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11110028 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7565 ORANGE BLOSSOM DR CONTRACTOR:PETRANOVIC DUSAN AND PERMIT NO: 11110028 MIRJANA OWNER'S NAME: PETRANOVIC DUSAN AND MIRJANA 7565 ORANGE BLOSSOM DR DATE ISSUED: 11/07/2011 (Alb&R'S PHONE: 4083433886 CUPERTINO,CA 95014 PHONE NO: _1W LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class Lie.N MECH r RESIDENTIAL r COMMERCIAL r Contractor Date 1 hereby affirm that 1 am licensed under the provisions or Chapter 9 JOB DESCRIPTION:PROPERTY LINE CLEANOUT;DIG IIOLE AT PROPERTY (commencing with Section 7000)or Division 3 of the Business&Professions LINE Code and that my license is in full farce and effect. ABOUTS' I hereby affirm under penalty or perjury one of the following 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 Sq.Ft Floor Area: Valuation:$1156 permit is issued. APPLICANT CERTIFICATION APN Number:36611055.00 Occupancy Type: I certify that I 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 to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save PEW)AJ OT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WT SUANCE OR granting of this permit. Additionally,the applicant understands and will comply 18L D INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. °aaneDate: Signature Dale 10 OWNER-BUILDER DECLARATION RE-ROOFS: 1 hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material berg installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"012 BETTER I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's IIAZARDO.US MATERIALS DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Ilealth&Safety Code,Sections 25505,25533,and 25534. 1 will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(x)should I store or handle hazardous material. Additionally,should 1 use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District 1 will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,I must Owner o6 authop/��.re/1 agent: forthwith comply with such provisions or this permit shall be deemed revoked. - ^ ""^T:LA�-n-/ Date: I �� APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save i1knity,and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address and expenses which may accrue against said City in consequence of the 6 .mg of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. �p 1 I understand my plans shall be used as public records. I, Signature...�1` t1�.1�Q.l-G(JV(�Cr Date Licensed Professional • CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36611055 .00 DATE ISSUED. . . . . . . : 11/07/2011 RECEIPT #. . . . . . . . . : BS000015245 REFERENCE ID # . . . : 11110028 SITE ADDRESS . . . . . : 7565 ORANGE BLOSSOM DR SUBDIVISION . . . . . . : CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : PETRANOVIC DUSAN AND MIRJANA ADDRESS . . . . . . . . . . : 7565 ORANGE BLOSSOM DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : MIRJANA PETRANOVIC CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : PETRANOVIC DUSAN AND MIRJANA ADDRESS 7565 ORANGE BLOSSOM DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : • FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1 .00 41. 00 0 . 00 41 .00 0. 00 1BCBSC VALUATION 1, 150.00 1. 00 0 . 00 1.00 0. 00 1BSEISMICR VALUATION 1, 150 .00 0.50 0 . 00 0.50 0 . 00 1PPERMITFE FLAT RATE 1 .00 44 . 00 0 . 00 44 .00 0. 00 1PRSEWER UNITS 1.00 22 . 00 0 . 00 22 . 00 0. 00 1TRAVDOC FLAT RATE 1 .00 44 . 00 0 . 00 44 .00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 152 .50 0 . 00 152 .50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 152.50 VISA --------------- TOTAL RECEIPT 152. 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION • ADDRESS: 7565 ORANGE BLOSSOM DATE: REVIEWED BY: APN: BP#: *VALUATION: $1,150 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1 RPSS USE: PERMIT TYPE: WORK PROPERTY LINE CLEANOUT•DIGGING A HOLE AT PROPERTY LINE ABOUT 5' DEEP SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1PRSEWER 1 # $22 TOTALS: $22.00 Alerdr. Plou Chap k Plumb.Plan Check 0.0 hrs $0.00 Ilea.Mau Checl, -V'crk Per"it Fee. I Plumb. Permit Fee: 1PPERM/T Lilac. Perndi:f-Ce. • Other Alech,hap. Other Plumb Insp. 0.0 hrs $44.00 Other lilec. Drsp. Li df•c6.Imp. Fee: Plumb. fn".Fac: blur.Imp. Fee: NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . Thesefees are based on the preliniina in ormation available and are onl an estimate. Contact the De 1 or adtln7 info. FEE ITEMS (Fee Resolution 11-053 Eff 7/1//1) FEE QTY/FEE MISC ITEMS Plan Check Fec, Suppl. Y(°h'r" PME Plan Check: $0.00 Permit Fee: Supp/. Insp Fee PME Unit Fee: $22.00 PME Permit Fee: $44.00 7-7 Construction Tax7-17 Administrative Fee: (ADMIN $41.00 Work Without Permit? C) Yes (D No $0.00 Advanced Plannin;**beer: Travel Documentation Fee: ITRAVDOC $44.00 i Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item • Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS:; $152.50 $0.00 TOTAL FEE: $152.50 Revised: 10/01/2011 GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO,CA 95014-3255 M I •CUPERTINO (408)777-3228 • FAX(408)777-3333- buildinO(cDcuoertino.Org sc PLUNGING �( MECHANICAL ��ELECTRICAL MISCELLANEOUS PRomcr ADD 6SQr /i/l�sl"".I �r r�`i/ AINI I ()-JJ OWNER a el' q"V 11C Xt7 3 1�3 346 eMAR AD RES9 !^ t o Y11 Y•' STATe.L@ I 11I6^ FAX CONTACT NAME PHONE E-MAD. ST=ADDRESS CITY,STAM ZIP FA% OwNFJI ❑ OWNER-BUflDER ❑ OWNER AGENT ❑ LTJNTRACTOR ❑CON-MACrOR AGENT ❑ AAOBTELT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACMR NAME LICENSE NUMBER LICENSE TYPE BUS.LICA COMPANY NAME E-MAIL FAX STREBTADDRESS CITY,STATE,Z@ PHONE ARCHCTECr/ENGINM NAME IZEM NUMBER BUS.LIC F COMPANY NAME' E-MAIL FAX STREET'ADDRESS MY,STATF,ZIP PHONE OF ErSFO mDUPLEX ❑ MULTI-FAMILY PROTECT IN WBDIAND ❑ YE9 PRCTEC N ❑YES 13 THE BLDG AN ❑YES ING: 13COM MOAL URBAN DITERFACE AREA 13NO FLOOD ZONC ❑No E[CHLER HOMEI ❑NO DFSCRO"RON OF WORK 1hs�a/Ct" ro . lUt e&&-t cry+-t 41j-j41&0cc, uj �! TOTAL VALUATION. / /J 0 RECEIVED BY: By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the pmpetty er's behalf I have read this application and the iaformation I have provided is correct have read the Description of Work and verify it is accurate. I agree to comply with al]applicable local ordinances and state laws relating m bta7 g con ctl �1 I authorizelrepr/esentatives of Cupertino to enter the above-id of d property for inspection poses. Signature ofApplica—VAgenN - �`�r l/tQ�yY Date: SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY M OVER-THE-COUNTER }d ```��F ❑ EXPRESS _ ❑ STANDARD u ❑ LARCE 6 ❑ MAJOR MPPAfucdpp 1011.dbc revised 06/11/11 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION • 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228- FAX(408)777-3333- buildincQcuoertino.orc 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: SM D S r l0� pl� � i APN BPa OWN NAM€ „ff. ,lC// OWNER ADDRESS v DESCRIPTION OF WOR : l n l f 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.) -410 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material • personally. I, 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. -'W�2. I understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. . ,W3. I understand as an "Owner-Builder' I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. -X4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the to al value of my construction is at least five hundred dollars($500), including labor and materials, I may be considered an "employer" under state and federal law. AL6. I understand if I am considered an "employer'under state and federal law, I must register with the state and federal 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 /m/e to serious financial risk. its} 7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family residential 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. • 4811 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. OirnerBuilderForm 2010.doc revised 04/14/10 . I understand I may obtain more information regarding my obligations as an "employer"from the Internal Revenue 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.cslb.ca.gov for more information about licensed contractors. ILV10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. ,L11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide V plicable laws and requirements that govern Owner-Builders as well as employers. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. 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 those 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 acceptable to the city may be required to be presented when the permit is issued to verify the property owner's sign atur . Property Owner's Signature: % Date: ----------•— --- ----------- -------------- --n - -rew- --------------- --------------Writ----- -------•----- -------- --------- (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: OwneriluilderFonn 2010.doc revised 04114/10 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 U P E RT I N O Telephone: 408-777-3228 Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: 756,F Q P PERMIT# 0Z OWNER'S NAME: ' aI ' PHONE# GENERAL CONTRACTO BUSINESS LICENSE# ADDRESS: qqA�keCITY/Z I PCO D E: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. 106 /�� I am not using any subcontractors: " Signature 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 Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock . .. Tile Owner/Contractor Signature Date