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09030110foo IU 7yU iU. l— �O Ay �p0 KmrA �Zr ERE i BUILDING DIVISION PERMIT )ING ADDRESS: OWNER'S NAME: ARCHTTECI'/BNGLNEER: I hereby affirmthat I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class Lle• S Date Contractor ARCHITECTS DECLARATION 1 understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct. alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit w rile a signed statement that he is licensed pursuant to the provisions of the Contractor's Licensc Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Conuactoes License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon, and Fwh onuacts for such projects with a contractor(s) licensed pursuant to the Contractor's ose Law. I am exempt under Sec B & P C for this mason Owner Date 5 1 WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a Certificate of Consent to self -insure for Worker's compen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Workees Compensation Insurance carrier and Policy number are: Carrie Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE Job Description IINSTALL WASHER/DRYER.UNITS IN APTS-INCLUDES E/M/P'S-SEE PERMIT #09030198 FOR PLAN CK COMMENTS. Ft. Floor Area Valuation APN Number Occupancy Type F32609041.246 (This section need not be completed if the permit is for one hundred dollars ($ 100) or less.) I certify that in the performance of the far �wQprk hich this permit is issued. I shall not employ any person in any manner so to cpmcubjlaii tV Workers' Compensation Laws of California. D Cb3 VV 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 mus forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Namc Lender's Address I certify that I have read this application and state that the above information is correct. 1 agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NO -POINT SOURCEREGULA ONS. ! Signature of Applicant/Contractor (� are HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Corte, Section 25532(a)? ❑ Yes @'N0 Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? �.(�� ❑ Yes Llr'i I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safely Code, Sections 25505.25533 and 25534.1 undersand that if the building does not currently have a tenant, that it is my responsibility to notify the occupant of the requirements which must be met prior issuapce of a Certificate of Occuparjty_ Owner or Date Issued by Re -roofs Required Inspections Type of Roof All roofs shall be inspected prior to any roofing material being installed. If a roof i s installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant All roof coverings to be Class "`' or better Date PERMIT NO. PERMIT ISSUE DATE S CONTROL NO. BUILDING PERMIT (NFO BLDG ELECT PLUMB D D O Job Description IINSTALL WASHER/DRYER.UNITS IN APTS-INCLUDES E/M/P'S-SEE PERMIT #09030198 FOR PLAN CK COMMENTS. Ft. Floor Area Valuation APN Number Occupancy Type F32609041.246 (This section need not be completed if the permit is for one hundred dollars ($ 100) or less.) I certify that in the performance of the far �wQprk hich this permit is issued. I shall not employ any person in any manner so to cpmcubjlaii tV Workers' Compensation Laws of California. D Cb3 VV 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 mus forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Namc Lender's Address I certify that I have read this application and state that the above information is correct. 1 agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NO -POINT SOURCEREGULA ONS. ! Signature of Applicant/Contractor (� are HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Corte, Section 25532(a)? ❑ Yes @'N0 Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? �.(�� ❑ Yes Llr'i I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safely Code, Sections 25505.25533 and 25534.1 undersand that if the building does not currently have a tenant, that it is my responsibility to notify the occupant of the requirements which must be met prior issuapce of a Certificate of Occuparjty_ Owner or Date Issued by Re -roofs Required Inspections Type of Roof All roofs shall be inspected prior to any roofing material being installed. If a roof i s installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant All roof coverings to be Class "`' or better Date rY OF CUPERTINO BUILDING DIVISION PEPMT BUILDING ADDRESS: OWNER'S NAME: ARCHITECT/ENGINEER: i o a LICENSED CONTRACTOR'S DECLARATION U 1 hereby affirm that I am licensed under provision of Chapter 9 (commencing Z with Section 7000) of Division 3 of the Business and Professions Code, and my license is �< y in full force and effect v� Z License Class Lic. tf E, o Dam Contractor LU ARCHITECTS DECLARATION E < I understand my plans shall be used as public records )yU c u w Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractoes License Law for the 00 following mason. (Section 70315, Business and Professions Code: Any city or county . 9 which requires a permit ro construct, alter, improve, demolish, or repair any structure o Z yo prior m its issuance, also requires the applicant for such permit to file a signed statement 2 that he is licensed pursuant to the provisions of the Contractor's L.( mm Law (Chapter 9 u$ (commencing with Section 7000) of Division 3 of the Businessand Professions Code) or ,, that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 70313 by any applicant for a permit subjects the applicant to a civil penalty of not mom than five hundred dollars ($500). ❑ I, as owner of the property. or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered forsale (Sec. 7044. Business and Professions Cade: The Conuactoes License Lawdoesnot apply 10 an owner Of property who builds or improves thereon, and who doessuchwork himself or through his own employees, provided that such improvements are not intended or offered forsale. If, however, the building or improvement is sold within one year of compWian, the owner - builder will have the burden of proving that he did ant build or improve for propose of sale.). ❑ L as owner of the property, am exclusively contracting with Bcensed contractors to construct the pmject (Sec. 7044. Business and Professions Coda) The Contractor's Li- ccnse Law docs not apply to an owner of property who builds or improves themon. and. sohets for such projects with a contractor(s) licensed pursuant m the Contractor's K=aw. I am exempt under See. B & P C for this nuison Owner _ � ......r. Data 5 G. 1 It, I hereby affirm under penalty of perjury one the following declarations: ❑ I have and will maintain a Certificate of Consent to self -Insure far WindwesCompen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of dee Labor Code, for the performance of the work forwhich this permit is issued. My Worker's Compensation Insurance carrier and Policy number are: Carrier. Polity Na: CERTwiCATE OF K`xEMFnON FROM WORKERS' COMPENSATION INSURANCE Cfhis section need not be completed if the permit Is foronc hundred dollars ($10M or leo) I certify that in the performance of the rk for hick thUSp It is issued. I shall not employ any person in any manner so me b workcrecompensation Laws of California. D = Applicant NOTICE 7 0 APPLICANT, If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code; you must Qforthwith comply with such provisions or this permit shall be deemed [evoked. z ^'~ CONSTRUCTION LENDING AGENCY [tet ).4 I hereby affirm that. there is a construction lending agency for the performance or pa the work for which this permit is issued (See. 3097, Civ. C.) W Q L.cndees Name z Lcndees Address U 0 I certify that I have toad this application and stat that the above information is LL ►� correct I agree to comply with all city and county ordinances and state laws relating to 0 U building construction, and hereby authorize representatives of this city to anter upon the a above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against rn liabilities, judgments. costs and expenses which may in. any way accntcagainstsaid City U Z in consequence of the granting of this permit ► t APPLICANT UNDERSTANDS AND WILL COMPLY WrrH AL NO POINT SOURCE REGULA 0� 1� �6� '0056..lJh Signature of Applicant/Contracmr lbsto— HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupantsmre or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? .! ❑ Yes tgrro Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the. Bay Area Air Quality Management District? �'� - ❑Yes Lftvo Job Description IINSTALL WASHER/DRYER,UNITS IN APTS-INCLUDES E/M/P'S-SEE PERMIT #09030198 FOR PLAN CK COMMENTS. Ft. Floor APN Number Occupancy Type 32609041.246 Issued by: Re -roofs Type of Roof Required Inspections Date _5 &D , () 9 All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. 1 have mad the hazardous materials mquimme is underChapter6.95 of the Califor- nia Health & SafctyCode, Sections 25505.25533 and 25534.1 understand thatif the building does not currently have a tenant, that it is my responsibility, to notify the occupant of the requirements which const be mel prior iss of a Ccnificam of Sinature of Applicant A I9 "iCe � amp I /I lX g PP Owner or authorized aCenl ` Dato - Date All roof coverings to be Class 'n" or better PEKMrr NII. PERMIT ISSUE DATE S e 9 CONTROL NO. BUILDING PERMIT INFO BLDG ELECT PLUMB 0 a 0 Job Description IINSTALL WASHER/DRYER,UNITS IN APTS-INCLUDES E/M/P'S-SEE PERMIT #09030198 FOR PLAN CK COMMENTS. Ft. Floor APN Number Occupancy Type 32609041.246 Issued by: Re -roofs Type of Roof Required Inspections Date _5 &D , () 9 All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. 1 have mad the hazardous materials mquimme is underChapter6.95 of the Califor- nia Health & SafctyCode, Sections 25505.25533 and 25534.1 understand thatif the building does not currently have a tenant, that it is my responsibility, to notify the occupant of the requirements which const be mel prior iss of a Ccnificam of Sinature of Applicant A I9 "iCe � amp I /I lX g PP Owner or authorized aCenl ` Dato - Date All roof coverings to be Class 'n" or better CITY OF CUPEf�TiNO CITY OF CUPERTINO GENERAL BUILDING PERMIT APPLICATION FORM D9�30//O APN # Date: Building Address: Mailing Address (if differe t from building addr ss): ?a t14V C - Owner's Name: B *ro J L4 Gt ��0✓t Phone #: HOA: (Exterior work only) Yes No o 0 2 -co If yes, provide letter from HOA Contractor: / Phone: Fax: Contractor License #: Te 1 Cupertino Business License #: Contact: Phone: L4 2 52— _-7 6 44 3 Fax: Lfog- % lo— ZS-Residential Commercial ❑ Job Description: r Building Permit Info: Bldg Elect Plumb Mech Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV -HT, V -B v - 4-2— Valuation: / Square Footage: Project Size: Express ❑ Standard Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it to the applicatlbn or if applicable, include in plan set & the sheet index. Points Achieved: For help, contact Build it Green at www.builditgreen.org Revised 02/05/09 CITY OF CUPElkTINO CITY OF CUPERTINO GENERAL BUILDING APPLICATION FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Group Permit Type 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) additional stucco application B 1 WINREP Replacement windows/sliding glass door (ea 8 windows) B 1 WINMEWSTR New Window -structural shear wall/masonry (includes plan ck fee) B 1EPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fee M 1 PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P 1 STPLNCK-(3 Hr Min when not over counter) Standard Plan Check (when no E/M/P) hourly -stand alone B 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES /X f`\ 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B 1 TRAVDOC Travel & Documentation B 1BUSLIC Business License B (--'F -1�-P 07 5 of 5 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. _*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. "fflof the work B. A of of the work (complete section below) Contractor Address/City. Phone # State License # Type of work to z t-6f:��,-zwgti r4 t L -f -I-91 2 6 6 i ec-l„u-��� q- - ZC4 -$-?D� J. (^� S.: 3. V/,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. PersorVTirm Address/City Phone Number Type of work to be ormed �/ // P.T dC , (v . 0 -fl -I 20 S a L - ZC4 -$-?D� J. I declare ender 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: ��-� Date: 61.2,10 1 Job Address: 02oq �s d� #a4 6&qo W�wo Ok Permit # On SO 110 Any changes to the. information provided on this form shall be submitted to the Citv of Cupertino Build Department. _a City of Cupertino Building Department CITY OF (� 10300 Torre Avenue C, 113 E R T I N� J 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 axe 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 pei-mit 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 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