12030075 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10235 VICKSBURG DR CONTRACTOR:JOSE PEREIRA&MINGO PERMIT NO: 12030075
MEHTA
OWNER'S NAME: JOSE PEREIRA&MINOO MEHTA 10235 VICKSBURG DR HATE ISSUED:03/162012
OWNER'S PHONE: 4084999550 CUPERTINO,CA 91014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL C0111MERC[AL
11
License Class Lie.N REMODEL BATHROOM 104 SQ FT
Contractor Date
1 hereby affirm tlmt I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full free and effect.
hereby affirm under penalty of perjury sue of the following two declarations:
I have and will mainmin a eeriticale of consent to self-insure for Worker's
Compensation,at.s provided for by Section 3700 of the Labor Code,for the
performance of the work for whichthispermit is issued. Sq.Ft Floor Area: Valumion:$5000
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,fon the perfrrnahce of die work for which this
AI'N Number:36967011.00 Occupancy"Type:
permit is issued.
APPLICANT CERTIFICATION
(certify that I have read this application mid state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.(agree to comply with it[[city mal county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,will hereby authorize representatives of this city to enter
upon the above mentioned property torr inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses whidt may accrue against said City in consequence of die
granting of this permit. Additionally,the applic,•mt understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Sectio
91.18.
RE-ROOFS:
Signature Date AI I rwfs shall he inspected prior(only roofing material being instal led.If a roof is
inslulled without first obtaining an inspection,I agree to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION
hereby affirm that 1 nm esengx from the Contractor's License Law for one of Signature of Appl icnt: Date:
One following two reasons: ALL ROOF COVERINGS TO BE CLASS':A"OR BETTER
h,Ls owner of the property,or my enployees with wages as their sole compensation,
will do the work,mid the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1.as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIAL,';DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous mmerials requirements under Chapter 6.95 of tine
California Health&Safety Code,Sections 25505.25533,and 25534. 1 will
hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
decimations: Ilealth&Safety Code.Section 25532(1)should 1 store or handle hazardous
1 have mill will mniamin a Certificate of Consent to self insure for Worker's material. Additionally,should 1 use equipment rr devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the ;air contaminants as defined by tine Bay Area Air Quality Management District 1
performance of the wort:for whichthis permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25M,25533,and 25534. 1
Section 3700 of die Labor Code,for de perfomt:mnce of die work for which this _ 9 1,K- o..,
permit is issued. Owner or authorized agen —[late: L1�
I certify that in the performance of lie work for which this permit is issued,I shall r
not employ any person inany manner so as to become sul?iect to the Worker's
Compensation laws of California. If.after making this certificate of exennption,I CONSTRUCTION[,ENDING AGENCV
become subject to die Worker's Congensation provisions of the Lahor Code,I must I hereby affirm aha there is a construction pending agency for the performance of
forhwitm comply with such provisions or this permit shall he deemed revoked. w'ork's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
1 certify thin I have read this application and state that the above inforraion is
correct.I agree no comply with all city and county ordinances and state paws relating
to building construction,and hereby authorize representatives of this city in enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify acid keep harmless the City ol'Cupenino against liabilities,judgments,
costs,and expenses which may accrue against said City it consequence of die I understand my plans shall the used as public records.
granting of this pemnit.Additionally,the applicant t understands and will comply
with all non-point source re" bans per the Cupertino Municipal Code,Sectio Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10235 vicksburg dr. DATE: 03/16/2012 REVIEWED BY: bobs.
APN: BP#: *VALUATION: $5,000
"PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Repair
PRIMARY SFD or Duplex PENTAMATION 1R3SFDREM
USE: PERMIT TYPE:
WORK sfd bathroom remodel non structural.
SCOPE
11e,lr P/,nr Chnk P/um/x Plan Check Elee.Plan Check
Ahwh.Permit Pee: Plump.Permit Fee: Elec. Parnate Pee:
t hirer Alr.lr.hisp. Other Plmrh hip otht".Gem limp. Li I
lfLJl /nsp• Fee• Mouth.lisp.Fee: Mae.Imp. Fee:
NOTE: This estinmte does not include jeer due to other Departments(i.e. Planning,Public Works. Fire,Saninuy Sunver District School
District,etc.). These ees are based on the trelininan iu ornmlion available and are on/j,an estimate. Contact the De t or addn'I info.
FEE ITEMS (Fee Resolution 11-053 EA' 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 104 1 s.f. Remodel, Bath(<=300 sf)
Suppl. PC Fee: Q Reg. O OT 0.0 lirs $0.00 $588.00 1REHRESRAT
PME Plan Check: $0.00
Permit Fee: $0.00
SuppI. Insp. Fee,.S Reg. 0 OT 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Construction Tax
Administraaive Fee: 0
Work Without Permit? O Yes (j) No $0.00 0
Advanced Planting, Fee: $0.00 Select a Non-Residential 0
Tr,rne/Docurneniation Fees: Building or Structure 0
Strong, Motion Fee: 1aSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: litclik $1.00
SUBTOTALS: $1.501 $588.00 TOTAL FEE: 1 $589.50
Revised: 1/19/2012
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 36907011 . 00
DATE ISSUED. . . . . . . : 03/16/2012
RECEIPT #. . . . . . . . . : BS000016288
REFERENCE ID # . . . : 12030075
SITE ADDRESS . . . . . : 10235 VICKSBURG DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JOSE PEREIRA & MINOO MEHTA
ADDRESS . . . . . . . . . . : 10235 VICKSBURG DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JOSE PEREIRA
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : JOSE PEREIRA & MINOO MEHTA
ADDRESS . . . . . . . . . . : 10235 VICKSBURG DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 5, 000 .00 1 . 00 0. 00 1 . 00 0 .00
1BSEISMICR VALUATION 5, 000 .00 0. 50 0. 00 0.50 0 .00
1REMRESBAT SQ FEET 1 .00 588. 00 0.00 588 .00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 589 .50 0 .00 589 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 589.50 amex
---------------
TOTAL RECEIPT 589.50
RESIDENTIAL PROJECT COVER SHEET
Assessor's Parcel Number:
Name of owner.
Project address. o t;c -�Az_
CI ntact person. �cQE (94 Phone.
Fax.
Net square footage of lot. "7 S�?D
Existing Pro osed
Square footage: First floor: Z7. 1 2 Z I
Second floor:
Garage:
TOTAL:
Are there at least two 10 foot by 20 foot clear spaces inside the garage? Y N 04 64-
Is privacy protection planting required for the project? Y N U.JN
Build it Green Total Points
On what floor(s) is work being done? C x o ct >4 � v-
Brief description of work. �j p�It 12E Mo �E L SAl� P q&L C10 G )
C`bde editions: 2010 CBC fN)2010CFC N)2010 CMC N)
r- 2010 CPC N)2010 NEC N)
�t California Green Building Standards Code 2x10,4MUNITYDEVELOPMENT DEPARTMENT
BUILDING DIVISION-CUPERTINO
APPROVED
Effective 1/01/11
This set of plans and specifications MUST be kept at the
job site during construction. It Is unlawful to make any ,
t0 ® changes or alterations i f same, B to deviate-
herefrom,without approval from the Building Official F 1V�i�
COPYBY
The stamping r this plan and specifications SMP
AR 16 2012
of held to permit or to bean approval of the vlolate Liof any provisions of any City Ordinance or State Law.
S xi, BY
DATE
PERMIT NO.
Plan Review Process Work Book Page-8- Revised 17/21/10
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OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228 • FAX (408)777-3333• buildinona cuoertino.org
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:
SITE ADDRESS _TA_PN BP#
OQ'eZr
OWNERNAME �EfnOWNER ADDRESS C (Na U^y
DESCRIPTION OF WORK: ,
fQA6121r-
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.)
v 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.
—2,.1 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.
Q ✓_3. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
Q+ 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.
4. 1 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
total value of my construction is at least five hundred dollars(S500), including labor and materials, I may be
considered an "employer' under state and federal law.
(� ✓ 6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and
oa 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
me to serious financial risk.
✓ 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.
v'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.
OwnerBullderForm 2010.doc revised 04/14/10
9. 1 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.cs[b.ca.gov for more information about licensed
contractors.
✓ 10. 1 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.
11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
rQ ✓ 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
l,V 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 ac eptable to the city may be required to be presented when the permit is issued
to verifythe property owner's si not e.
Property Owner's Signature: Date: .3 \ 7.OTL
---------------------------- -------------------------------- ----------------------------------------------------
(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 fora 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:
OrvnerBuilderForm 2010.doc revised 04/14/10
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 950143255
CUPERTINO (408) 777-3228 • FAX(408)777-3333 • btiildina(c)cupertino.orOD�
❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT k
PA0"A➢D7RFS, f, ,C I A ( 1 0/f .
v
..e_;rot Y&-Iq Tf•C�-�
Sr1 ADDRESS CITY, S,'ATL ZIP .
IOL S Vf S ✓ �Gt 17 cc 9" lf. Na
CONTACT NAME PHONE E-MAIL
STAEETADDRESS CrY.STATE. ZIP FAX
0 OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHTIER ❑ENGINEER ❑ DEVELOPER ❑TENANT
CANTitA, SiORNAQ LICENSE Nt1M0ER LICENSE TYPE BUS.UCp
CONOANY.NAME E-MAIL FAX
ST=ADDRESS CITY.STATE,ZIP PHONE d7.
ARGOTECT/ENGINEERNAME (/v ^_ LICENSENUMBER BUS.LIC�p`
COMPANY NAME /l/•�7 E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
EXLSTING USE PROPOSED USE CONSTR TYPE MSTORIES
�-I USE TYPE OCC I SQ.FT. VALUATION(S)
EXIST
NEW FLOOR D
AGI ° r \
BATHROOM OTHER
REMODELAREA O R..''MOOELAREA REMODEL AREA
PORCH AREA DECK TOTAL OECIVPORCH AREA WAAG'c AREA: DETACH '
❑A TACH
0 DWELLWG UNTS: TOTAL
❑YES SECOND STORY ❑YES
BEING ADOEI! ❑NO ADDITION'.. ❑NO
PRE-APPGCATION ❑YES F YES,PROVIDE COPY OF TOTAL VALUATION'❑NO PLANNDGAPPROVAL LETTEA SERRBGM ❑NO RNSaOC) s
By my signature below,I certify to each of the following: I am the pronerry owner or authorized agent to act on the prpperty owner's behalf,T have read this
application and the information I have p ' ed is correct. I have read the Description of Work and verify it is acnn-ate. I agree W comply with all applicable local
ordinances and stain laws relating m i t g COns�tedon. I authorize representatives of Cupertino to enter the above-id tiff d ptopery far inspection pmnoses.
Signature of AppGcandAgrnt Date: �, IS_ 20(2
SUPPLEMENT 1NFMMATION REQUIRED PLAY CHECK TYPE \ROUTING SLIP
_New SF D or Multifamily dwellings: Apply for demolition permit for C�3–ova—rfar-cODYTRR ❑'BDn.DINc PLAN REviEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ ExPRESS ❑ PLANNING Pt 1N REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure C3st'ANDARD ❑ PUBLIC*WORKS
T—=if any Hazardous Materials are being used as part of this project.
❑ LARGE ❑ FIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application. ❑ MAJOR ❑ SANITARY SEWER DISTRICT
❑ vrvutONMENTAL 8F.ALTH
BldgApp_2011.doc revised 06/21/71