12010160 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10118 BANDLEN'DR CONTRACTOR:MARINA PLAZA LLC PERMIT NO: 12010160
OWNER'S NAME: MARINA PLAZA LLC 4546 EL CAMINO REAL STE C DATE ISSUED:01/26/2012
OWNER'S PHONE: 4084226029 LOS ALTOS,CA 94022 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ' ELECT PLUMB
License Class Lic.# MEC.H RESIDENTIAL COMMERCIAL i
Contractor Date
I hereby affirm that[am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TAPIOCA EXPRESS STE G-REPLACE WATER HEATER AT
KITCHEN LOCAL.
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure fir 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.
1 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:$1200
permit is issued.
APPLICANT CERTIFICATION APN Number:32634066.00 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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnity and keep harmless the City of Cupertino against liabilities,judgments. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section / /
9.18. Issued by Date:/ '
Signature Date
OWNER-BUILDER DECLARATION
RE-ROOFS:
I 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 being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,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 otfered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
1.as owner of(tie property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with tlue Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I 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 arty manner so as to become subject to the Worker's Health&4ajrize:dela -t-O
CoHus 255051 25533,and 25534.
Compensation laves of California. If,after making this certificate of exemption,I
become subject to the Worker's t_'ompensadon provisions of the Labor Code,[must Owner au
Date: ,2
forthwith comply with such provisions or this permit shall be deemed revoked.
FONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATIONI certify that I have read this application and sffirtate that the above€nformation is I hereb, am that thenstruction 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
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applic t understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulatii�rr er the C ertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
Signature Date — Licensed Professional
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rzig: Sub: Blk: Lot:
APN 32634066 .00
DATE ISSUED. . . . . . . ; 01/26/2012
RECEIPT #. . . . . . . . . BS000015853
REFERENCE ID # . . . ; 12010160
SITE ADDRESS 10118 BANDLEY DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER MARINA PLAZA LLC
ADDRESS 4546 EL CAMINO REAL STE C
CITY/STATE/ZIP . . . : LOS ALTOS, CA 94022
RECEIVED FROM . . . . : INFINITY 168 CORP.
CONTRACTOR LIC # *OWNER*
COMPANY MARINA PLAZA LLC
ADDRESS 4546 EL CAMINO REAL STE C
CITY/STATE/ZIP . . . : LOS ALTOS, CA 94022
TELEPHONE
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- -
1ADMIN HOURS 1 .00 41 . 00 0. 00 41 .00 0 . 00
1BCBSC VALUATION 1,200 .00 1.00 0 .00 1.00 0.00
1BSEISMICO VALUATION 1,200 .00 0 . 50 0. 00 0 .50 0 . 00
1PCWHEATR UNITS 1 .00 26 .00 0 .00 26 .00 0.00
1PPERMITFE FLAT RATE 1 .00 44 . 00 0 . 00 44 .00 0 . 00
1TRAVDOC FLAT RATE 1 .00 44 .00 0 .00 44 .00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 156 .50 0 .00 156 .50 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 156 .50 #11383
---------------
TOTAL RECEIPT 156 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- -----------------------
518 WATER HEATER
OWNER-BUILDER DISCLOSURE FORM
COMMUNI T Y DEVELOPMENT DEPARTMENT> BUILDING DIVISION
103DO TORRE AVENUE- CUPERTIND, CA 95014-3255
EUPERTIhFO (4DB)777-3228 • FAX (4DB)777-3333 - buiidinofacuoeyino.gm
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 ADDRE554,W AP BPS
OWNFD mAF 1 OWNER ADDRESS
19
DESCRIPTIA OF WORK: V� !
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.)
1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
E311
Owner-
B I er'building permit that erroneously implies that the property owner is providing his or her own labor and material
pe onally. 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
4ins rance 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
th construction and are not hiring a licensed Contractor to assume this responsibility.
fec. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
t myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
instead of my own.
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
In ers on permits and contracts.
5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
dered an "employe" under state and federal lav✓.
6. 1 understand if I am considered an "employer" under state and federal lav✓, I must register with the state and
a] 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
Jmeo serious financial risk.
7. 1 understand under California Contractors' State License Lav✓, an Owner-Builder who builds single-family
ential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
s d subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is p ormed 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
'•an financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
de cts in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04/14/10
49. 1 understand I may obtain more information regarding my obligations as an "employer"from the Internal
enue Service, the United States Small Business Administration, the California Department of Benefit Payments,
a the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CS LB) at 1-800-321-CSLB (2752) or wv✓w.cslb.ca.gcv for more information about licensed
con dors.
10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
a he 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 11 applicable lauds and requirements that govern Owner-Builders as well as employers.
lassiyou
I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
tion I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
tract with someone who does not have a license, the Contractors' State License Board may be unable to
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 per it. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the cit may be required to be presented when the permit is issued
to verify the property owner's signature.
Property Owner's Signature: Date:
------------------------------------------ - - - -- --- -_ - - - -- --- - - -- - -- -- -----------
(NOTE: The following Authorization Form requiredto 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 Mork):
Project Location or Address: ZM
Name of Authorized Agent: _Ie/o 1-42?z1a Tel No
Address of Authorized Agent: e
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 maybe quired to presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
01477e•BuilderFor77: ?010.doc revised 04114110
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333• building(@cupertino.org misc
CUPERTINO
CRfPLUNMING ❑MECHANICAL [1 ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS 'FN#
OWNER NAME ` , PHONE D E-MAIL
STREET ADDRESS CITY ST TE, FAX
CONTACT NAME / P O '' //� E-MAIL
STREET ADDRESS �i CITY. FAX
CJ OWNER ❑ OWNER-BUIDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SM or DUPLEX ❑ MULTI-FAMII.Y PROJECT IN WIIDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: 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 property owner's behalf. I have read this
application and the information I have provided is correct., have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction.`I authorize representatives of Cupertino to enter the above-identified property for inspection pulpmes.
Signature of Applicant/Agent: Date:
UPPLEMENTAL INFORMATION REQ=D OFFICE Us NLY
OVER-THE-COUNTER
❑ EXPRESS
Y
U
❑ STANDARD
U
❑ LARGE
a
❑ MAJOR
MEPMfscApp_2011.doc revised 06/21111