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05040161 • CITY OF CUPERTINO BUILDING DIVISION PERMIT ;CONlT,"CT,ORINFOR,MATION -' BUILDING ADDRESS: PERMIT NO. SHELLEY & RICHARD SUE 05040161 R' AM PERMITLSSUEDATE picp_blrlm�p SUE meRE?4% BR lNE: SANITARY OL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH ] Y00 LICENSED CONTRACTOR'S DECLARATION Job Descri Ion ' I thereby&from that I am Inclosed under previsions of Chapter 9(commencing With Section 7M))of Division 3 of me Business and Professions Code,and my license is n full farce and effen. ;'q_ ansoCuls ue.g SEWER LINE & WATER LINE Contractor h ,t q D¢aT'S DELL ARCIIITECTS DECLARATION 1 undcrstanJ my plans&hell be used As public records 3 G Licensed Pmfusional 5 OWNER-BUILDER DECLARATION Y 1 hereby affirm that I am exempt from the Contractors License Law for the !no following meson.(Secuun 7031.3,Business and Professions Calc:Any city or county $ which requires a permit to cnnstmcL her.improve,demolith,or repair any structure FZY pool o its iuuince,idbo,equim5 thcapplicant former permit o file.signednnemcm G mathislicensedpurouttothprovisionsofftCommon'sLirenschw(Chapter9 Sq.Ft.Floor Area FF$ (commencing with Section 7")of Division 3 ort be Business and Professions Com)or that he is exempt me¢frem and rte basis for me alleged exemption.Any violation of Section 7031.5 by cry applicant for a permit subjects the applicant to a civil penalty of er nm are m m ..Five hundred dollars($500). 3'gy�Tp. 0 0 Occupancy P Y Type 01,uownerofthepmpmn ormyemployeeswirewagesu Chirsmecompemadon, will do me wods,and me structure is not incurred or offered for sale(Sm.7014,Business and Professions Cnda:The Colosusers License Law dose not apply on an owner of Required Inspections property who builds&improves thereon,and who docs suchwork himself&through his own employees.provided that such improvements tie not Wandod morfcred for sale.If, however,me building or improvement is sold within one year of completion,me owner- builder will have the burden Of moving mat he did ret build or improve for pope a of ole.). 0 1,as Owner of the pr spcny,am exclusively contracting with licensed contractors to construct he prefect(Sec.7644,Business and Professions Cods.)The Conuacmr's Li terse Law does not apply to in owner of property who Wilds or improves thrton.and, who conturcu for such projects with a conoacmr(O licensed Pursuant to Ih Contranm's License Law. �1.lamex, tunndeerr Sea B&Fcfo,thl'reason Owner �D in !4-2&-05- W -2L-05 W� R'S COMPENSATIO DECLARATION 1 hereby AINm under pcmlty of perjury one of the following declarations: 1 have and will maintain a CenlBcne of Consent toselFinsum fa WorkeBCompton - ation,u provided for by Section 37M of the IAWr Code,for the performance of tit work for which this permit is issued. 0I harn and will maintain Workeru mq Worker's Compensation Insurance, uimd by Section 37W of me Labor Code,for me performance of the work for which this permit Is Issued. My Workers Compensation Insurance carrier and Policy number art: Carrier: Policy No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not becompleted If tit perm Is Intent,hundred dollars(SI(p) or less.) 1 cenify th.t in the performance of the work for which this Mrmit is issued.I atoll raw employ any person in any mMrte sou m Willi subject to the WillCompensation Law,MCatiforyr/ Applicant�r 4¢t� Q— NOTICETO APPLICANTVD,after making this Cemricac of Exemption,you should become subject to the Worker',Compensation provisions of the Labor Code,you must ,J,z forthwith comply with such provisions or this permit shall h deemed revoked. tiO CONSTRUCTION LENDING AGENCY (~ I hereby affirm mat them its construction lending agency for me performance,of Cme work for which this permit i,issued(Sec.3(197,Cat.C.) Q Lender's Name CW 7 Z Indere Address (J Q 1 orr ify that I have read this application and trate that the ahove information is Ftorten.I Agra to comply with aft city end county ominance,and Stan,laws relating in 0O Wilding construction.and hereby Authudm mpesenutives of mil city to enter upon[be oned mr,p a above me judgment. nt.coy for inspection which m. (We)agree to save,indemnify and kap harmless the City of Cupertino against (~fA liaemseecl.n me the Ira ovd expenses which may in any way eamc against mid City in U Z, APPLICANT of DERST N Sthis pc WI _ r-• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCEREGULATIONS. �0.[e�� . 1- y-a�-os Slgnawre " nUComsumRe-roofs r Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will me applicant or future building occupant store or handle huudous material U darnM by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety ode.Section 25332(a)? All roofs shall be inspected prior to any roofing material being installed. Oyu pNu Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove It ha'nrdnus air cmnumirsnra As defined by the Bay Arta Air Quality Management all new materials for inspection. trim? ❑Yes (allo 1 have mad me haumous materials requirements under Chapter 6.95 of the Califor- niaHealm&Safety Cao,Sodom 255)5,25533 and 25534.1 understand mu if tit Wilding Jas not currently have A tenant met h u my responsibility to nosily Or occupant of me repuiremenu�hich must be mm pour m issuance of a CemOcec of Occupancy. �KKLL////11//moi//OO Signature of Applicant Dale �_ .. owner or aufficA&M agent Date All roof coverings to be Class "B"or better Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 coo, Fax(408)777-3333 UPERTINO Building De artment JOB ADDRESS: PERMrr#©s—oy O ' 6 I 1041 0 - OWNER'S NAME: SUE TruS-- PHONE # 8 .53'2 z4 I GENERAL CONTRACTOR: FAX # I am not using any subcontractors: V- 7L-h.4;7 ignature .Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing 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 OWNER-BUILDER VERIFICATION 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. _ 1 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. PersorVFirm 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 Owners Signature: Date: Job Address: Permit# U S 04 © 1 l0 1 Any chances to the information provided on this foray shall be submitted to the City of Cupertino Build Department. SCITYOF City of Cupertino Building Department 10300 Torre Avenue C U P[p'T'I N O 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 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 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 compensatiore 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 an Recycled Paper CITY OF CUPERTINO USw REPIPE/SEWERS/FAIN SERVICE CUPEkTINO PERMIT APPLICATION FORM APN # Date: 5 3 `l0 11 -2io-oma Building Address: 10 Owner's Name: P one#: a.rc✓ 5 U E I tl T (21 69) --ZS-7 - a `l / ntractor. License#: (Se Contact: Cupertino Business License #: Building Permit Info: Bldg ❑ Elect ❑ Plumb G5 Job Description: R e-p to-cee 0.n d Ire-pc A r` Se.w e-, %,.-xe — tick r ptoLce n Residential Commercial ❑ Cost of Project: 4 I - Isoo • Qty. if Applicable Fee ID Fee Description Fee Group PPERMITFEE Plumbing Permit Issuance PLUMBING BPREPIPE Repipe of Fixtures PLUMBING BPERMFEE Bldg. Permit Fees BUILDING BPFIXTURE Pbl . Fixture PLUMBING BPWSVCS Main Water Service PLUMBING BPSEWER Sewers PLUMBING BPSEWAGE Sewage Dis osal PLUMBING BUSLIC Business License BUILDING