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05010084 CITY OF CUPERTIN '*J" ' BUILDING.DIVISION PFR ' C®NTRACTnR INFIRM �' N ? . BUILDING ADDRESS: FIRST BAPTIST CHRUCH CUPERIPTINtDNO05010084 19515 HOWARD CT OWNER'S NAME: PERMIT ISSUE DATE FIRST BAPTIST CHRUCH CUPER IN019515 HOWARD CT. 01/13/2005 PHONE: SANITARY NO. CONTROL NO. HITEC(ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH L� l� Q l� !op LICENSED CONTRACTOR'S DECLARATION Job Description {Z C 1 M¢by affirm IM1m esr 1 am lived under pmvisions of Chapter 9(commencing tso so with Section 70W)of Division 3 of the Business and Professions Code.and my licenm is +�<„ in mu force and effect. ELECT—OUTDOOR BOX .W/PVC CONDUIT 7 i2 2 License Class The.P k,o Dae Cunlummr L ARCHITECTS DECLARATION C w U I understand my Plansshell be used as pohlis neemts c p'F^ Licensed Pmfcssomal �7 OWNER BUILDER DECLARATION 2 2 Y 1 M1amhy of m that I am exempt from the Contractor's License Law for the 0 0 following mason,(Section 7031.5,Business and Pmfes,sons Code:Any city or county <m E which requires a permit w construct.alter,improve,demolish m repair structure $200 ?xj poorm lis issuance.also(esquires the applicantfor such permit to file a signed statement 'exo thaNmiabcensedpursuant mthe provisions nnheContraem,sLicense Law(Chapter 9 Sq. Ft. Floor Area Valuation "e1— (commencing with Section 70W)of Division 3 of the B usinces and Professions Cork)or that he is exempt Beneficial and dm basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a Permit subjects the applicant o a civil penally of pi Occupancy Type not more than five hundred dollars(SSW). VLLI uowner cribs property,or is employde orowagesrHeirsale cam.Rmmess will Pr Ne work,and the he Co a la not intended d or offered formic(Sec.t oan owner of sea ertywh obis Code:The Canaacmr's license res dam or apply lf am owner or Acquired Inspections pmpeny who builds or improves ch improvements m and who ares such work or off redor through M1it. ownemplayeasilding or that improve esisold wthin am not Year of completion. mpeemtl fche or ownerr req Nebuil the orimprovementissalte did tateyear ofd prove for L000wner: builder will hare the burden of proving that he did not builtl or improve for puryou of sale.). Q L as owner of ct property,am sine si and contracting with licensed contractorstar'si. cense athepmjecl(See to an Business and Professions Code:)The Conhereon,Lid cense Law docs not apply to es owner of property who builds or improves Contra,and. / who contracts for such projects with a contracmr(s)licensed pursuant m tlm Contractor's nu Uw. la a tooter a .B&PC for Nis mazon 0 p �� '—Da WORKER'S COMPE ATION DECLARATIO I hereby affirm under penalty of perjury mu of Ne following drelarations: - Q l have and will maintain a Certifead of Corunuo self-insurefor Worker'sCompco- 'an,az provided for by Senior 3709 of te hIabof Code.far the performance of the k(or which this permit is issued. I have and will maintain Worker's Compensation Insurance,as required by Section 37 W of Ne labor Code.for Ne performance of the work for which Nis permit is issued. My Worker's Cnmpemation Insurance carrier and Policy number art: Cartier: Policy No.: CERTIFICATE OF EKEMPTON FROM WORKERS' COMPENSATION INSURANCE .. (Thlfsectinnored mulhdeomplemd iflhe permitisforrnehundmddollars(DIW) or leas.) 1 certify that in the a fi�yn 9[c of IAc work for which Nis permit is issued.I shall not . employ any person in any ryVmicr W as to become subject to the Worked Comperuaion Laws of Cal fps ADatd NOTIc t ( a4 ZEAL in NOTIC TO 1.theA :IL oar making Illi­S of Exemption.you should become s Ito IM1c worker's Compensation pmvisions of the lsMr Cadc,you must �O (onhwilNcam ply with such provisions or this Permit shall he deemed revoked. Z CONSTRUCTION LENDING AGENCY I hereby aRrm Nat there is a consmrainn lending agency for the performance of 1v 7 the work Lou which this perms k issued(See.3097,Civ.C.) I] Q lender's Name 1 lender's Address J Q 1 certify that I have read thisty and county and sura that and above information is � F bandit.I agree m comply with all city and retire ntaiwnccs and sur t laws relating upt e �U above-meding ntioned construction.and hcrchyauthorimoses.representatives of this city menur upon the Y UJ above-mentioned to save for im indemnify an keep ha. (Wc)agree m save,indemnify and keep harmless the City of Copcnino against tq Liabilities,judgments,costs and exPdnxes which may in any way acme against said City ! / Of the grami ag of J z in dUNDERSTANDS IAND his (WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCEREGUL T10 S. / Re-roofs one of ApplieanUConlmetor Date HAZARDOUS MATERIALS DISCLOSURE Type Of Roof Will the applicant or future building occupant store or handle ha/mdUYs mamnal as defined by the Cupertino Municipal,Code,Chapm,9441-ifid the Hcallh and Safety Code.pre:25532(a)? All roofs shall be inspected prior to any roofing material being installed. Will the apNicam nr ff/u�wtr+\d buildingocnlpam use cynipmem or advidrs whichIf a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as dchncd by the Bay Arca Air Quality Management all new materials for Inspection. District? %HeslM PI No , road the haamdousonsedals requirements under Chapter 6.95 of Ne Califor. afetyCade,Sectors 255(15,25533 and25534.1 tmeemend List Nc building ntly have a tat n[Nat Il is my responsibility la natty the MYupant of II¢wmch ItII/pnarnis�,raCertificateo(aetipandy. of Applicant Date oried agent All roof coverings to be Class "B"or better ��` • • G>- CITY OF CUPERTINO CITY OF PERMIT APPLICATION FORM CUPERTINO / PN # / Date: _ Building Add r s Ili n ddress (i fferb t r n buildn ddTess) Owner's Narne:p Phone#: [� 1�77 c'�. _ Z 49V Conlracto License#: �OW Contact: Phone: Cupertino Business License#: Fax: Building Pennit Info: Bldg ❑ Elect ❑ Plumb ❑ Mech ❑ Job Descripti n: eI('poaR a X t"t/PVC Cd_'1QA .0 Residential g Commercial E] Sq.Ft. Floor Area: S/Sq.Ft.: Cost of Project: 7 5?s 51 Occupancy Gr p: Type of Construction: Please check th project is a second-story addition: ❑ Oirroject Size: Standard ❑ Large ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> l OOK to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILERS 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 <= IOOOA ELECTRICAL BELEC1001 Elec 600V> 1000A ELECTRICAL BELEC200 Elee Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING • z� 2-73 1 yrs 3z� . yZ SCC CITY OF CUPERTIN# CITY OF PERMIT APPLICATION FORM CUPEkTINO Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg 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 Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn SprinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP .Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfm MECHANICAL BREMAIRHAN 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 > I 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 BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Beating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL 2 of 3 L� t . ITY OF CUPERTINOO atYOF PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREAIN ENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEIS JCRE 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 j EPERMITFEE Elee Permit Issuance ELECTRICAL MPERMFEE Mechanical sq. foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Change BUILDING • • 3 of 3 004ER-BUILDER VERIFICATieN 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 YG .3iG4[ 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 - erformed .................................................................................................................................................................................... I declare under penalty of perjury that the above is true and correct. I have rad and understand the Owner-Builder Informa on (r R�Side ._ ^/ 3�C j � ��� r N 6 T r412/ U- Property Owner's Signa Date: Job Address: ��JyO�i /� /Q 12 UQ, Permit#6 1� 10 08 Any ch g s to the information provided on this form shall be submitted to the City of Cupertino Build _ -Department. 'EC I VED inN 1 3 2005 City of Cupertino Building Department I CITY OF 10300 Torre Avenue C U P S I N O Phone: 408 777-3 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-budder 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 yourself 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 projecrand 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 obligatictm. induding_statie and federal income tax withholding,federal social security taxes,workers compensation insurance,.`disability insurance costs,and unemployment compensation rib - - contutions. 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 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 _ f '•'�.�' '-� r (J1 YP 1.' !r.'C •tR t�W/4 c,l rrY � .�. �� N - fl r t° 'oiC �t�� + .�r. rA. � '•Fr, nI I�MJ`. Y : c �� t 19..y 11�LY �. �[s•li w:'f. "• -r x�•- -�- o. 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