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09030196CITI' OF CUPERTINO PERMIT NOW BUILDING DIVISION BUILDING ADDRESS: PERMIT NO. 20875 VALLEY GREEN DR #103 TBD — TO BE D OWNER'S NAME: PERMIT ISSUE DATE PHONE:RET JkMfAwA0CONTROL NO. ARCHTTECT(ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 o a 0 LICENSED CONTRACTOR'S DECLARATION 70b Description I hereby affirm that I am licensed under previsions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and affect INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES License Class Lic. d DateContractor M/E/P' S—SEE PERMIT #09030198 FOR PLAN CK ARCHITECTS DECLARATION I understand my plans shall be used as public records COMMENTS. Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from tie Contractors License Law for Ute following mason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure Sq. Ft. Floor Area Valuation prior to its issuance, also requires the applicant for such permit to file a signed statement Law 9 that he is licensed pursuant to the provislons of thecontractoesLicensc (Chapter (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 100 that he is exempt therefrom and the basis for the-alloged`exemption. Any violation of APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant W a civil penalty of not mom than five hundred dollars (5500). 32609064.103 ❑ 1, as owner of the property, or my employees with wages as their 3010 compensation, ns Required Inspections q P will do the work. and die structure is not intended or offered for sale (See.7044.Business an owner of and Professions Code: The Contractors License.Law does sot apply toe property who builds or improves thereon, and who does such workhimself orthrough his own employees, provided that such improvements are not intended oroffered 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 sate.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044. Business and Professions Code:) The Conttaemt'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 Contr tcwfs License Law. ❑ I am exempt under Sea . B & P C for this reason Owner Date 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 issueA My Worker's Compensation Insurance carrier and Policy number are: Cartier. Policy No.: CERTIFICATE OF EXEMP ION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for ono hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as 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 shallhe deemed revoked. ) 4 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 Name Lenders Address 1 certify that I have mad this application and arm that the above information is correct I 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 j liabilities,judgments, costs and expenses which may in any way see= against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT- Issued by: Date SOURCE REGULATIONS. Re -roofs _ Type Roof Signature of Applicant/Contractor Date HAZARDOUS MATERIALS DISCLOSURE of Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code. Chapter 9.12, and the Heshh and Safety Code, section 25532(x)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes [3 No 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 materials for Inspection. District? ❑Yes ONO 1 have read the hazardous materials requirements underChapter 6.95 of the Califor- nia Health &Safety Code, Sections 25505,25533 and 25534.1understand tlhatifthe building does not currently have a tenant that it is my responsibility to notify the occupant or the requirements which must be met prior t0 issuance of a Certificate of Occupancy. Signature of Applicant Date All roof coverings to be Class 'A" or better Owner or authorized agent Date ' CITY OF CUPEkTINO CITY OF CUPERTINO GENERAL BUILDING PERMIT APPLICATION FORM APN #01?0 O 113 -2 4 — �3 Date: /� _ / - `�., `� Building Address: I Z q, cc // r% p� ✓. /�J Mailing Address (if different fro buildin address): Owner's Nar--- Phone #: HOA: (Exterior work only) Yes U No 1 L! 2-S3 If yes, provide letter from HOA Contractor: Phone: Fax: Contractor License #: �� J{ L! Cupertino Business License #: Contact: Phone: 9-552.—%(, V� Fax: Lf OS' C? 0 ZS Residential Commercial ❑ Job Description: Building Permit Info: Bldg N!r Elect Uv Plumb Mech 19' Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV -HT, V -B A—Z Valuation: 100 Square Footage: Project Size: Express ❑ Standard Q'*' Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Points Achieved: For help, contact Build it Green at www.builditgreen.orgy Revised 02/05/09 CITY OF CUPERTINO 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 1BSEISMICR Seismic Residential B 1BSEISMIC0 Seismic Commercial B 1TRAVD0C Travel & Documentation B 1BUSLIC Business License B 1� [3 aZ.Ai V -C ce 5 of 5 City of Cupertino Building Department DCITY OF NO f 10300 Torre Avenue CU 1 E k I I r! 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 unlesss-they are personally performing theirownwork. If your work is being performed by someone other than yourself, you may protect vourself 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 andmaterial 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 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. _ 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 --'We .. of —w� all K'S ►t,MAE% & I Nlve�7�1` 18�'11, . , , e , � . o � ,. . . ARM, s� 3. 1L 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. I declare wander penalty of per jm-y that the above is true and correct. I have read and understand the Owner -Builder Information (reverse side). Property Owner's Signature: _ Date: 6121I0S T Job Address: 0$ S Y lo, ?Jl i l�l�o, Permit # Anv chanzes to the_ information provided on this form shall be submitted to the City of Cupertino Build Department. ..Phone Number Type of work to . . r I declare wander penalty of per jm-y that the above is true and correct. I have read and understand the Owner -Builder Information (reverse side). Property Owner's Signature: _ Date: 6121I0S T Job Address: 0$ S Y lo, ?Jl i l�l�o, Permit # Anv chanzes to the_ information provided on this form shall be submitted to the City of Cupertino Build Department.