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11110167 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21666 STEVENS CREEK BLVD CONTRACTOR:BARBARA KALMAN PERMIT NO: 11110167 TRUST,ETAL OWNER'S NAME: BARBARA KALMAN TRUST,ETAL 21666 STEVENS CREEK BLVD DATE ISSUED: 11/29/2011 C—0 R'S PHONE: 4085560200 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION r r r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.N MECH r RESIDENTIAL r 1 COMMERCIAL "- Contractor Date 1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:MONTE VISTA MARKET-I FLUSH MOUNTED BLACK (commencing with Section 7000)of Division 3 of the Business&Professions LETTERS Cade and that my license is in full force and effect 318"THICK&8"HIGH ON FRONT FASCIA,BLADE SIGN 30"X24"UNDER CANOPY&LIGHTED WALL SIGN ON 1 hereby affirm under penalty of perjury one of the fallowing two declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$1600 APPLICANT CERTIFICATION 1 certify that 1 have read this application and state that the above information is APN Number:35717012.21666 Occupancy Type: correct.1 agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. Signature Date Issued by: Date: OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: All roofs shat]be inspected prior to any roofing material being installed.If a roof is 1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for will do the work,and the structure is not intended or offered for sale(Scc.7044, inspection. Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to Signatur8 of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation,m provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should 1 store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Health afety Code,Sections 25505,25533,and 25534. become subject to the Worker's Compensation provisions of the Labor Code,I must Owl) forthwith comply with such provisions or this permit shall be deemed revoked. e th ]zed agent: Date: I APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that 1 have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating I hereby affirm that there is a construction lending agency for the performance of work's to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name i1ftify and keep harmless the City of Cupertino against l iabilities,judgments, 0i expenses which may accrue against said City in consequence of the Lender's Address granting of it rmit.Additionally,the applicant understands and will comply with all non-p in source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. 1 I .1 A'I I understand my plans shall be used as public records. Signature Date I W Licensed Professional ! I ! ( SIGN PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 IS • CUPERTINO (408)777-3228•FAX (408)777-3333•building Gncupertino.org PROTECT ADDRESS 1 ql 4 ��/ �,/_ A APN#�55� Com] OWNER NAME// .(/I /'Y r<'II y�Pl ^fJ F MOQ.r% �/e� •�i STREET ADDRESS O D ^/ O O CONTACT NAME 7 7 P A ya G �I STRE$f' D R S ^ I CI ,STATE, ZIP w C� -bi/ "If I "Air/ O re.; 1:1 OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER KIENANT CONTRACTORNAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX SFRP.ET ADDRESS CITY,srATE,Z.IP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE.,ZIP PHONE ES ION 4F WORK /�� , ho okK 6( /t Or 3/ hA01*944-$� f USE OF ❑ FD or Duplex ❑ MUIII-Family ILLDMINATEU SIGN TYPE NO,OF SIGN AREA VALUATION STRUCTURE: Commercial (YIN) (CODE) SIGNS (SQ.FT.) (F) SIGNTYPECODES: N B - BANNER SIGN l M - MONUMENT(GROUND)SIGN BL BLADE SIGN �( / P - PROTECTING SIGN D - DEVELOPMENT ID SIGN SP - SPECIAL EVENT BANNER • / 1 /vu ^ DI - DIRECTIONAL SIGN /T. - TEMPORARY •Y V E - ELECTRONIC / W { WALLSIGN RP.ADERBOARD WI - WINDOW SIGN RECEIVED BY: Ft V�IrLAJ�f�I.CTV / By my signature below,I certify to eac of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this/ application and the information I have/tiovided is correct. 1 have read the Description of Work and verify itis accurate. 1 agree to comply with all applicable local ordinances and state laws relating ar dird collstruction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/AgenC Date:--/" jrG f / SUPPLEMENTAL INFORM ION REQUIRED OFFICE USE ONLY _Site Plan PLAN CNECK TVPE ROUTING SLIP /Elevations ❑ OVER-TH&COUNTER ❑ BUILDING PLAN REVIEW -IL Sign Details-including UL listing(s)applicable ❑ EXPRESS ❑ PLANNING PLAN REVIEW tStructural Calculations(if applicable) ❑ STANDARD ❑ OTHER: `Copy of Planning Approval Letter or Meeting with Planning prior to ❑ LARGE submittal of Building Permit application. ❑ MAJOR SignApp_2011.doc revised 03/31/11 • CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35717012 .21666 DATE ISSUED. . . . . . . : 11/29/2011 RECEIPT #. . . . . . . . . : BS000015432 REFERENCE ID # . . . : 11110167 SITE ADDRESS . . . . . : 21666 STEVENS CREEK BLVD SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : .BARBARA KALMAN TRUST, ETAL ADDRESS . . . . . . . . . . : 21666 STEVENS CREEK BLVD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : MONTA VISTA MARKET CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : BARBARA KALMAN TRUST, ETAL ADDRESS . . . . . . . . . . : ' 21666 STEVENS CREEK BLVD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : • FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 1, 600.00 1. 00 0 .00 1 .00 0. 00 1BSEISMICO VALUATION 1, 600 .00 0 .50 0.00 0 .50 0. 00 1EPERMITFE FLAT RATE 1.00 44 .00 0.00 44 .00 0. 00 IESIGN UNITS 1 .00 44 . 00 0.00 44 . 00 0.00 1SIGNWNONE EACH 1 .00 260. 00 0.00 260. 00 0.00 1TRAVDOC FLAT RATE 1 .00 44 . 00 0.00 44 .00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 393 .50 0. 00 393 .50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CASH 1.50 CHECK 392 . 00 #235 --------------- TOTAL RECEIPT 393 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 101 FOUNDATION 103 UFER 104 REBAR 105 ANCHOR BOLTS 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION • ADDRESS: I DATE: REVIEWED BY: APN: BP#: I "VALUATION: $0 *PERMIT TYPE: Building Permit NA,YCHECK-T1716: P PRIMARY ENTAMATION 10EAP5 USE: Sign PERMITTYPE: WORK SCOPE SIGN TYPE FEE ID QTY SIGN FEE Wall Sign,Non-Electric 1SIGNWNONE 1 $260 Wall Sign, Electric $0 TOTALS: $260.00 dfo h. PI,or Check Plumb. Pian Check #Branch Circuits 1 $44.00 bR;rh. Per,a hce: Plunrb.Perarit fee: IESIGN Elec.Permit Fee: /EPERMIT " • `orhei M. h.hap, Orbe Numb Insp. Other Elec. Insp. 0.0 $44.00 Al:ch. Imp. Nee; Plunrlr, [n.rp.krc: Eiee.Insp. Fee: NOTE: This estimate doer not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District etc. . These fees are based on the prelildina In ormatlon available and are only an estimate Contact the Dept for addn7 info. FEE ITEMS (Fee Resolution 11-053 LYf 7/1111) FEE QTY/FEE MISC ITEMS Plan Check Pec: Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 F/urnh.;tl:fechJLilac Permit Fee: $260.00 Suppl. Insp.Fee:Q Reg. 0 OT 0,0 Ins $0.00 PME Unit Fee: $44.00 PME Permit Fee: $44.00 Construction nix Administrative Fee. Work Without Permit? Yes No $0.00 Sign Master Plan: Q Yes No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 Strong Motion Fee: $0.00 dr, Select an Administrative Item • Bldg Stds Commission Fee: $0.00 a L) SUBTOTALS: $392.00 $0.0011 'TOTAL FEE: $392.00 Revised: 10)01/2011 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION • 10300 TORRE AVENUE-CUPERTINO. CA 95014-3255 CUPERTINO (408)777-3228 -FAX(408)777-3333-buildinarrDcuoertino.oro Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SI:$, DDRESS t'1 _ �0. i VAPN BP11 1 ( ( ( c.I iO.�WNER ADDRESS n� DESCRIPTION OF WORK: ( `TV rV � L �- We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, Initialed your understanding of each provision, signed, and returned this form to us at our official address Indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) x1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- • wilder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. 1, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. V2. 1 understand building permits are not required to be signed by property owners unless they are responsible for e construction and are not hiring a licensed Contractor to assume this responsibility. Kero . 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may tt myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her j74. instead of my own. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numb rs on permits and contracts. 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the t to value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer"under slate and federal law. . I understand if I am considered an"employer" under state and federal law, I must register with the state and f eral government,withhold payroll taxes, provide workers'compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me ttoo serious financial risk. - 7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family resr ential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects In the workmanship or materials. _ OlOi1e!-BuilderFollH 1010.doc revised 04114110 i 9. I understand I may obtain more information regarding my obligations as an "employer"from the Internal even. Service, the United States Small Business Administration, the California Department of Benefit Payments, • and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB)at 1-800-321-CSLB (2752)or www.csib.ca.gov for more information about licensed c�o�nnWctors. 6 r 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I a am ti>6 party legally and financially responsible for proposed construction activity at the site address listed above. 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide b'y,,all pplicable laws and requirements that govern Owner-Builders as well as employers. Y 112. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information 1 have provided on this foam. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not ose Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS:Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be Issued,this form must be completed and signed by the property owner and returned to the agency responsible for Issuing the permit. Note:A copy of the property owner's driver's license, form notarization, or other verification ac table to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: 11A< Date: (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner-Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Tel No Address of Authorized Agent: I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. •Property Owner's Signature: Date: ON91e'Buildel'FolYI] 2010.doc renisc-d 04114110 ® j o �n ' , z m � ' to D I . z � ' FFRJ �-�l I ': •�91ig �� A ®, Mill KIM rn IEEE I . o > g y a 3 ' 3 o = 00 t q 5 � � � � W0 jaf Q o 3 i dl 0 � w � 20 � , N a °. � z 111 11 m �, m u z m � 0alit Dc MOM " p1 5 > 0 1e Z � Z l� 0 T m < a) + � � Z Mm yma ��131 A z CO) m N