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05080200CITY OF CUPEkTINO CITY OF CUPERTINi_ PERMIT APPLICATION FORM a APN # Date: Fee Description Fee Group L m, , l � � (if Ad Buildin g Mailin g ess di Addres �-,� ferent from building address): I � � lc �' Owner ame: ' l Phone #- r� Contractor: License #: Tf —2 MECHANICAL Contact_ Phone: Vie. Cupertino Business License #: ktiv Faxc MECHANICAL Building Permit Info: Bldg Elect [ Plumb ❑ Mech ❑ Job Description: �' LYt��- �'?ci,- o�" t11t„ 41 X41-- tqC�� 1;� a rZ' ty ► ��;': 11 Residential ❑ 6 �o _ , Comm rci , Sq.Ft. Floor Area: $ /Sq Ft. BBOILER5 Cost of Pr "er± ry Occupancy Group: BCONSTAX Type —of Cons cti Please check this box if the project is a second-story addition: ❑ Project Size: Standard Large ❑ Major ❑ BUILDING 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 of 3 3 C .�.' i '1°1 CITY OF CUPERTINO BUILDING DIVISION PER] BUILDING ADDRESS: I SASHA CUKIC OWNER'S NAME: SASHA CUKIC ARCHITECT/ENGINEER: n O p LICENSED CONTRACTOR'S DECLARATION U �. 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing a ywith Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. 'D ? License Class Lic. k ah p Date Contractor J ARCHITECTS DECLARATION yyf < I understand my plans shall be used as public records JyU iN Licensed Professional < OWNER-BUILDER DECLARATION n J I hereby affirm that I am exempt from the Contractor's License Law for the im O following reason. (Section 7031.5, Business and Professions Code: Any city or county >< Pi which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 F- (commencing with Section 7000) of Division 3 of the Business and Professions Code) or a 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 (8500). C9' 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 Contractors 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.). ❑ I, 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 who contracts for such projects with contractor(s) licensed pursuant to the Contractor's License Law. ❑ I am czempt under Sec. , B & P C for this mason Owner t�"� "' Date 1 z 7 0 ER'S e!OM15ENSATION DECLARATION I hereby affirn under penalty of perjury one of the following declarations: ❑ 1 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 Workers Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number are: Carrier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is Intone hundred dollars ($100) or less.) I certify tha! in the performance of the work for which this permit is issued, I shall not employ any person in any man cr so as to become subject to the Workers' Compensation Laws of California. Date 1 Z /O.t"" 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 .J ,Z forthwith comply with such provisions or this permit shall be deemed revoked. Z O CONSTRUCTION LENDING AGENCY (� I hereby affirm that there is a construction lending agency for the performance of (l the work fur which this permit is issued (Sec. 3097, Civ. C.) LL) Q Lender's Name Lender's Address �z U Q 1 certify that 1 have read this application and state that the above information is LL F-' correct. 1 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 enter upon the GTt above- mentioned property for inspection purposes. GL (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses wl i may in any way accrue against said City iJ Z in consequence of the granting of his per . APPLICANT UNDERSTAND AND ILL COMPLY WITH ALL NON -POINT SOURCE REGULATIONS. Signature of Appli n roc or Date HAZARDOU ATERIALS 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 Code. Section 25532(x)? ❑ Yes ❑ No 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? F1 Yes No I havc read the hazardous materials mquiremcnts under Chapter 6.95 of the Califor- nia Health & Safety Code, S uons 25505, 25533 and 25534. I understand that if the building does not currently have cnan, that it is my responsibility to notify the occupant of the requirements w �h m bey prior to issuance of a Certificate of Occupancy. I `r— 9/ 42 CLF Owner u tit onzctl aecnt Date PERMITNQ0 5 0 8 02 0 0 PERMIT ISSUE DATE 08/22/2005 SANITARY NO. CONTROL NO. BUILDING PERMIT INFO BLDG ELECT PLUMB 0 0 0 Job Description REMODEL -ADD BATHRM & REPLACE WINDOW IN MS BEDROOM /RELOCATE KITCHEN Ft. Floor Area 3S716 TI: I .-00 Required Inspections Issued by: `1�■I ����/� Re -roofs Type of Roof Va pancy Type Date r 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 al l new materials for inspection. Signature of Applicant Date All roof coverings to be Class "B" or better CITY OF CUPERTINO Item 1 of 1 PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 35716011.00 DATE ISSUED.......: RECEIPT #.......... REFERENCE ID # .... SITE ADDRESS ...... SUBDIVISION ....... CITY .............. IMPACT AREA ....... 08/22/2005 30871 05080200 21796 STEVENS CREEK BLVD CUPERTINO OPERATOR: conniew COPY # : 3 OWNER ............: SASHA CUKIC ADDRESS .......... CITY /STATE /ZIP ...: CUPERTINO CA, 95014 -2700 RECEIVED FROM ....: AIDA CUKIC CONTRACTOR .......: LIC # *OWNER* COMPANY ..........: SASHA CUKIC ADDRESS .......... CITY /STATE /ZIP ...: CUPERTINO CA, 95014 -2700 TELEPHONE ........: FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---- - - - - -- BPERMFEE ------- - - - - -- VALUATION ---- - - - - -- 25,000.00 ---- - - - - -- ---- 331.56 - - - - -- 0.00 ---- - - - - -- 331.56 ---- - - - - -- 0.00 BPLANCHK PERMIT FEE 331.56 442.47 0.00 442.47 0.00 BREMFURN NO UNIT 1.00 14.31 0.00 14.31 0.00 BREMVENSYS NO UNITS 1.00 10.26 0.00 10.26 0.00 BENERGY PERMIT FEE 331.56 159.15 0.00 159.15 0.00 BSEISMICRE VALUATION 25,000.00 2.50 0.00 2.50 0.00 PPLBG SQUARE FEET 240.00 19.20 0.00 19.20 0.00 ELECTRIC SQUARE FEET 240.00 19.20 0.00 19.20 0.00 EPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00 MPERMFEE SQUARE FEET 240.00 19.20 0.00 19.20 0.00 MPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00 PPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00 TOTAL PERMIT ---- - - - - -- ---- 1132.96 - - - - -- 0.00 ---- - - - - -- 1132.96 ---- - - - - -- 0.00 METHOD OF PAYMENT AMOUNT NUMBER ----------- OTHER - - - - -- ------ - - - - -- 1132.96 --------------- VISA - -- TOTAL RECEIPT 1132.96 M OF CU PEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777 -3228 Fax (408) 777 -3333 Building Department JOB ADDRES : - "t � PERMIT # d ip Cl � �`d e ID o BUSINESS LICENSE # PHONE # -OWNEIZ'SNANIE:----�;��,31ria GENERAL CONTRACTOR�L�, �• t}� AX # 3��' I am not using any subcontracto s: Z� °'� ; Signature '� ate Please check applicable subcontractors and complete the followutg information Owner/ Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing �' 1O�c l 'oi�� Electrical Excavation Fencing Flooring. Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/ Contractor Signature Date U - NER- BUILDER VERIFICA' _)N 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 be performed 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 verformed 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: v Dater Job Address: Z 9 6 S', EveiV s e C Permit # Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. t ?r CITY OF City of Cupertino Building Department 10300 Torre Avenue C U P E T 1 N 0 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 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 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