09030159 CITY OF CUPERTINO
BUILDING DIVISION PERMIT S LCTQK I�E0 ISN.
BUILDING ADDRESS: PERMIT NO.
20990 VALLEY GREEN D TBD — TJ BE D
PERMIT ISSUE DATE
OWNER'S NAME:
—'F'i-vRET CONTROL NO.
..TONE:
BUILDING PERMIT INFO
ARCHITEcT/ENGINEER:
BLDG ELECT PLUMB MECH
300 LICENSED CONTRACT'OR'S DECLARATION Job Description
ext I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z,u withSccdon7000)ofDivision3ofdeBusincssandPro(cssionsCodc,andmyliccnscis
in full fora and effectINSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
y
Z License Class Lic•B
Date^ Contractor E/M/P' S—SEE PERMIT #09030198 FOR PLAN CK
3 O
ARCHITECTS DECLARATION COMMENTS.
1 understand my plans shall be used as public records
7yU
4 O H Licensed Professional
N 3 OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following mason.(Section 7031.5,Business and Professions Cale:Any city or county
e$ which requires a permit to construct.alter,improve,dcmolLch,or repair any structure
4;- prior to its issuance,also requires the applicant for such permit to rile a signed statement Valuation
_ that he is licensed pursuant to the provisions of the Contractor's Lin cnsc Law(Chapter 9 Sq.Ft.Floor Area
Y F- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $100
y 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 APN Number Occupancy Type
not more than five hundred dollars(5500). 32609053 . 668
❑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 for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's 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
7sa 1.
I,its owner of the property,am exclusively contracting with licensed convectors to
construct the project(Sec.7044,Business and Professions Cale:)The Contractor's 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 pursuant to the Contractor's
License Law.
❑I am exempt under See. B&P C for this mason
Owner ^-�`^ Date 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 Cake,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Career: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be completed if the permit is for anc hundred dollars($100)
or less.)
I certify that in the performance of the work for w'h this permit is issued.I shall not
employ any person in any manner so o hCcrpnc sjec{�o Workers'Compensation
Laws of California.Date 1 C7 1 f J
Applicant
NOTICE TO APPLICANT:If,atter making this Certificate 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 be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[~i I hereby affirm that there is a construction lending agency for the performance of
a 5 the work for which this permit is issued(Sec.3097,Civ.C.)
L4 A Lender's Name
0.Z L.cndees Address
U C) I certify that I have read this application and stale that the above information is
{Z h ^ correct.I agree to comply with all city and county ordinances and state laws mlating to
V building construction,and hereby authorize representatives of this city o enter upon the
0
0 U above-mentioned property for inspection purposes.
LL (We)agree to save,indemnify and keep harmless the City of Cupertino against
rF-t to liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
►-t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by..
so1JRCE_ NS.
r—.✓ Re-roofs
Signature of Applicant/Contractor Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Munich al Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532(x)? 1 All roofs shall be inspected prior to any roofing material being installed.
❑Yes o
If a roof is installed without first obtaining an inspection,I agree to remove
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 all new rr aterials for inspection.
District?
❑Yes Ly>ru
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand 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 mel issuance of a Certificate of Occup Signature of Applicant Date
'W tir
r./i.. A =ti All roof coverings to be Class in"or better
Owner or authorized agent Da
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. _ of the work
B. A portion of the work (complete section below)
Contractor Address/City. Phone # State License # Type of work to
/
ye—CA U 2 (lo C5 C �•u
Gan U r
3. �/ I will utilize unlicensed person(s) other than my immediate fanvly 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.
Persen/Firm
Address/City Phone Number Type of work to be
Performed
H oC
J uv
--e- a b c C�1-
d/
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: Date: (ZI 0 9
Job Address: I `� U ta.�w d� 6 g htnA� (?A- Permit # 0'3 0 301 S
Anv changes to the. information Provided on this form shall be submitted to the Citv of Cupertino Build
Department.
City of Cupertino Building Department
CITY OF 10300 Torre Avenue
C O P E kT 1 N O 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 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
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
1 CITY OF CUPERTINO
CUPEkTINO GENERAL: BUILDING
PERMIT APPLICATION FORM
APN # �2 �S3
Date: a�LU 20, 2��f
Building Address: ZVee ////o
�✓ee� �
O G(P +�, b
Mailing Address (if different from building addr ss):
Owner's N e.
Phone #:
HOA: (Exterior work only) Yes ❑ No f
L4o - ZS3 d O
If yes, provide letter from HOA
Contractor:
Phone:
f
Fax:
Contractor License #:
Cupertino Business License #:
Contact: `G�.�c� c✓c`ue✓
Phone: 9 og- .2-52-76q-3
Fax: 900 - X73 - (o ZS -
Residential . Commercial
Job Description: nn
(i
CITY OF
CUPEiZTINO
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
1 EPERMITFEE
Electrical Permit Fee
E
1 MPERMITFEE
Mechanical Permit Fee
M
1 PPERMITFEE
Plumbing Permit Fee
P
l ELCPLNCK
Stand Alone Electric Pln Ck (hourly)
E
1 MECPLNCK
Stand Alone Mechanical Pln Ck (hrly)
M
1 PLMBLNCK
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
1 BCBSC
Cal Bldg Standards Commission Fee
B
ALL PERMIT
TYPES
1`\
1BSEISMICR
Seismic Residential
B
1BSEISMICO
Seismic Commercial
B
1 TRAVDOC
Travel & Documentation
B
1 BUSLIC
Business License
B
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