04090093 (2) CITY OF CUPERTINO �' T 717 10 11
BUILDING'DIVISION' -` PERMIT_-`"_ ��4�aJ,. ygl, � i'���
BUILDING ADDRESS: ANNE H HA PERMIT N0.04090093
ER'S NAME: PERMIT ISSUE DATE
ANNE R RA
P ONE: SANITARY ONTROL NO.
ARCHITECdENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u00
LICENSED CONTRACTOR'S DECLARATION JobDescri tion
he
1 mby affirm de
Net 1 am licensed unr pewmiou of Chapter 9(commencing p
wish Section 7000)of Division 3 aides Business and Professions Codi my license is
infull form and affect. 7 ' FENCE & GATE
S�? License Class Lie.p
n— Dan Contractor
ARCHITECTS DECLARATION
IUnderstand myplaaaaballheUsed aspublic weeas START JOB WITHOUT PERMIT/BPERMFEE DOUBLED
�yU
iLicensed Professional
N OWNER-BUILDER DECLARATION
ContrION
I hereby affirm Nat 11. exempt from tits Contns Co License Lew for the
p O following moon. (anis a]co L;B.altar, and Professions Code:Any city at county
which myuima ce.also
m construct.the,alma improsu demolish,fie pair any tWduac
y$ prior In its iuuenm.also mquiru powbarllant for such Permit toicenssigned w(hlcmcnl
that he is licensed punuenlln the Provisioas of the Contractor's License law(ChaPtcr9 Sq.Ft. Floor Area Valuation
y+FQ (commencing wife Section 7000)of Division 3 of the Business and Professions Code)or
y
that he is exempt themfmm and Ne basis for the aReged exemption.Any violation of
Smuon 7031.5 by any applicant for a permit subjects Nc 1pPIXW10 a evil Penalty of APN Number Occupancy Type
not mom one five hundred dollars(5500).
❑L as owner m(the pmpeny,m my employees wife wages. .1.(See
compensation,
will dm thework endo: 1a,Con Is Connector's
Ucecde Law
do Londe(See.7044,owner ss
of
and Pmfeuions Code:The Contndon, ndwho Law dose not apply lf an owner of Req O
Own
who
yebuildsviimprovumemo%,andwho dosesuch wait himulredthrough his ED
own employees,provided that such Impm old wit are not intended oroRemd for Owner,
however,Ne building or of pmenl is sold a within one year of mpromf r Ne owner-
builder .will have Ne hussars of proving that he did not build or impmrc for purpose of
sale.).
OCT ,,S- 28%
❑1,a mvner of ct property,,B exclusively contracting wife licensed Comments n
came La the es not (Sec.to in Business and ry,wh ions Cade:)The ConOrmors.Li- BUILDING■ �I�
cease law docs not apply o m owner of property,who belles or improves Con m ac and, B U DIN
whocontractsLo ts for such proKcts wife a contncwKaj licensed pursuant to tin Contnnora
License Law. /V-
❑lamexemptmolar5ee.�.B&PC( this on
et Dna.`Z�
I ORKER'S COMPENSATIOND RATION
' Iitem y elftnn under penalty of perjury one of Ne following metantlons:
❑1 herr and will maintain a Cenificam of Common salt-insure for Worker's Compact-
a..,as provided for by Section 3700 of Me,Labor Code,for Ne performance of she
work for which Nia permit is issued
0 1 have and will maintain Worker's Compensation Insurance,as acquired by Section
3900 of to labor Code,for Ne performance arms work for which this permit is issued.
My Worker's Compensation tlon Insuncanner and Policy number am:
Cartier: Pelicy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisuclion need not he completed if the permit is faronc hundred dollars(SIM)
or less.)
I certify Nat in fee performance of to work for which this permit Is issued,l shall not
employ any Person in any manner an az to became Wajcm to the Workcn'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
Warsaw Subject m the Workers Compenulion PNNalona Of fee labor Codc,you must
.J Q forthwith comply with such provisions or this Permit shall M deemed mvoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm Nat mem iso construction lending a,awy for Ne parformanec of
Nrthe work for which this Permit is issued(Sm.IDB?,Civ.C.)
aQ Lender's Name
z 1<nder's Addrtss
U Q I certify that I have mad this application and soon Net the above information is
D.F correct.l agree to comply with all city and county maintains and sate laws mleling to
DU building construction,and hereby authntlre mpresematiru of this city to enter upon lite
W ahove-mentioned property for iupccumn purposes.
(~ D. (We)agree to save,indemnify and keep hartnleu the City of Cupertino again%
fA
liabilities,judgments.costs and expenses which may in any way accrue againalaid City 11//
61'� to consequence of the granting of this permit. -
Fa APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N -POINT Issued by: Date
SOURCE RE ULATI 5. _„
1 Re-roofs /
ignamre f pplican Contmcmr "' De `
HAZARDOUS MATERIALS DISq.OSURE Type of Roof
Will me applicant or future building Occupant store or handle haaardmus material
dented by the Cupertino Municipal Code,Chapter 9.12,and the HeapN and Safety
a.5e%ion 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes �Nu
sew the applicant or mom banding omnPam u egapmem nr d vna winch If a roof is installed without first obtaining an inspection,I agree to remove
emit Immid.us air contsminants as dcrincd by the Bay Arca Air Quality Managcm..I all new materials for inspection.
District? ll''
❑Yes I Nrt
1 have mad Ne h t aaouus\\mncrials mquiremcnts under Chapnr6.95 of the Calif n.
nia Nealm&Safety Cade,Sections 25505.25533 and 25534.1 understand dualities building
does not currently hero a tenant.Nat it is my wapomihility m nobly tie occupant of Ne
mguiremcnas which asst here do m i%enm ora Cenlfianof Occup Y' Signature Of Applicant Date
Own rmauthoTricd aFcns Da '
All roof coverings to be Class"B"or better
CITY OF CUPERTINO ^'-
BUILDING DIVISION PERMI� G4.1NTA A -T
UR
BUILDING ADDRESS: ANNE H. HA PERMIT NO 04090093
OWNER'S NAME: FINALED PERMIT ISSUE DATE
WE: OCT Off/��a�.I/�00(4 SANITARY CONTROL NO.
ARCHITECTMNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Fu in nihir
0 0 0 0
a O O LICENSED CONTRACTOR'S DECLARATION11-60'
Z1 hereby affirm Net 1 em liwnsed under provisions of Chapter 9(commencing - Jo crlption
< wiNSection1Q90)ufDivision3ofthe Businessattd Professions Code,andmylicenwis
in full force and effect. 7 ' FENCE & GATE
License Class Lk.#
nF Date Cammer"
ARCHITECTS DECLARATION
1 undcmmnd my plans shall he used w public records START JOB WITHOUT PERMIT/BPERMFEE DOUBLED
icyU
;.t; Licensed Professional
g OWNER-BUILDER DECLARATION
<� I hereby affirm that 1 em exempt tram the Contractor's License Law I'ar the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
X 2�i which requires a,pmmil to construct.alter,improve,demolish,or repair any structure
at
prior m its issuance.also requires the applicant for such permit m file a signed statement
psi th. cislicensedpursuanttotheprovisionsoftheConlrncmr'sLicenselaw(Chapter9 Sq.Ft. Floor Area Valuation
'FG (commencing with Section 9000)of Division 3 of the Business and Professions Cnde)ur
y Net he is exempt therefrom and the basis for Ne alleged exemption.Any violation of 5000
Section 1031,5 by any applicant for a Permit subjects the applicant to a civil penalty of ane APN Number Occupancy
not myu than five hundred dollars(S500). P Y Type
❑1,as owner of the property,or my employees with wages as their arm compensation,
will do the work,and the structure is not intended or offered for sale(Sic.1044,Business
and Professions Code:The Conusctors License Law does not apply to an owner of Required Inspections
prapertywho builds orimp haves Hereon,and whodoessuch work himselfor through his
awn employees,provided thatsuch improvements ere not intended araffered for sale.If,
however,We building or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or improve(or purpose of
sale L
❑1,as owner of the property,am exclusively contracting with licensed contractors to
constmct the project(Sec.1044.Business and Professions Code:)The Character's Li.
cane law does not apply to an owner of property who build&or improves themon,and
who contracts for such projects with a contractor(s)licensed pursuant in the Contractors
License Law. -
❑lamexempt ordthis as
order .B&PCf,
Owner ll�, Date
�'
WORKER'SCOMPENSATION-DECLARATION
1 hereby atm under penalty of perjury ow of the following declarations:
l have and will maintain a certificate of consent to self-in&um for Whim's Compen-
sation,as provided for by Section 3100 of Ne Latin,Code,for Ne performance h(the
work for which this permit is issued.
❑I have and will maintain Workeh Compensation Insurance,as required by Section
3100 of the Labor Cade,for the performance alum wok for which this permit is issued.
My Worker's Compensation Insomuch carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('fhb section need not he completed if the Permit is intone hundred dollars($100)
tir less.) t
1 artily that in the performance of the work for which this permit is issued,I shall not _
employ any parson in any mannerm az to become subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked.
z Q CONSTRUCTION LENDING AGENCY
E^4 I humpy ailuro that Ono,is.cotvrucunn lending agemoy bathe performance of
C4' > the work for which this permit is issued(Sic.3091,Cie Q
lLl A Leader's Name
xa7. z Lender's Address
U Q I certify Nm 1 have read this application and said,that the above information is
p,i— correct.I agree to comply with all city and county oNinaem and state laws missing to
QU building construction,and hereby auNorim representatives of this city to emir upon the
W shove-mentihnedpmpcnt fan imspectihn purposes
y
Wed agreeo saw,indemnify and keep harmless the City of Cup nina against
tti % liabilities,judgmentsecosuand expmtsmmit. may in anyway accmc againstsaid City
IJ 7 A consequence of UNDERSTANDS
in6 of this permit
t� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N N-POINT ISSUCd by: Date
SOURCE RE ULATIgqNS. _
_' " 1i, 4 l.S�o Re-roofs
ignamre of imam ConuncmrDel
/ HAZARDOUS MATERIALS DISCja0SURE Type of Roof t'
'Will the applicant or future building occupant store or handle haamdous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(&)? _(,IN. All roofs shall be inspected prior to any roofing material being installed..
Will thea applicant or future building occupant use equipment If a roof is installed without first obtainingan inspection,I agree to remove
pct s p q pmenl o,devices which P g
it hazardous air contaminants az defined by the Bay Arca Air Quality Management all new materials for inspection.
Disvict? `��
❑Yes p{Nu
I have mad the havablouuss\\matcrials requirements under Chapter6.95 of the Califon
nit Halth&Safmy Code,Sections 25505,25533 and 25534.1 understand thotif tM building
does not curemly have a mount,that it is my responsibility m nuuty the Occupant of the
rcquiremcmxwhicn ustbcm4 no wi. mcf.certificacia0mcp y - Signature of Applicant Date
Own r'orauNoriicdagcnl Da
0 All roof coverings to be Class"B"or better
OWJVR-BUILDER VERIFICATIO6
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
vc cca vivacu
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 above is true and correct. I have read and understand the
Owner-Builder Information(reverse side).
Property Owner's Signature: O� O
Job Address: Permit# QaOq MJ ;
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 Avenu
C U P S RT I N O 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
pecifiedFor 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 city or county. They are also required by law to put their license number on all
pemnits 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
ATY OF CUPERTINO p
CUP,TYo- O PERMIT APPLICATION FORM
ERTN Date:
t /S
a
Building Address: Mailing Address (if different from building address):
D 7A-4)0 6 41 VO
Owner's
--
Owner's Name: Phone#:
08— -PST— 7
Contract r: License#:
Contact: Phone: Cupertino Business License#:
Fax:
Building Permit Info:
131dElect ❑ Plumb ❑ Mech ❑
Job Descriptio • ./-
Residential ❑ Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of Proje t:4- Occupancy Group
Type of Ci ons .io Please check this box i the project is a
second-story addition: ❑
ro'ect Size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI 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
1 of3
OTY OF CUPERTINO
CUPERTINO PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTWE 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 Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 clip 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 Furnace > l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
• BREMINHOOD Installation of Hood MECHANICAL
s+ BREMMISC Misc Apparatus, ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
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
2 of 3
9 CITY OF CUPERTINO
CUPIwoTiNo PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
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.
BS WIM 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 Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
3 of 3
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he bui.ding Dept., i y of Cupe.t;no• Z
i he stamping of thi ,an;nd specii0tiom q
;HALL NOT be he :) pe.mit ur to be Of J
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