03020091 CITY OF CUPERTINO
BuanNc DIVISION PERMIT Cp�1TRACTOr RSI^ FURMAII£ON:
PERMIT N0.
BUILDINGADDRESS: STAVANG CURTIS W AND TER SA G
10551 N PORTA eRMrr Lssue
O '.NAME:
STAVANG CURTIS W AND
SANITARY N0. _ NO.
BUILDING PERMR INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
30o LICENSED CONTRACTOR'S DECLARATION Job Description
I be'eby in that I am Ilaned under pmvitlom mf Chepmr 9(commencing
a�1 with Section 70110)or Divitlon Ja(NC Busiau and PmfeWons Code.and mylicense is
I.fall force ml.ifat UPGRADE BATHRM/KITCHEN/REPLACE WINDOWS
[�_ License Class Lie.0
qqq Dam Cbntnctor
tARCHITECTS DECLARATION c w, _
u I understand my plana shall W used u words
ords rl,MALED
1,y,r1 Licenced PmfcWonal
h D.l OWNER-BUILDER DECLARATION
.�r�i I hereby affirm Net I am exempt form dm L'onlOerm'a Licanse Law for the FEB 2 6 2004
❑o following-warm.(Seedan 713 L5,Businessand Pmfexsio^+Code:Any city or county
S which requires•permit m Construct,111.1,Improve,demolish,or¢Pat'any aWmare
t^ pdoriniu—w—,Jw'cquires tWlpplicanl for such permit 10 file a signed statement mSq.Ft.Floor Area V �aj;i00
—4< IhelW is llccnseJ pu'sovnuo Nc pmviaton or Ne ContnnniLlConse Law(CMpmr9 '��'�D UUU
111 (comencing with Seellon700B)dDivulon3 of me Business and Profession-Code)-1
d 1 Net W is ea mm,mention,and Ne bub for the alleged exemption.Any violation of
Semon 7031.5 by 6"applicant for•permit wbjeW the applicant 10•civil Penalty or .3 'iMitgr. 00 Occupancy Type
not more man ova hundred dollars({500).
❑1.asowner of the property,or my employees with wages u their sole cempenutian,
will do the work,and thecwclum is not lntudW m offered forsale(Sm.7011,11ualmm FOUND— MInspections
and Pmic lons Code:Tee Cantramfs License Law dace not apply m an owner of
property who WIldsorIONIC.Nnomm,and w1odaeuah wort Montalto,through his 102 — PIERS
own employees,Provided that such impmvemenu see not intended or offered for sale.It. 103 UFER
however.Ne building or I,Pmwment b sold within one year of Completion.the owner-
builder will have me burden of proving that he did not Wim^r improve roe Pnmose of 104 — REBAR
ii1e.)' - 105 - ANCHOR BOLTS
1,As owner or Om property.am exeimivedy Contracting with licensed contractors to
mnswct the pmject(SCo.701a,Business and Pmfeation eine:)The Coalncmra U. 106 — SEWER & WATER
comm law does aotapply tom owner of Property who Wilds or improves them,.and, 202 — UNDERFLOOR PLUMBING
who contracts for such pmjccts with a contractor(s)licensed pursuant o tite Contactors
a uw. 203 - UNDERFLOOR MECHANICAL
l ire ue/mµ[untler See. Bd:PCfar this reason 204 - UNDERFLOOR FRAME
Date ZWO's 205 - UNDERFLOOR INSULATION
WORKERS COMPENSATION DEC"RATICIN
I hereby affhm under Penalty of perjury am or me following decimations: 301 — ROUGH PLUMBING
❑)have end will omintsm.c.nlRnma consent to scif-m-um for WorkeM1 Compen- 30Z — TUB & OR SHOWER
xenon,a provided fa by Section 3700 of me Labor Code,for the performance of the 303 - ROUGH MECHANICAL
workforwhimtthipeamuisfaad' 304 - ROUGH ELECTRICAL
❑I haw and will maintain Workers ComPenadon Iwuana,u required by Sado^
3700^fineLAW Code,for don Kgo'mmmof Ne wort f.,hith this permit is Wood. 305 — FRAME
My Wortee,Compensation lnceraae carrier and Policy number see: 306 — HOEDOWNS
Carrier. Policy No.: 307 - INSULATION -
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE 308 - SHEETROCK
(Tbbsectlonoed notWcompleted if theTermllbforoahundeddollan(SIM) 309 - EXTERIOR LATH ________
n'a") _ ___ .. .
1 ceNfy that In the Performance of the work for which this permit B Wild.I shall not 310 = INTERIOR LATH
employ any person in any manncran as m bcCome subjal la Om WarlmTe Commensation 311 — SCRATCH COAT
Lawao(California.Dam313 - ROOF NAIL
Applicant
NOTICE 70 APPLICANT:IL ane'matingmis Certificate of Exemption.youshould 501 - FINAL ELECTRICAL ENERGY
become subject to the Worker's Compensation provisions of the IAba Code.you must
,JZ forthwith Comply wit such pmvWonorNispormiuWm
llldarnrev
ednkcd. 502 — FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503 - FINAL MECHANICAL ENERGY
4 thereby AM.met them is.convection lendingage.,for me Pelformaa.of 504 — FINAL BUILDING ENERGY
x>
the.,it for which this permit Isiuwd(Sec.3097.Co.C.) 505 - FINAL ELECTRICAL
Ls1 Q Lender.Name
uA&,'sAdd. 506 - GAS TEST
UO I Certify that 1 have read this application and tum that the above information is 507 - FINAL PLUMBING
D.F curetM
..I agree to comply with all city and county onaaea and sum laws misting la
O V building eonsnctian,md Wrebyaumor)x representatives of Niscity loemu upon dm FIN MEC CAL
1,q aWve-mcmiond pmpeny for Inspection purpose{
(We)agree m sew.Wnde,mWfY and trcp harmless the City of Cupertino against 0 9 F I
ylisbilinu,jdgme^u,eosu and expenses which may In any way acme against mid City C, NG
V in consequutee of the granting of this per mil. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 C WORKS
SOURC ULATI S.
Re-roofs
AN afApplicanUContrata sus Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding Occupant mom or Wndlc hazardous material
de0ad by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safely
e,seed..35S33ayn ��'///ttt All roofs shall be inspected prior to any roofing material,being installed.
DYca �No
Will Nc apPlicmt or f''ulu\re\building occupant see equipment car devices which If a roof is installed Without first obtaining an inspection,I agree to remove
coil hammous air contaminants u defined by Ne Bay Area Air Quality ManagC,enl all new materials for inspection.
Du,ic17
❑Yes
I havereal the WAAN mwls,quimmenuundcrChapmr6.95ofthe Glifon
ni l4 iNkSafctyCde,Sa.25505.MS33ad35531.1 unOcrund Natiftiro Wilding
does not mamly have a tmlanl Nu it li my nal emlimlWty m rad do occupant of Nc
require uwhichnaWmelpdormiuumaofaCedfmamo up Signature of Applicant Date
I - All roof coverings to be Class "B"or better
Own ormN 1mdagtm Dem
' v 1IVP�� 111, r
CITY OF CUPERTINO t
BUILDING DIVISION PERMIT T^I(a?
-
PERMIT NO.
emLDING ADDRESS: STAVANG CURTIS W AND TER SA G
10551 N DniDTAT. A17 PERMITwue
OWNER'S NAME:
STAVANG CURTIS W AND SANITARY NO. TRCL NO.
BUILDING PERMIT INFO
ARCHITECUENGINEEK: - BLDG BLEU. PLUMB MECH
0 0 0 0
0o LICENSEDCONIRACTORSDECLARATION Job Description
1 hcfobY sinrm that 1 am licamea under ProvWans of Chapter 9(commencing _
withsacdon]IXID)of Division SurNO BuRnam.nd Pro ..im.Code,andmylkenseh
in fall fares and e@n. UPGRAD
Uemse Clue Lie.II mt+�thy-F 2 EN/REPLACE WINDOWS
Gate G^mrsnar 4
ARCHITECT'S DECLARATION
i 1 undmatud my Phnuhall 14 used u public rmOam FEB
i
'u. Licensed Professional
is OWNER-BUILDER DECLARATION �', nt�G. -
1 hereby in.last I am aempi from the Contractors Lima.law for the BUILDING�/
yO o
following=.a..(Section 7031.5.Businut and RafeWun Code:Any city Of countyv
d a g which acquire,a Permit be tomamaL alar.Improve,dcmnllsh,or repair any couctum
paler W its issuance.also requires the applicant for such permit ro Ole a signed rutcmenl S Ft.Floor Area cV2],UBCIon
< thathehlimnedputmanitotheproviaioaofthe Co.mweaUauelaw(Chapter9 Q• YbUUU
2j $ (.=.let with SeNon70B0)of Divulon]ofihc Bunneuand Profemimm Code)m
` .. tial he ts aempt therefrom and dte bath ren do alleged esempilon.Any violation of -
Section 7031.5 by any applicant far a permit Sabina,the applicant W a civil penalty or 3WtUft*51r. 0 0 Occupancy Type
not acme than Ove hundred dollars(8500).
1,u owner alibi property,a my employes with"gnu thehsoh mmpenalian.
willdoeuwarkandtheawnambnoiManaea ororcered fm este(sec.701A,Budnw — FOUND M Inspections
and Pmfesalon Code:The Cmneart Llama Law dem rot apply b an owns m
- _._... propenywho builds orimproesthemon.and whodmaauch work himselforthrough hit _ -102 — PIERS
own employma a re
a.provided thneuch improvements t Intended craneaW
d for e.ir. 103 — UFER"T-_-..-
however,the building or improvement is said within mm you orcmmpledan,the o"c,
border will haw 0a burden of proving that he did am build an Improve far PutpaW of 104 - REBAR
ear) 105 - ANCHOR BOLTS
❑h at;manner of the propenY,am eaclniwly contracting with licensed Mommetae to
comtruct the poeect(Sa.7OSA.Business and Proraslots Cade:)The ConMmtm'sU- 106 — SEWER & WATER
ma co
colaw ds not apply to an owner of property who bunds or Improves themon.and, 202 — UNDERFLOOR PLUMBING
who mntaca ter such pmkm with a eammnorD)licensed pursuant In the Communard
}.Icp�m law .203 - UNDERFLOOR MECHANICAL
Alun aempl under See .B k P,.0 for this�ra2omen 204 - UNDERFLOOR FRAME
r \ f - Da"�F� 205 - UNDERFLOOR INSULATION
WORKERSCOMPBNSATON DrcLAR�N 301 — ROUGH PLUMBING
I hereby aflitm ander pwlty of perjury am order following dmlunlmn:
have and will mai^din•Cemnaaof Canenimmif-ImummrWwkelcomPe^- 302 — TUB & OR SHOWER
Staten,asptmidcd for by Section]700 of the labor Code,for the performgnm of the 303 - ROUGH MECHANICAL
work mgwmehthis pemutsmuee 304 - ROUGH ELECTRICAL
❑have and will maimalo Workers Compntution Insuance.u squired by Section
yl00 err the Labor Carse.rarthepurarmmmof Wewmkrwwbirh Wspermitl$Wt . 305 — FRAME -
MyWorker's Comiwadanmtmnmcarrier and Policy number aof: 306 — HOLDOWNS .
Carder. Policy No.: 307 - INSULATION
CERTIFICATE OF EXEhIFITON FROM WORKERS
COMPENSATONINSURANCe 308 - SHEETROCK
ml;seNmmad not ho completed if me,permit h for me hundred mllus(SIM) 309 — EXTERIOR LATH _
tileµ) . 310 INTERIOR LATH
-
I certify that in the performenm or the work for which this permit is Issued.I shall nm f
employ any penon in any manner an u W became subject to the workers'Compensation 311 — SCRATCH COAT
Laws of California.Dam313 - ROOF NAIL - 3
Applicant
NOTICE TO APPLICANT.ICsftu making this CenNeaa of EumPdon,you shauW 501 - FINAL ELECTRICAL ENERGY
become subject a Ne Watters Compensation provisions of W labor Code,you muss
,JZ forthwith comply with such provision orthis Permit shall hcdemand avased. - 502 — FINAL PLUMBING ENERGY
zo CONSTRUCTION LegDINGwENcv 503 - FINAL MECHANICAL ENERGY
(...`". Iamebydnmthat tmoflsacomtrunionlendingagencyfor the Raian^aumof 504 FINAL BUILDING ENERGY
g4it the wart for which this permit laissnd(Sm 7097.CN.Cd 505 - FINAL ELECTRICAL }
W A landera Nurse ..
aZ LcndersAeeert 506 - GAS TEST
U0 I certify that I haw food Ws application and sloW that the above hrormulun is 5 07 FINAL PLUMBING U.^' donees.1 sgta W comply with all city and county aminuaes and sate ls"mladny W
OE
building construction,and hereby authodx mprere^wiws or Nhdtymemu upon ac FIN MEC (,'AL I
W abavmmenWned property far lnpccdon requests.
g� (we)agree to nes,Indemnify and keep hsrmku the City of Cupertino against O 9 F I
y Ilabilidea,Judgmmu.entsInd expenses which my In any"yacrneagainst old city 5 NG
V 7
I.mntegnna of the gnml^g of this permli. 1
L7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5
SOURC GULATI S. -
Re-roofs
not mfAppR mUConlrascior'CcHAZARDOUSMATFJUAISDISCLOSURE ate Type of Roof
VIII ftapplicant or future building occupantuar
Roof orhsrmle hdou maWrild
Is da0na by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cade.Section 25573(1)7 All roofs shall be inspected prior to any roofing material being installed.
Dye. KNo
Will tite applicant or future building Occupant este equipment m devices which If a roof is installed without first obtaining an inspection,I agree[o remove
mm
fall haumnus air comein^ts u dc0ned by the Bay Ams Air Quality Management all new materials for inspection.
District?
❑Yes iR"a,yL..'��
I have red m haramrma materials reyuircmenu under Chapter 6.95 of the CRifor.
nit Hal"SmctyCoec,Sections,2550.25533 and 25534.1 understand the,trust,building
Jose not rarely have•Want,d u It It my resmammilty W and
04—want of fttri¢ uwhichmu bemd orWWuanccoACcNOnten a Signature of Applicant Date 1
Own o".0miredegcnI Dour
All roof coverings to be Class"B"or better
OVWR-BUILDER VERIFICATICO
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)
Contractpr 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
performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information
//(reverse
,,�sii,de).
Property Owners Signa tux /--��` ' Datp- -212110
n 3�
Job Address:\ D /0.5:Y A). /n�. /'G2TAf/ �W r Permit# �
Any changes to the information provided on this form shall be submitted to the Cy of Cupertino Build
Department.
} fF
CITY OF City of Cupertino Building Departm�
nn 10300 Torre Aven
C U PE IST I N V 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 iprprovements 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 yontrself 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 compensatic
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 Pape,
On
0 Wtri ~ 400 �� � 105�1 N. AiM& AP
n
a
l
AppROVED
fP7 A6COMANCE WI H THE CITY OR
coup DES N ORDINAMM
SfNEb._ FEEL COPS .
Till, set of pl ns and specifications MUST
ty@ kept on ' to lob at all times and it is un+
tawful to ake any changes or alterations
on same without written permission from
the building Dept., City of Cupertino,
The stamping of this ph n td
SHALL NOT be held tper nit or,to ie are
approval of the violatic I oil any prop:
)f any. City Ordinance x S ate LTN
i 1L FEB 212003
9y
l
JPITY F CUPERTINO? • 03o2- 0
"k
COPE TWTO PERMIT APPLICATION FORM
APN# Date:
Building Address' 1 Q�.�. �V:.� ^ ��
Owner's Name: �j C •/- Phone#: fjf�,Q 2 53- 2-
P4 f_u—In
Contractor: TLL License#:����))
Contact: Cupertino Business License#:
Ou -263-2-7
Building Permit Info:
&dk El ct P mb M ch�J :R r -
Sq.Ft. Floor Area: $/Sq.Ft..
Cost of Project: �"- Occupancy Group:
Type of Construction:
uanti Fee ID Fee Description . Fee Group
BAPPLOTHER . Other Appliances MECHANICAL
BBLDGFEE Bldg Permit sq. 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> 1.75MBtu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX hid/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 Ener BUILDING
BENERGYADD Ener Add Multi BUILDING
BINVESTIGA Investi ation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
I of 3