02090196 t;ITY OF CUPEW11NO
BUILDING DIVISION PERMITCONTRACTOR INFORMATION �"
BUILDING ADDRESS: ROAD CHRIS & CINDY HENRY PERMITNO.02090196
OWNER'S NAME: PERMIT ISSUE DATE
CINDY 1-HENRY
'ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+00 Lm in.,IDCONTRd under
DECLARATION
of CON Job Description
I ionhereby701 affirm Incl 1 am licensed under provisions of.,Chapter 9lcommcnsi I. p
wi to Sconce 70101 of Division 3.f be Buxinea anO Pro(essinns Codc.and my license is
O m in full force and effect.
License Class .p NEW GUEST HOUSE & GARAGE
°am Contractor
ARCHITECTS DECLARATION 638 SQ. FT/229 SQ FT GARAGE
I U (understand my plain shall he used as public mmNs
1=1 N A t.E D
so Licensed Promadonal
M
affirm that I am exempt from the Contractor's License Law for the JUN OWNER-BUILDER DECLARATION 2 0 2004
d<y I hereby a
p O following mason.(Section 7131.5,Business and Praim
fte u Code:Any city or county
u$ which.quires a Permit to cnnswch,alter,imprnac,JcmotisA.or,pair'any structure
prion,its issuance.alsorequires dmapplieant forsuch Permit 10 file a signcdslalemenl
.€<
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq. Ft. FIDING Valua�iepB164'
2 (commencing with Section 70id)at Division Sof the B usim..,and Profesainm Code)or
,W§
_ that he is exempt damcfrom and the basis for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a pe.I, objects the applicant to a civil Penalty of
Ir .
.at mom an five hundred doll..($500). - 3 a V8 2IOMher 0 0 Occupancy Type
❑ I,as owner of the propcny,or my employees with wages u their sale compensation,
will do the work.and the structure is not intended Or offered for sale(Sec.7W,Business
and Profesalons Codc:The Contratal's License Law does not apply to an owner or Required Inspections
property who builds or improves thereon.and who does such work himselforlhrough his 101 - FOUNDATION
own employers,provided that such improvements stunt indicated oroRered forsale.If, 1O2 — PIERS
however,the building ar improvement is sold within one year of completion,Ne owner-
builder will bare the burden of proving that he did not mild or improve for purpose of 103 - UFER
1,as owner of Ne propsny.am exess cluxivcly contracting with licensed contracto.to 104 - REBAR
co wn Ne project(Sec.)014,BminPro@seism Cotle:)The Contractor's Li- 105 — ANCHOR BOLTS
ante tnoteaw do.aoot apply ho an ow ro m ray who Wilds or improves lnemon,and '106 — SEWER & WATER
who contracts for such on r(s)licensed pursuant to the Contractor's
UC)Iwo La 202 - UNDERFLOOR PLUMBING
❑tem ext rS ,B&PCfnnhis mason
203 - UNDERFLOOR MECHANICAL
Owner WORKER'SCOMPE IONDECLARAOTION -tom 204 - UNDERFLOOR FRAME
I hereby amrm ander Pen.11yo dory an.a fine following tleelarationa: 205 - UNDERFLOOR INSULATION
I have and will maintain a Certificate ofCmsseln to self-insure for Worker's Compcn- 301 — ROUGH PLUMBING
lion,az provided for by Section 37W of the labor Codc,for the Performance of dine 302 — TUB & OR SHOWER
work far which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 303 - ROUGH MECHANICAL
3700 of the Labor Code,for the performance of the work for which this Permit is issued. 304 - ROUGH ELECTRICAL
My Worker's Compensation Insurance carrier and Policy num her am:Policy NO, 304 — FRAME
Carrier. CERTIFICATE OF EXEMMON MOM WORKERS' 306 — HOLDOWNS
COMPENSATION INSURANCE 307 - INSULATION
nr[.a.)(This section need not W completed If the Permit is for one hundred dollars(S TOB) 308 - SHEETROCK
1 certify Nat in the perfnsmance of the walk far which this Pc,.I,is issued,1 snail not 3 09 EXTERIOR LATH
em play any peon in any manner an as to become subject to the Workers Compensation 310 — INTERIOR LATH
Laws or California.Date
Applicant 311 - SCRATCH COAT
NOTICE TO APPLICANT:If.atter making this Cenificsm of Exemption.you should 313 - ROOF NAIL
become Subject to the Worker'a Compensation provisions of the Labor Chadic,you in=
�zz rannwiIncomply with such Provisions,orthis Permit shall Ise dammed revoked. 501 - FINAL ELECTRICAL ENERGY
z 5i CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
I hereby aRam that there is a construction lending agency for the Performance of 503 - FINAL MECHANICAL ENERGY
Ya the work fur which this permil Is issued(Sec.3[197,Civ.C.)
q IandcraNam. 504 - FINAL BUILDING ENERGY
Z z Lender's Aedreas —
Jp Icenifythat Iban read this application and smtcthat lieaban information I, 505 FINAL ELECTRICAL
y F correct,1 agree to comply with all city and county ordinances and amen laws relating to 506 - GAS TEST
C.1 building construction,and herebyeuthorive representatives of this city to enter upon the — FIN PLUMB G
W ahove-mentioned property for inspection purposes.
(We)agree m saw.indemnify and keep harmless the City of Capcnino against 0$ F I AL
h liabilities,judgments,costs and expenses which may in any way active against said City 5
J 7 in consequence of the granting of this Permit.
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: INC, Dale
SOURCE REGULATIONS,
Re-roofs 514 NAL PUBLIC WORKS
Signature of ApplicaHAZARDO Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building e.Chart aro¢nr handle Health sea material
as defined by the Cupenina Municipal Code.Chapter 9.11,end the Health anJ Safety
.dc,Setfion 15532(a)a All roofs shall be inspected prior to any roofing material being installed.
❑Yn ❑Nu
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 homrdnus air contaminants.dclincd by the Bay Arca Air Quality Management all new materials for inspection.
Strict?
❑Yes ONO
I have toad the bmaNams ma is requirements under Chal wr&95oftheCadfor-
oesnolN�SafclyCodc � Y{ JJ 1553 .]on nuntl Nal if dtc Wilding
does not cu H YY I i as ami mildly the w:cupanl of tic
m I eniatamarOccupancy, Signature of Applicant Date
owneras orivn agcm Data roof coverings to be Class "B" or better
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. _ 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 ab e ' true and correct. I have read and understand the
Owner-Builder Information freversgsid
Property Owner's Signature: Date: —i
Job Address: �� �— '� l �� Permit# 0
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
City of Cupertino Building Department
CITY OF 10300 Torre A,
C U P[kT I N O Phone: (408)777-322
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 $200 or more for the entire project, and such persons are not licensed as
contractors or subcontractors, then you may be an employer.
If you are an employer,you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding,federal social
security taxes,workers' compensation insurance,disability insurance costs, and unemployment compensation$
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
CITY OF CUPERTINO ` e
BUILDING DIVISION PERMITCONTRACTOR IIYFOR ATION:',
BUILDING ADDRESS: PERMIT NO02090196
OWNER'S NAME: PERMIT LSSUE DATE
E; SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
y0Z, LICENSED CONTRACTOR'S DECLARATION
w 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
Zoo with Section]MIB of Division3of Ne Business and Profwuinns Code.and mylicenu is
I lfix.mderbot. NEW GUEST HOUSE
i m mLicense Class Lic.a
Date Counsel., 638 SQ. FT/229 SQ FT GARAGE
ARCHITECTS DECLARATION -
I understand my plans shall her used as public records JUN 2 8 2004
3,I- Licensed Professional
OWNER-BUILDER DECLARATION B
aI hemhy nlfirm that l am exempt from the Contractor's License Law for the BUILDING
,0 following ration.(Section 7131.5,Business and Professions Code:Any city or county
K m E which requires a permit to construct.Elten improve,demolish,or repair any socwm
rmi prior In in issuance,also requires the applicant for such permit to Glc a signed statement
s< that he is licensed pursuant 1.the pre,iniopsordo,Connector-,u.s.Law(Chapter9 Sq. Ft. Floor Area Valuation
rc�Ca (commencing with Section 7")of Division 3 of the Business and Professions Code)or
that he is exempt thcmBom and the basis for the alleged exemption.Any violation of $78164
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy
not more Nan five hundred dollars WOOD.WOOD. ane. 33602034 . 00
p y Type
p-1 1.as owner oflhe property,or my employees with wages as their sole compensation,
will do the work,end the arumum is not intended moffemd tonal.(Sec.IDM,Business
and Protections Code:The Contractor's License Law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who docs such work himmlfomhmugh his
own employees,provided that uch improvements arenot intended or offered fonale.If, 101 — FOUNDATION
however,lie building or improvement is sold within one year of completion,the owner
builder will have the burden of proving Nal he did not build or improve for pre,.of 102 - PIERS
TIC.).
s ❑1,as owner of the property,am exclusively contracting with licensed contractors to 103 —
UFER
Conswel the project(See 7W,Business and Professions Code:)The Connectors Li. 104 — REBAR
circle Law dors not apply m an owner of property who ilda or improves thereon,and 105 - ANCHOR BOLTS
who compacts for such projects with. un a) '.upurauant to she Contractors
I. ne'=1* 106 - SEWER & WATER
axe a ec. — P C foi this mann
C �`L��(a(�L�'�.� 202 - UNDERFLOOR PLUMBING
ow r .R•sMPEN N R ION 203 - UNDERFLOOR MECHANICAL
(hereby storm under renaky of a of following duclaatiom: 204 - UNDERFLOOR FRAME _
I taveandwillmaintainsCenifi mrcmnsemmmlr-in sum forworker'scmm,xa- 205 - UNDERFLOOR INSULATION
k n,as provided for by Section 3700 of the Labor Code,for the performance of the 301 - ROUGH PLUMBING
work for which this Permit is issued. 302 - TUB & OR SHOWER
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of thw LahorCode,for the perform.neeofthe work fnrwhieh thispcmtit la issued. 303 - ROUGH MECHANICAL
My workers Compensation Insurance Carrier and Policy oumhwr am: 304 - ROUGH ELECTRICAL
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS' 305 — FRAME
COMPENSATION INSURANCE 306 - HOLDOWNS
Crhisseetion need not lw completed tithe fnrmh is formic hundred dollars(SIM) 307 - INSULATION
I Certify 308 - SHEETROCK
employ
Nat c fin in any mann of the work for subject to
permit is issued,l shall not
employs aliforiainanymanner an as to become subjecuo Neworkcri Compensnion 309 — EXTERIOR LATH
Laws of ApplicanCalifornis.Datc 310 - INTERIOR LATH
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should 311 - SCRATCH COAT
become subject to the Worker's Compensation provisions of the Labor Code.you must
,Jz forthwith comply with Such provisions or this permit shall be deemed revoked. 313 — ROOF NAIL
zC CONSTRUCfIONLENDINGAGENCY 501 — FINAL ELECTRICAL ENERGY
'F hereby 502 - FINAL PLUMBING ENERGY
wr> Newnrkmpwhiehmitp mit i:iaamedcsee.3o97,Cil.c.) 503 - FINAL MECHANICAL ENERGY
Vl Q Lender's Name
a2 nder'sAdtlmas 504 - FINAL BUILDING ENERGY
U O I certify Nat I bevc read this application and slaw that Ne above information is 5 0 5 - FINAL ELECTRICAL
(~ Comet.I ague 10 comply with all city and county ordinances and state laws relating 1°
0505
U building Construction,and hereby aulhoric,mpresemadvesofthiscitytoenteruponthe WGAS EST
ahovo'W') ince toed coy for inspection us.
(We)ague m ave do d k p harmless lh try of Cupertino against 0 7
rfq liabilities, co Cad x nscsw chm in ay eccmc against and City 5 IC,
U,Z in eonsequcn ti
^' APPL T U D W 0 LY WITH ALL NON-POINT Issued by:5 Date
b1U_7-75&NAl_i PLANNING
Re-roofs 54 INAL PUBLIC WORKS
arc of ApplicenUCmnR Dae
HAZAR ERIALS DISCLOSURE Type of Roo
Will the applicant m wilding weripanutere or handle hasirdoue material
as defined by the Cup unicipal Code,Chapter 9.13,and the HCahh and Safety
Code,sUtt0on35s33fayn
Yes 1 All roofs shall be inspected prior to any roofing material being installed.
�"
Will the applicant or future building occupant use equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
naaardnus sir comantinanix as defined by the Bay Area Air Quality Management all new materials for inspection.
tier?
❑Yes No
I have mad Ne harardnu to quire on 'Chapmr&.95oftheCa1ifor-
niaHcaW 0 5 4255 .luntl Box if the Wilding -
d currently h e lNnsi o I'y thw rcCup.(of the
cam 0f °p'°e Signature of Applicant Date
ow rauthorircJspent Date All roof coverings to be Class "B" or better �/
i
C 1 CITY OF CUPERTINO u-0 90
CIU OF PERMIT APPLICATION FORM
CUPERTINO ,meg
PN# �,' Date: 9-3a -ate
Building Address Y O
Owner's Name• KSI Phone#: �f 1
CIt�iS� C`a� nr asa- i
Contractor: License#:
+ b
Contact: G - Phone#� aJrc� y,y OY�3�I89
Applicant/Co tractor: Fax #:- 6Y
3-7-127
uilding Permit Info: �, �%
Bldg ' Elect Plumb ech
Jobpt,
sidential: is
Sq.Ft.Floor Area•
Architect/Engineer: Valuatio
Type of Construction: Occupancy o
i
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances 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 Comm. Housing Mit. Fee BUILDING
BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Re's MECHANICAL
BNEWMULTI New Multi-family Res ELECTRICAL
BNUCOMME New Comm Electric , ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
1 of 3
x
w
r, �µ CiTY OF CUPERTINO
CITY PERMIT APPLICATION FORM
CUPEkTINO
Quantity Fee ID Fee Description Fee Group
BNUMULTI New Multi-family Res PLUMBING
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 Pian 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 S rinklerBackflo PLUMBING
BPSTORM Stom7/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain&Vent PLUMBING
LJ 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 Fumace MECHANICAL
BREMFURNOV Relo Fumace> 10K 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
BREN20WER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BRENIMPALT Re air/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Si s,Mar uee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
2 of 3
(Cp,- CITY OF CUPERTINO f i
CITY OF PERMIT APPLICATION FORINT
CUPEIZTINO
uanti Fee ID Fee Description Fee Group
BRE AN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSE&2FAM Single &2 Family BUILDING
A Single Family New Add BUILDING
ECIAL Special Insection BUILDING
Wim SwimmingPool BUILDING
TEMP
Temporary Power ELECTRICAL
BTEMPPERM Tem or BldgPermit BUILDING
BTEMPSVCS Tem Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electricals foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals , foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE PlumbingPermit Issue PLUMBING
Iff
PPLBG PlumbingFees foot PLUMBING
ZADDCHG Address Chane 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
BBOILERS Boiler> 1.75 M Btu MECHANICAL
•
3 of 3