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CITY OF CUPERTINO
ZNaRMt�.'Nr'-x.:
BUILDING DIVISION PERMID ,,Co,;it
BUILDING ADDRESS:
PERMI'N"03120118 NOO3120118
OWNER'S NAME:
PERMIT ISSUE OATS
HONIG RODNE
2
JE:
SANITARY CONTROL N0.
ARCHFIECrIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
u under ndPr Profession,Coder 9 (commencing
1 hcrchy affirm mat i am if Me Business
with Becrcea0efecDivision3 of me 6osinesand Prufcuiuns Code. andmylianseis
C ® a�{p��
rlN�` ®
mfeBsClaan, effect.
SOLAR PANEL/UPGRADE
License Class Lic. tr
Dale Contractor.
ARCHITECT'S DECLARATION -
APR 1 4 2004
1 understand my plans shall he used az public rccnrds
11 1 L 9
BUILDING.
' Liccn$cd Pndcssimnal
ON
j OWNER -BUILDER DECLARATION
Contractors
1 hereby affirm that I am exempt hum the @nirecmo Liana law far the
• • 'tl _
i 1.5, and Pfafcuinns Calc: Any city nr county
massa (Scctiuto
which pmmit co 1, alter,
which m cnnamm, pike improve, demolish, or repair any Structutatemem
Sq. Ft, Floor Area
Valuation
its isrs n
re forruch a gnedsmmmem
a prior 0a incensed law9
C.ut,C,.r'S t...filo
pni,is osofnt
9thatshc is licensed pursuanunthe provisionsnftheCommcmr's License (Chapter
pursuant
(commencing with Section 7") of Division 3 Of the Business and Professions Code)ser
( that he is exempt therefrom and me basis for me alleged exemption. Any violaton of
3 MN200i1err Q O
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not more Iran rive hundred dollars (s50B).
1, as owner of the property, or my employees with wages as their sole compensation.
- Required Inspections
9 P
will do the work, and the swcium is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs not apply in an owner of
pmpeny who builds or improves thereon, and who does such work himself or through his
Own emptoyccs, provided that such improvements are not intended or oRened for sale. If.
however, Ne building ar improvement is sold within one year of completion. Ne owner -
builder will have the burden of proving mm he did not build or improve for purpox of
sale).
❑ 1, as owner of Ne property, am exclusively convecting with licensed contractors to
consumer the project (Sec. 7044, Business and Professions Codd:) no Cm n.etor's Li.
cense law does not apply to an owner of prepeny who bailers or improves thereon. and
w(h�0 contracts ch projects with a contractor(s) licensed purmanil to the Contractor's
en
Clit Law.
L1 am axe mile Sec. _ B & P C for this reason
I Date 'ZI4 it[(!
I/ WOR 'S COMP ATIO ECLARA IBZ
I hereby affirm under penalty of perjury one of me following declarations:
I haw and will maintain a Cenipcate of Consent o self-insum for Worker's Compcm
atimm, as provided for by Section 37M of me Labor Code, for the Performance of the
'
work for which this permit is issued.
1 new and will maintain Worker's Compensation Insunntt, az required by Section
37W of the Libor Code. for the Performance of Ne work for which this permit is issued.
My Worker's Cum pensumber Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(leis section need nothccm sides d if the permit Is fur enc hundrcd,mllare(51(10)
'.
or Icss.)
I certify thin in the a rfmmence of the work for which this permit is issued. I shall not
employanypCracnlnany meT w az�ll Co}�C aubjC'I IQ I he WOrkcrs'CnmpCnsum.
Laws of Qehfmn'Ie�D) 5. C"" - (.f%"
-
Applima nor UJ//V/ V AAAAAA /�I'al
N0TIC APPLICANT: If, after making this Cenifream of Exemption, you should
become $Object to the Worker's Compensation provisions of the Ichor Code, you must
forthwith comply with such provisions or this permit shall he deemed rewind.
-
CONSTRUCTION LENDING AGENCY
--I hereby affirm Met there isamm agency I'nr the Performance of
> (S.C.3nlending
fur which this permit is issued (Sec. J097, Civ. CJ
Lenderk
Lenders Namc
� Lender's Atltlrcss
D 1 minify mat 1 have read this application and stem that me above information is
correct. 1 agree to comply with all city and county On inances and state laws relating to
building construction, and hereby authorize representatives of Otis city to enter upon the
for inspection
above-mentioned property purposes.
/ l
(We) dance to save, indemnify and keep harmless the y ac of Cupcnsts against
swhie may in any the
liabilities, judgments,)rtoemu indemni Py
n meeg.inusaid City
/
z in nonsequ of the graining of this permit.
'-1 APPLIC UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
/1•.,
Issued by: Date
SOUREGU ATIONS.
K ��3
1 7e, �,
Re -roofs -
Type of ROOF
�F�
JU mf Applica Conmcmr _b Dam
S(/ AZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle havarsous material
- ..
az dcfne, by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 25532(.) -
All roofs shall be inspected prior to an roofing material beim Installed.
P P Y g g
❑Yeas
If a roof is installed without first obtaining an inspection, I agree to remove
win me applicant or future building occupant use equipment or devices which
.mit hmartlnus air mnmminanis u defined by the Bay Area Air Quality Management
all new materials for inspection.
Dishin?
❑Yes �(Ju
'
1 have read me hazardous materials requirements under Chapter 695 of the Cahfor-
riaHc.lm& my Cade, Secduns11505,25533 and 25534.1 understand mat if me building
Jas not c m rely h Qr a mnar, mat it is my responsihilily to madly the a:mupant of me
rcyit. whit must be met Cm.,munm,m`ICemIII FOC IF Y.
Signature of Applicant Date
z 3 &,'C-05
All roof coverings to be Class "B" or better
ow marretl ant Date
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Lau � 5.0 PPo-e-T
OWNER -BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform:
• A. All the work authorized by tb3s 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
Owner -Builder Information (revep
Property Owner's Signat}yg(
Job Addr7:
the above is true and correct. I have read and understand the
DOI 2 3 Dp-e b 3
Permit #
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Devartment.
0
Dear Property Owner.
City of Cupertino Building Department
10300 Torre Avenyr
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 m Recycled Paper
CITY Of
CUPERTINO
r1
WITY OF CUPERTINOO
PERMIT APPLICATION FORM
o3iavllP
NNAPN
#
� /� , �jj
J"
Date:
Building Address:
Mailing Address (if
different from building address):
Owner's Ne:, >
�- .v/G
Phone #:
Contractor:
License #:
Contact:
Phone:
Fax:/pIll
Cupertino Business License#:
ildmg Permit Info:
g'�\
El ct
Plumb ❑
Mec
Job escription:
'Itesidential ❑
o r
Sq.Ft. Floor Area:
/Sq.Ft.:
�t
Cost of Project:fryD
Occupancy
up:
Type of Constructio
Please check
second -story
this U ox if the project is a
addition: ❑
Quantity
Fee ID
Fee Description
Fee Group
BAPPLOTHER
Other Appliances
MECHANICAL
BBLDGFEE
Bldg Permits . foot
BUILDING
BBOILERl
Boiler <= 100,000 Btu
MECHANICAL
BBOILER2
Boiler > I OOK to 500K Btu
MECHANICAL
BBOILER3
Boiler> 500K to IM 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 <= IOOOA
ELECTRICAL
BELEC1001
Elec 600V > IOOOA
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
w
1 of 3
,� z�i °-s-
t,43,5 -?:- a'---
CI OF
CUPEkTINO
*ITY OF CUPERTINO,
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
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
BP CEP
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
BPSEWER
Sewers
PLUMBING
BPSPRINK
Lawn S rinklerBackflo
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
BRENL IRHAN
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 Fumace > 1 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
i.�
2of3
SIR,
CITY OF
CUPEkTINO
CTY OF CUPERTINO*
PERMIT APPLICATION FORM
Quantity Fee ID
Fee Description
Fee Group
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 Signs, 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 I
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
Mechanicals . foot
MECHANICAL
MPERMITFEE
Mech Permit Issuance
MECHANICAL
PPERMITFEE
Plumbing Permit Issuance
PLUMBING
PPLBG
Plumbing Fee sq foot
PLUMBING
ZADDCHG
Address Chane
BUILDING
3 of 3
•
CITY OF CUPERTINO -
77,
"`rip L'+ 'L� per ♦ j-j��'T
c�NTkk(ftbR14.24 ORMATIQN,
.
BUILDING DIVISION PERMIT
.
-.,.,
BUILDING ADDRESS:
PERMIT ND. 03120118
OWNER'S NAME:
PERMIT ISSUE DATE
HONIG R DN
E: - -
SANITARY N0. CONTROL N0,
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a 0 0 0
LICENSED CONTRd..dmSDECLARATION
1 hereby affirm that I am licensed under provisions o(Cbader a (commencing
with Section ID(Xy Division J of NC Business end Pmfcssinns Calc, entl my license is
Job] 8�641's�•_,-_.
C ff>U�lysslJ! ■ ��
oIL��IL
ec
in full force and effect.
SOLAR PANEL/UPGRADE -
License Class LR. X
Dae Gamrsrm
APR 142004
ARATION
DECLARATION
understandARCHbe to useS
I understand my plans shall 11 hed u PuM1lic mcnrds
13U1L DING
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affifm 1 oro exempt from Ne Contractors License Lew for the
o
on Profession, Cnde:Anylily at, wanly
following mason.(Section IDnsu Business and
improve. demolish, or silmygned
which rcyuscs a permit re consumer, alley, nt
e a
statement poor In its lensed pursuant alw mquime the applicant s of thesuch permit m f Ic s signed ataumem
for such
that rer9
Sq. Ft. Floor Area
Valuation
menccensedSectiohors)ofDivision3theeBusiness ndProflaonsCodna
(commencing with Section ]000) of Division J Business and Professions Code) or
tof he al of
that he is campy therefrom and the basis for the alleged exemption. Any
it Penalty
Seton any applicant fora permit subjects the applicant to a civil penally of
3 MI�I�83ber 0 0
OccupancyT e
a than five
not more than five hundred dollars ($50)),
YP
❑ L as owner of property, or with Nei( sole
Business will
andr
is intendedformat
Nework,ands: sloOmisnot's (oracle(Sec.7
Inspections
aBusiness
and Pr The Contramars Law aces Dat apply to an owner or
License Law
,Required
ertywhianrldsor nd who gh his
properlywhobuildsmemphasesmimprverwhodoesSuch omalred
wn employees. provided orded for
then avers improv arc not intended for
mpleered
however, the building or improvement is sold within one year of completion, On owe
buildingori sold wit owrcL
of
builder will have the burden of proving Nat he did not build or improv for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contacting with licensed contractors to
construct the project (See. 7W. Business and Professions Code:) The Comments' Li-
crom! law docs not apply to an owner of property who Wilds or Improves thereon. and.
who contracts f ch projects with a eantnneds) licensed pursuant v the Contractors
Law.
�nse
1 am doe ode Sec. B & P C (or Nis mason
1 WOR 'S COMP ATIOI ECLARA
1 hereby affirm under penalty of perjury, one of the following declarations:
haw and will maintain aCenificato of Consent to self -insure far WorkersCompcn-
Milan, u provided for by Section 3700 of the Labor Code, for the performance of the
work for which Nis permit is issued.
1 have and will maintain Worker's Compensation Insurance, u required by Section
3700 of Or Labor Code, for dm performance of Ne work for which this permit is imudd.
My Workers Compensation Insurance carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(This se ntnn need not hecomPlmdd If the permit is farone hundmd dollars (SI00)
or Ices.)
1 cradfy that in the performance of the work for which this permit is issued. I shell not
employ any person in any mat�tCrdo asW aople�ubjccl to�he Workers Compensation
Laws of QQaliforn'tryDa n
,
Applicaml n lC ,
NOTIC APPLICANT: IL after making this Certificate of Exemption, you should
become subject to Ne Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this Permit shed! be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that Ram is a construction lending agency for the performance of
the work for which this pertnil is issued (SIL. 3091. Civ. C.)
tender's Name
Lenders Address
1 certify that 1 have read Nis applic,am. and sum Net the above information is
correct. l agree to comply with all city and county ordinances and auk laws minting to
building construction, and hereby auNorim representatives of this city to enter upon the
allow -mentioned property for inspection purposes.
(We) agree to use. indemnify and keep harmless the City of Cupertino against
liabilities. judgment. casts and expenses which may in any way across against mid City
in conte c of the granting of this permit.
APPLIC UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOUR EGU ATIONS.
2Za3
sswatur
Re -roofs
Type of Roof
ig u olApplic AZARDOUSMATERIAfSD15CLO' R Data
Will the applicant a, future building occupant more or handle hazardous material
-
u defined by the Cupertino Municipal, Code, Chapter 9.12, and the Health and Safety
Code, Section
an zss3xa7a -
All roofs shall be inspected prior to any roofing material being installed.
�11
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant nsc equipment or devices which
hazardous air momentums as defined by the Bay Area Air Quality Management
all new materials for inspection.
UI)IrtCl1
❑YesU
1 have mad the meardous materials royuimments under Chapter 6.95 of the Califor.
a aHcalth nyColc, Seen= 25505.25573 and 25570.1 understand thu if the building
docs not c arty h W a Lenart, Nal it is my responsibility to nobly the occupant of the
myuire whim must be mel priurm's Vance ofe Ccnifcauof Occupancy.
Signature of Applicant Dale
23 nhZ-03
All roof coverings to be Class "B" or better
Ow raathc(ized ant DaLe