03010075 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATIOM
BUILDING ADDRESS: FRED MARTINEZ PERMIT NO.
10735 PENINSULAR AV 03010075
OWNER'S NAME: APPLICATION SUB DATE
ak FRED MARTINEZ 01/13/2003
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
020 LICENSED CONTRACTOR'S DECLARATION Job Description
U P 1 hereby affirm that 1 am licensed under provisions oo
f Chapter 9(commencing
with Section 71410)of Division 3 ofthe Business and Prufeasions Code,and my license is
mmufOreeaadeffibm ELECT PANEL UPGRADE
License Class hit.0 OZ,§ Dale Contractor
g ^�^� ARCHITECTS DECLARATION
gshy&a Iunerstand my plans shall he cardas public records1%OaU
LLo� Licensed Professional ! RLDl OWNER BUILDER DECLARATION
aE I hereby affirm that 1 em exempt fru.the Cumrectors License Law for the
.0 0 following rerson (Serono 7031 5 Business and Professions Code Any city Or county
u $i which requires a pernh w construct,eller,improve,demolish,or repair any structure L _
Nte prior hr its issuance,also rcyuims the applicant for such permit to rile a signed statement
that W is licensed pursuant in the provisions of the Contractors License Law(Chapter 9 Sq.Ft. Floor Area $V ation
$ (commencing with Section 7XXB of Division 3 of the B urines and Professions Code)or
that W is exempt therefrom and die basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil Penalty of Wr;6wu Occupancy Type
not more than five hundred dollars(1500).
❑1,as owner of the progeny,or my employees with wages u their axle cnmpensalion,
will do the work,and the structure is not intended or offered for sale(Sec.7144,Business
and Professions Code:The Contractor's License Law does not apply to an owner of 304 - ROUGH Lr].1Wn'KJ,-L`.1+ ions
properly who builds or improves Hereon,and whodoessuch work himself or through his
own employees,provided Nat such improvements are not intended or offered for sale.If, 505 — FINAL ELECTRICAL
however,the building or improvement is sold within one year of completion,Ne comer,
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
ciento d the project(Sea 7044,Business and Professions Code:)The Contractor's Li- _
cense Law does not apply to an owner of property who builds or improves Neuron,and
who contracts for such projects with a coni=m(s)licensed pursuant to the Contractor's
License Law.
)and 0 in on on. B&P C for this..on
Owbe
p
tX/A x WORKER'SCO PENSAI—F TIONDECLAAXf1ON
1 hereby aRrm under penally of perjury Due of the following declarations:
I have and will maintain a Certificate of Consent to aclf-insure for Worker's Compen-
ation,as provided for by Section 37W of the Labor Code,for the performance Of the
work for which this permit is issued.
1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of Ne Labor Code,for the perfnr.mce of On,work for which this permit is issued.
My Worker's Compensation Insuranm carrier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nor he completed if the permit is forone hundred dollars WIM
or less.)
I certify that in the performance of the work for which this perroir is issued,I shell of
employ any person in any mandrin as to become subject to the WorkersCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject In The Worker's Compensation provisions of the"her Code,you must
O Z forthwith comply with such previsions or this permit shall be deemed revoked.
O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a cnnsWctinn lending agency l or the performance of
(Y.1 17 the work for which this permit is issued(Sec.NAG,Ci,C.)
W Q Lender's N.
z Lender's Address
U I cattily that I have read this application and sum that the above information is
Lka h cermet.l agree to comply with all city and county ordinances and state laws relating to
Q U building construction,and hereby aurhonse representatives of this city to enter upon the
r W above-mentioned property for inspection purposes.
„F,a
(We)agree to save,indemnify and keep harmless the City of Cupertino against
V) liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this Permit.
�+ APPLICANT UNDERSTANDS AND WILY COMPLY WITH ALL NON-POINT Issued by:3 Date
SOU An (`_
Re-roofs
Signature of ApplicanVContracmr D
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle ha sNous material
as defined by rhe Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)' All roofs shall be inspected prior to an roofing material beim Installed.
❑Yes �N0 P P Y g g
Will the applicant or future building Occupant use equipment tar devices which If a roof is installed without first obtaining an inspection,I agree to remove
tit hazardous air conaminanu s delmod by the Bay Area Air Quality Management all new materials for inspection.
icl7
❑Yrs Nn
1 have read the harsNous materials requirements under Chapter 6.95 of the Califor
-
nisHealth&Safety Cade,Stations 25505,25533 and 25534.1 undersand the Tthc budding
does not cureary have a Is.ID1.thm it is my responsibility to ratify Ibe
rc pans o e
of, arta me onO anco OfaCcrtifiumnf. Occu enc
q s£ �" _ p Signature of Applicant Date
All roof coverings to be Class "B" or better
.c,idstatormcd agent Dare
f OWNER-BUILDER VERIFICATION
1. (Check one) I711mmediate family(parent,spouse or child)will perform:
A. the wgrk 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 1 g 2003
B. _ A portion of the work(complete sectio be11
Contractor Address/City Phone # acense # 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
performed
.....................................................................................................................................................................................
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 SignaturD�:
job Addr-7 /6 Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
t s +
City of Cupertino Building Depart
CITY OF 10300 Torre
RTINO Phone: (408)777-3228
CUPE
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 yottrself 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 ani 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 plat 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 compensa ti
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 aid 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 at 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
Pdnted on Recycled Paper