03110016 CITY OF CUPERTINO a *++' + •�:' :^' a *�?,''
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
`�k�aS+>+. ^',
BUILDING ADDRESS: BERT & ANN HENDERSON PERMITNO03110016
2s/6327 RoT,T,TNnFR RD
tI :'S NAME: PERMIT ISSUE DATE
ERT & ANN HENDERSON 11/04/2003
SANITARY NO, CONTROL NO.
ARCHMC'rfENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
efop LICENSED CONTRACTOR'S DECLARATION
f1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
with Section 7").r Division J of the Business etM Profaidmis Code,and my license is
° mfull area and erre, SIDE DOOR TO GARAGE F" NALE®
r t- Date Contractor r-I
TS DE
eqq ARCI3ITELTS DECLARATION
G2 lunderstand an,plans shall he mcdupuhlic rccnNs •g qq O q
to Licensed Professional NOV 1 2003
OWNER-BUILDER DECLARATION 1sat��llsYw
'
i q 1 herchy air,,.dust I em exempt from the Contractors License Law for the
pO following motion.(Section 7031.5,Business and Professions Code:Any city(am county 1 0 0
m which requires a permit construct,alter,improve,demolish,or repair any structure Ila/
prior la its issuance,also requires the applicant for such Permit o file a signed statement
gs< that he is licensed pursuant u,the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
21"'S (commencing with Section 7000)of Division 3ofthe Business and ProfessinmDark)or 36919001 . 00
y .. mat he Is exempt therefrom and this basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of APN Number Occupancy Type
not mart than five hundred della.(SSW).
❑I,as owner of,he property,on my employe.with wages u Meir sole rompensatian,
will do the woirtuad theswcture is not intended morrered hassle(Sec.7044,Business Required Inspections
and Pra(eaiom Code:The Compactors License Law docs not apply u an owner of q p
pmperywha builds or improves themon,and whodas such work himulfor through his
own employees,provided that such improvements at not intended of offered for We.If.
however.the building or improvement it said within one year of completion,the owner.
builder will haw the burden of proving that he did not build or improw for purpose of
sale.).
❑h as Owner of the property,am exclusively contracting with licensed conormu is to
construct the project(Sec.70,14,Business and Professia.Code:)The Coruscate,U. _
come law dose not apply to an owner or property who hAide or improves themon,and,
who contracts far such projects with a eonwcsor(s)licensed pursvam to the Convector's
dteenu Law.
,*I Car aundersec. .B&PCfor O33oxWp
eta
WO E CO ENSA NDECLA�ONa�
Ihereby affirm under penalty of perjury am of the following declerations:
1r I haw and will maintain a CenlOcate of Consent to self-insamrorWorkehCompen-
atitn,M provided for by Section J7O0 of the labor Code,for me performance of the
work for which this permit is Hated.
❑1 haw and will maintain Workers Compensation Insurance,.required by section
7700 of the Labor Cada.(or the pctformancc of me work for which this permit is laved.
My Worker',Campensmion Int auric:carrier and Policy number me:
Caniee Policy No.: _
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
M13 section mcd not hecompkied light permit is for one hundred dolls.(11011)
or less)
I anify that in the performance of the work for which this permit is issued.I shall not
employany Pe m nyman r . oma subject tothe Workers Compenvdar
Laws of C,lifo ate
APppliam L�/ifw
TO AM:IL inner makingmit i n of Exemption,you should=subject the Worker'sCompensationprovisions of me Lab¢Cock,you mum
[ forthwith coply with such provisions or this Permit hal
Ec damN rewtetl.
Z O CONSTRUCTION LENDING AGENCY
1 herchy ar0rm that due.it a conawctinn mprimg ,ney for the perfurmana or
me work for which this permit i,issued(See.3097.Civ.C.)
yQ Lendeh Name
Z Lenders Add..
U Q 1 certify mat 1 haw read this application and sus that the above Information is
Use t- corer,1 agree to comply with all city and county omimarsces and sure laws relating to
OV building Contwction.and hereby authorie,rcpreaemitiws of this city to enter upon the
Dl above-mentioned property for inspection purposes.
LL (we)agree to sew,indemnify and keep harmlea the City of Cupertino against
,y In liabilities,judgments.costs and expenses which may in any way we=against said City
his
V s7�• APPLICANT eUNDERSTANDSAND WIof tILL COMPLY WITH ALL NON-POINT Issued by: Date
SO GULATIONS
Re-roofs
Sign re or Applican/Comnctor 9FILc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant tar future building Occupant store or handle hem adous material
a dcnned by the Cupertino Municipal,Codc,Chapter 9.12.and the Health and Safety
sO'ban
n21111 11, All roofs shall be inspected prior to any roofing material being installed.
hY. Nu
Will the appliant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
qffi It hazardous air comamin ms u defocd by the Bay Area Air Quality Management all new materials for inspection.
isuict?
❑Yes f,TNu
1 haw Aced thehatamous ma M5. requirementsunder Cha pauduaifthcCzlifaa-
doesnoth&Safctyhowasatiw.Our It. my resrd753J,1.Iumtmury thuiflM Wilding
does not currently how a tenant that It u my respomihility m ramify occupant of dm
myui uwhichmughein nn issuance of.Cerdficateof Y. Signature-ofApplicantDate
c tar amhoaiacd ag t Da All roof coverings to be Class oB^ Or better'
CITY OF CUPERTINO
BUILDING DIVISION PE RM
BUILDING ADDRESS; BERT & ANN HENDERSON PERMIT N003110016
I-622r)/6327 ROT-LINGER RD.
WR'S NAME: PERMIT ISSUE DATE
BERT & ANN HENDERSON 11/04/2003
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
FILM ELECT PLUMB MECH
0, LICENSED CONTRACTORS DECLARATION Job Description
I hereby of OM I am licensed moda,putwistm.or Chapter 9 bxOnormOclog
with Sdcm,.70`111).fDiAmrm 3.fdo.B.si.,dd P,dfcsd,,O,CWO..nd royflocruseis
in full to=and effect.
.Dv, SIDE DOOR TO GARAGE .
!MK LmeascClaid—Lic.ax FINALED
Dam.Contractor
ii ARCHITECTS DECLARATION
I understand my plane shall Im muctim;Public records NOV 8 2003
U
InLicensed Professional
0 OWNER-BUILDER DECLARATION
I batch,art,,.that I.m almotpi from the Cmum,wes License Law for the
a C following meson.(Section 7031.5,Business and PrOrcedom Code:Any city or county BUILDING
C.� which requiron;.Permit 1.c...Imel,Met,improve,demolish.Or repair any Unumhoo $1500
UZ" pricer In its whence,also mr,mmos the applicant for such Permit to rile a signed statement
that he is licensed pursuant to the pmviamps of the Contractor's Littre Law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Bushnell and Phroazinvo,Code)or 36919001 . 00
that he is exempt Omeafmon and the basis for the alleged exemption.Any violalbon of
Section 7031.5 by any applicant for a pennh subjects the applicant to a civil penalty of APN Number Occupancy Type
not mem flash five hundred dollars($500).
0 1,as owner of me Property,or my employe"with wages as their sole compensation.
will do the work,and orejumouthe is not intended or offered I...1.(Sec.7044,Basin. Required Inspections
and PrOfictuti...Code:The Contractors License Law does;not apply to in Owner of
,property who builds or improves therchn,and who doessuch work himselfor through his
Own employees,provided Oat such improvements are not intended oroffemd for sale.it,
however,me building or improvement is sold within one you of completion.the Owner-
builder will have On burden or pmving that he did not Wild or improve per purprom,or
sal..).
E]I.as Owner of the property,am exclusively contracting with licensed contractors to
COMIMCt the pMjCCL(See 7044;Business and Professions Code:)no Contractors Lt.
cense Law does not apply to an Owner of progeny who Wilds or improves lonum.and,
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
k§.
License Law.
I c of, S c Is&P C for this..an
a
ON
I hereby of under Penalty of perjury one Of the following declarations:
r—1 I have and will mountain a Camficate,of Consent to adr-losum fOrWOrkah"Crumpan'
later,as provided for by Section 3700 or the Labor Code,to the Performance of the
work for which this plumh is issued.
n I have and will maintain Workers Compensation Insurance,as paquirad by Section
3700.r the Lather end.,for the Performance of the work for which this perfal,is looted,
My Workers Compensation hostmersee carrier and Policy number am:
Cartier. Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
D"Ims section necal not w complcmd HIM Permit Is forron,hundred dollars($100)
for IOW
I certify due,I.the Performance of me work for which Oil Permit is issued.I shelf not.
,.P,.,.n . bf;;ftwoftercrompameation,
yho 10 10,an
1.1c.lip,
NC rn ANT:it.rter making this Clmal,Of Exemption,you should
bcoc;�;,, object I. be worsoor.crou,sheatim,Ila
or the Usse,code,you room
fOnetwiffi,mon,with such provisions or Oil ponnitmutil tv deconsul rowlead.
Z CONSTRUCTION LENDING AGENCY
;_; 1 harobaffl.Notherem.conumnuctirm lemA.S.,anc,fortne"funrumecof
Ne work for which this permit is issued(Sec.3W7,CN.C.)
Uj Q Loodee.Name,
z Lender's Address
U 0 1 certify that I haw read his application and show that the shadow information Is
u. coma I agree to comply with all city and county ordirsomeas and seats,laws milling to
0 V Wilding construction.and hereby autborrim mphosenialive,of that city 10 color upon Me
above-mendomcd pmperty for inspection purposes.
(We)agree to saw,Indemnify and keep harmless Im City Of COPordho Against
Y liabiliflea,judgrucots,costs and expenses which may in any way accrue against aid City
Te,
U Z in consequence of the gmuLing of this Permit. Issued by:91lto-�W_
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Date
SO &RIGULATIONS
4LIIII�,— / Re-roofs (:7
Signiff1m,o(ApidicanYContractor Ithom,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Of future building Occupant store or handle harardous MAIC691
as donned by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
rude.Section 25532(m7 All roofs shall be inspected prior to any roofing material being installed.
0 Yas u Will the appliant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Will Weanums air contaminants as donned by the Bay Area Air Quality Management all new materials for inspection.
Distria?
Elym; 9kNa
re
1 have ad the Weani,ma rommi.is re,oirchtcuts antic,Chapter 6.95 or the C.Iffor.
nix Health&Safety Cott,Sections 15505,25533 and 25534,1 undarmoral that if he Wilding
does not commily have A tonant,that It is my responsibility to nutty the.1.1.1 of 0.
hah must Im In I . I . r C.111-am of O`hW ture of Applicant Date
guyeect , , c Y. igna
S,
710mW..
mlem. All roof coverings to be Class"B" or better
dhi
0 0
6325 & 6327 BOLLINGER
. SITE PLAN &LOCATION OF PROPOSED NEW DOOR
79 . 0 012
BACKYARD BACKYA D �1D
AppROVED OV 0 2003
PoN ADMANC E WITH THE CITY OR H
NO CO ES N .0 DINAi' 59
SLIDING
N
��f, I&of p:aos ;n specilications 00T,
U'r,;�,k2 �on the jc'• at al4l NAST t SISI,
fi,,*U to make an/ changes or alterations
rnasaw vigt:cut viritten permission from
Lhe twiemg Dept. City of Cupertino.
Tb sUa p=ig of If is plan and sperificAONSi
xM LIL 110Y to he d to permit or to he tr;Ao
• ^irtil a9 t7ra vii lahon of any peovtsioTuq
116 3 tea, t ata IAN.
Z�r
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NG
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L.L H L.L H
LD LD
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D
DOCRGE DOOR
LAWN
DRIVEWAY
• BOLLINGER
OWER-BUILDER VERIFICAT#
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
• A. k!�', 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 bean 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
erformed
.....................................................................................................................................................................................
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; c t11A1Jeq3
Job Address: �K'- b3 2-� 13 Gl11C Ir t Permit# l
Any changes to the information grovided on this form shall be submitted to the City of Cupertino Build
• Department.
i
City of Cupertino Building Departm
CITY OF 10300 Torre AvenuW
C U P E T I NO 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
gffl
*ITY OF CUPERTINO*
CUP
EfZF PERMIT APPLICATION FORM 0 3 1 l n o 16
APN # Date:
367 D° 1 °3
Building Address: �J J
P/CJ`I1r�CQ / K\
Owner's Name: Phone #::t
Contractor: License#:
OWW-Ar'
Contact: Cupertino Business License#:
Building e't Info:
E ect ❑ ]dumb ❑ Mech El
ob D nption:
sidential 51ctrt_ clacx- 1e 9pxv, Commercial ❑
Sq.Ft. Floor Area: $/Sq.Ft.:
Cost of ProjOccupancy Group:
.t15m `
Type of onstruction:
Quantity Fee ID Fee Description Fee Group.
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
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
BMITIGATC I Comm. Housing Mit. Fee I BUILDING
* 236
Iof3 4r/ / � C�-r
*ITY OF CUPERTINO
a&ClITY-0
CUkTINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BNUSFD New Single Family Res BUILDING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
_ BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Repipe Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
B_PSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler%Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain & Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water HeaterNent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRI-AN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
2 of 3
an, .mWITY OF CUPERTINO*
CnOF PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Sips Add Branch ELECTRICAL
BREMSIGNS Remodel Sips, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Insection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanical sq. foot VF
CITn�IICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issuance PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
•
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