Sec.3097,Civ.C.)
A Lender's Name
= z Lenders Address
J Q I certify that I have read this application and state that the above information is
(y correct.I agree to comply with all city and county ordinances and slate laws misting to
Q V building consWetion,and hereby authorim representatives of this city to enter upon me
W ah.ve-mentioned preNny for inspection purposes.
(Wer)agree to save,indemnify and keep harmless IM City of Cupertino against
y liabilities.judgments,costs and expenses which may in any way accrue against said City ��s porm it. �ap
U z APPr
NTCof the grand AS or UNDERSTANDSIhrND WILL COMPLY WITH ALL NON-POINT Issued by: Date a'(Jf
EGULATIO
/I—�g-0 Re-roofs
ApplicanVC.mracmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Ae applicant or future building occupant store or handle haysrdous material
y the Cupertino MunicilCod,Chapter 9.12,and the Health end Safety
n 25532(x)? —/ All roofs shall be inspected prior to any roofing material being installed.
es L2 the applicant or mture building Occupant ase cile;pmcal or devices which If a roof is installed without first obtaining an inspection,I agree to remove
nm air contaminants u defined by the BayArcaAir Quality Management all new materials for inspection.
/
❑Yes sgNu -
C
I have read the harartlom materials requirements under Chapter 6.95 of the Califar.
.in Braila&Safety Coder,Smidurs 25505,25533 and 25534.1 undcrsund thu it Be holding
does not cuvmnly have a tenant,that it is my responsibility m And I the.ecupam Of the
actVarent,whic rannhinictpdortoissuanecor'acerfificatc�foccupancy. 3 Signature of Applicant Date
gy
or smhmired egcnt , - All roof coverings to be Class"B"or better
OWNER-BUILDER VERIFICATION
(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 perfonmed
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: 0 Date: I.2
Job Address: S W-E,e/V r F. C i , CL-'PF-6-71 N b pmt#
Any changes to the information provided on this form shall be submitted to the Cit of f Cupertino Build
Department.
r
•
City of Cupertino Building Department
CITY OF 10300 Torre Avenue
CU PEf�TINO Phone: (408) 777A7
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 Califon-da 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 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