10050155 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VALLEY GREEN DR APT 476 CONTRACTOR:UBS PERMIT NO: 10050155
OWNER'S NAME: UBS 20800 VALLEY GREEN DR DATE ISSUED:05/19/2010
NER'S PHONE: 4082530200 CUP-tRTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATIONF
BUDDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH r RESIDENTIAL F_ COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALL WASHER/DRYER UNITS INSIDE COMM'L APT
(commencing with Section 7000)of Division 3 of the Business&Professions BLDGS
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,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 provided for by Sq.Ft Floor Area: Valuation:$100
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:32609040.476 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state 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 ]HERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the :_80 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section �� S "
9.18. Issu>d by: Date:
Signature Date
f
kl OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of insta led without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
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, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I hai a read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the Calilornia Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safe y Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
mair tain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I Owner or authorizgd agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must �t,� _� X =-��Date:
ZS 1 10
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I herby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for N hich this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lencler's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lentler's Address
mnify and keep harmless the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I unc erstand my plans shall be used as public records.
9.18.
g --M 4 Lice ised Professional
Si nature l �Date q
`1 CITY OF CUPERTINO
OF
CUPEkTINO GENERAL BUILDING
PERMIT APPLIC.i.TION FORM
APN# Date:
Building Address•` �-` 4 7�
L�-o �c- o V
:� c/CE'c1 Esc
Mailing Address (if different fr building ad ress):
rm�('4A
Owner's Name: s Phone#:
U e
o
HOA: (Exterior work only) Yes U N �, 140 zS2�-OZ�60
If yes, provide- letter from HOA
Contractor: T e 0 Phone:
Fax:
Contractor License#:
Cupertino Business License#:
Contact: �^ Phone: Lf��, •�sZ-76 q.3
fvl�c Aa_e ( --1,;,kcd- Fax: q73-408- 73- (025
Residential Commercial
Job Description: i
psi 5-_,It w eL stl-e ll �)�.�e� U [-4-S
Co LAA V-t e✓-C t.0 l 14 Q.,4&,-, d d "L,�15
P
Building Permit Info:
Bldg V Elect Plumb Mech LTJ
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B Ef — 2—
Valuation: `00, Square Footage:
Project Size: Express ❑ Standard (� 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.)r
Revised 02/05/09
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20800 VALLEY GREEN DR APT 505 CONTRkCTOR:DEVER1 CONSTRUCTION PERMIT NO: 10050063
INC.
941 D BI'RRYESSA RD DATE ISSUED:05/06/2010
( ER'S NAME: UBS PHONE NO:(408)441-9598
OWNER'S PHONE: 4082530200
SAN JOSE,CA 95133
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# MECH RESIDENTIAL r- COMMERCIAL
Contractor Date
JOB DESCRIPTION:INSTALL WASHER DRYER UNITS INSIDE COMM'L AP
I hereby affirm that I am licensed under the provisions of Chapter 9 BLDGS
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Valuation:$100
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft floor Area:
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. APN P umber:32609040.505 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save
ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 1FROM LAST CALLINSPECTION.costs,and expenses which may accrue against said City in consequence of the 130 DAYS
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section —
.
9.18.
S' -ture Date
RE-ROOFS:
OWNER BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of instal ed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspe;tion.
I,as owner of the property,or my employees with wages as their sole compensation, Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signs ture of Applicant:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code). _.
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I ha,,e read the hazardous
5 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's Cali.'orn► Health&Safety Code,Sections 25505525533,Chapter 9
and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the
com aliance with the Cupertino Municipal Code,Chapter 9.12 and the Health
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. mai main compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall
Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's q
Compensation laws of California. If,after making this certificate of exemption,I Ow ier or auth rized a ent: te. ` / I D
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I he reby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
he above mentioned property for inspection purposes.(We)agree to save Leirder's Address
1. Anify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I u iderstand my plans shall be used as public records.
9.18. Li,:ensed Professional
Signature 1 t��(CJ �G�M��/L`^'�^ Date A
CITY OF CUPE 2TINO
PERMIT RECEIPT OPERATOR: patg
8 ITEMS OF 8 COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lct:
APN 32609040 . 505
DATE ISSUED. . . . . . . : 05/06/2010
RECEIPT #. . . . . . . . . BS000010337
REFERENCE ID # 100500E3
SITE ADDRESS 20800 VALLEY GREEN DR APT 505
SUBDIVISION . . . . . . :
CUPERT::NO
CITY
IMPACT AREA . . . . . .
OWNER UBS
ADDRESS 20800 VALLEY GREEN DR
CITY/STATE/ZIP CUPERTENO, CA 95014
RECEIVED FROM KANRYH�EVERAYALLIC # 24605
CONTRACTOR . . . . . .
COMPANY DEVERA CONSTRUCTION INC.
ADDRESS 941 D BERRYESSA RD
CITY/STATE/ZIP SAN JOSE, CA 95133
TELEPHONE (408)441-9598
FEE ID UNIT QUANTITY AMOLNT PD-TO-DT THIS REC- --NEW-BAL-
----
-
---------- -------------
----------
----- -----
------
------
00
1BCBSC VALUATION 100 . 00 1. 00
0 .00 1 . 00 0 •
1BREMRECEP NO. OUTLETS 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1BSEISMICR VALUATION 100 .00 0 . 50 0 .00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1. 00 42 . 00 0 .00 42 . 00 0 . 00
1MPERMITFE FLAT RATE
1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
1PREPPIPE FLAT RATE 1 .00 42 . 00 0 .00 42 . 00 0 . 00
1TRAVDOC FLAT RATE 1.00 42 . 00 0 . 00 42 . 00 -- -- -
TOTAL PERMIT
253 . 50 0 . 00 253 .50 0 . 00
METHOD OF PAYMENT AMOUNT----- REFERENCE NUMBER
------ -------- -----------
CREDIT CARD 253 . 50 AMEX
---------------
TOTAL RECEIPT 253 .50
CITY OF CUPERTINO
CITYOF
CUPEk INO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # Date:
Ct - vyo
Building Address:
'ZO �60
Mailing Address (if different fr building ad ress):
Owner's Name: Phone#:
HOA: (Exterior work only) Yes U No
If yes, provide letter from HOA
Contractor: Phone:
T Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone: v�,
Fax:
Residential Commercial ❑
Job Description:
.,.� psi 5-���� ��-,�.e� C �f�e� C) �• �S t cam- 5�'��
Rj dc) r L^ S
P
Building Permit Info:
Bldg V Elect Plumb Mech L�
Type of Construction(Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT,V-B Er — 7—
Valuation: /00, Square Footage:
Project Size: Express ❑ Standard � Large ❑ Major ❑
Green Building: Please complete relevant portion of th a Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set & the sheet index.
oints Achieved:
For help, contact Build it Green at www.builditgreen.cI
Revised 02/05/09
OWNER-BUILDER DISCLOSURE FORM
CttPEI[tTfb[O
Dear Property Owner(s):
An application for a building permit has been submitted in your lame listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS APN BP#
OWNER NAME OWNER ADDRESS
V k L_L A C C s Ar C(.,�O c r i t—)c 5 V O ' 0 'Y R(I Iv U
DESCRIPTION OF WORK:
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having :his permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, initialeA your understanding of each provision, signed, and
returned this form to us at our official address indicated. /,n agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permit ing authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF Il�FORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
1. 1 understand a frequent practice of unlicensed pers)ns is to have the property owner obtain an "Owner-
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. 1, as an Owner-Builder, may be held liable and Subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
IV9 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor tc assume this responsibility.
3. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a Iicen:ed Contractor and having the permit filed in his or her
name instead of my own.
—\14. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
AS-5. I understand if I employ or otherwise engage any pE)rsons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer" under state and federal law.
\6. 1 understand if I am considered an "employer" undE r state and federal law, I must register with the state and
federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also L nderstand my failure to abide by these laws may subject
me to serious financial risk.
r
V7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intont to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures doe:; not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general buildirg Contractor.
8. 1 understand as an Owner-Builder if I sell the propE rty for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
0,A,nerBuilde7-Form_2010.doc revised 04/12/10
V� 9. 1 understand I may obtain more information regardinc my obligations as an "employer"from the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or www.c.-lb.ca.gov for more information about licensed
contractors.
49—
10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for roposed construction activity at the following address:
�9 AUC 1(Fri _C-f C �y o- k i�? O� U pC �l I k3 a C� 9`S O I q
11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
_12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractcrs are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, tho Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a resu t of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of th sir workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lenc ing agency information .)
I hereby affirm that there is a construction lending agency for t-ie performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permit can be issued,this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the agency is required to be presented when the permit is issued to
verify the property owner's signature. S (O
Signature of property owner: Date:
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWIER'S BEHALF Q IL �(�- p-6--/V_ C s
(NOTE. The following Authorization Form is required to be cor-ipleted by the property owner only when designating an
agent of the property owner to apply for a construction permit f:)r the Owner-Builder).
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s) to act as my agent(s) to apple for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note:A copy of the owner's driver's license, form notarization, or other
verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
Oh72e7'Bui.lde7'Fo1791_2010.doc revised 04/12/10
OWNER-BUILDER NOTICE
_/MI"W/:.. jai��1i Z. .r :.7A�.;+f''`.'- .`
i' /1.-�'�i -`T;A"`. �` ..L-^ 'T-.Siliti�L:t :l.
C�LIF�ER�[Ih[O -
Effective January, 1, 2009, Assembly Bill 2335 amends California Health and Safety Code,
Section 19825, regarding disclosures and verificat ons required for all applicants seeking Owner-
Builder construction permits. These new application requirements provide an enhanced level of
consumer awareness and protection for property owners accepting the risks associated with
Owner-Builder construction permits.
"The Legislature hereby finds and declares that there is an urgent and statewide public interest in
assuring that building contractors comply with the Contractors License Law...and provisions of
law relating to Workers' Compensation Insurance -or building construction, that property owners
are informed about, and protected from, fraudulen:representations, liability for worker's injuries,
liability for material and labor costs unpaid by contractors, licensing requirements, and
employer's tax liabilities when improving their prc perty as owner-builders"
Important information you need to kr.ow BEFORE pulling your permit!
The term"Owner-Builder" can mean three different things:
"Owner as Worker", "Owner as Cor:tractor" or "Owner as Employer"
Understand each has Benefits or Risk, and it is possible to combine them!
Hiring a California Licensed Contractor means you do rot personally perform any of the construction work, the
permit is not taken out in your name, you are not personally responsible for the construction and you are not an
Owner-Builder. Instead, you become a "Customer' and CE lifornia law provides you the benefit of protection from
poor workmanship,failure to finish the job and financial risk due to worker injury.
Benefit/Risk: HLahest Benefits.-ad the Least amount of Risk
Owner-as-Worker is a type of Owner-Builder where you.personally pe7f01771 the construction work, the permit is
taken out in your name and you are personally responsible for the construction management, knowledge,
workmanship, and completion of the job. You benefit by Iiot paying others to perform this work for you and your
risk depends on your own ability to complete the job successfully.
Benefit/Risk: P L:e Ii�n�_f`.t with inLnci.ai ;i it
Owner-as-Contractor is a type of Owner-Builder where 3 ou personally act as your own General Contractor, the
permit is taken out in your name and you hire Californ.a licensed sub-contractors to perform portions of the
construction work. WARNING: The benefit of protection provided by law when you hire only California licensed
sub-contractors can turn to serious financial risk if you hire t7ilicensed contractors to perform any of the work.
Benefit/Risk: : - _-,:f;: and`<iznificant Financial Risk
Owner-as-Employer is a type of Owner-Builder where you pay any unlicensed individual to perform any
construction work valued at more than $500.00, the perrtit is taken out in your name and you are personally
responsible for their employment requirements, supervision, performance, safety and welfare while on your
property. WARNING: Cost savings benefit can turn to serious financial risk if you fail to deduct payroll taxes or
provide workers compensation insurance for each worker.
Benefit/Risk: i=' ith gni icant Financi:L R2i
Over 20,000 consumer complaints are i fled each year. Many complaints relate to
owner/builder projects and include workmanship and workers' compensation issues
Homeowners suffer financial harm due to defective workmanship and injured employees.
OwnerBuilder 2010.doc revised 04/12/10
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parfmt,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 c.o:
A. All of the work
B. IZ A portion of the work (complete section below)
Contractor Address/City. Phone # State License # Type of work to
C
�l..¢-ojow qS t Pf t Ivy. X50 - S -06g 2a� ie c�
3. V I will utilizeunlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand than I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compen3ation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City . Phone Number Type of work to be
erformed
vC oc�ville CA
fojc �Ug1S V. 9151 0 a (u+ ►
...............................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information (reverse side). i
Property Owner's Signature: C_��'� Date: � 16 110
Job Address: Ug00 ��a«e v� ctwl 5o� jVtA_+j AC C�- Permit# —
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.