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12020096 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 6113 BOLLINGER RD CONTRACTOR:CRANFORD JIM AND PERMIT NO: 12020096 MARJORIE M OWNER'S NAME: CRANFORD JIM AND MARJORIE M 6113 BOLLINGER RD DATE ISSUED:02/21/2012 CL'PF,RTINO,CA 95014-4629 PHONE NO: OWNER'S PHONE: 4083162847 _ _ ElLICENSED CONTRACTOR'S DECLARA"I ION BUILDING PERMIT INFO: BLDG F ELECT PLUMB License Class Lic.# MECH(� RESIDENTIAL COMMERCIAL Contractor Date JOB DESCRIPTION: REPLACE SIDING ON F.(CHLER 1IOMI:1300 SQF hereby affirm that 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 force and effect. 1 hereby affirm under penalty of perjury one of the following two declarations: 1 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 Valuation:$4000 performance of the work for which this permit is issued. Sq.Ft Floor Area: 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 APN Number:37538009.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above information is correct. 1 agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply l ! Date:2-- 2— ) with all non-point source regulations per the Cupertino Municipal Code,Section Issued b 9.18. Signature Date RE-ROOFS: ❑ or to any roofing material bei OWNER-BUILDER DECLARATION All roofs shall be inspected pring installed. If a roof is installed without first obtaining an inspection,I agree to remove all new materials for 1 hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: Date: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) ALL ROOF COVERINGS TO BF,CLASS"A"OR BETTER ER I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). IIA7ARDOUS MATERIALS DISCLOSURE hereby affirm under penalty of perjury one of the following three 1 have read the hazardous materials requirements under Chapter 698 of the declarations: nt to I have and will maintain a Certificate of n 3700 of thelLaborrCode�e for or the Worker's compliance California I with the Cupertino Municipal Code,Chapter 912 and 4the Health'&tarn Compensation,as provided for by Sectio Safety Code,Section 25532(x)should I store or handle hazardous material. performance of the work for which this permit is issued. Additionally,should 1 use equipment or devices which emit hazardous air 1 have and will maintain Worker's Compensation Insurance,as provided for by contaminants as defined by the Bay Area Air Quality Management District 1 will Section 3700 of the Labor Code,for the performance of the work for which this maintai compliane with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Ilealt Safety e,Se ions 25505,255Wd2,55I certify that in the performance of the work for which this permit is issued,I shallnot employ any person in any manner so as to become subject to the Worker's Ow er th pat Compensation laws of California. If,after making this certificate of exemption,1 become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION RUCTION LF,NDING AGENCY I reby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION'and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting of this pennit Additional) , he applicant understands and will comply I understand my plans shall be used as public records. with all non-point so cc regulati per th upertino Municipal Code,Section Licensed Professional 9.18. Signature Date, �� , CITY OF CUPERTINO PERMIT RECEIPT OPERATOR: suew 3 ITEMS OF 3 COPY # : 1 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 37538009 . 00 DATE ISSUED. . . . . . . 02/21/2012 RECEIPT # . . . . . . . . . REFERENCE ID # . . . : 12020096 SITE ADDRESS . . . . . : 6113 BOLLINGER RD SUBDIVISION . . . . . . • CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . • • • OWNER CRANFORD JIM AND MARJORIE M ADDRESS . 6113 BOLLINGER RD CITY/STATE/ZIP CUPERTINO, CA 95014-4629 RECEIVED FROM JIM CRAWFORD CONTRACTOR LIC # *OWNER* COMPANY CRANFORD JIM AND MARJORIE M ADDRESS 6113 BOLLINGER RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4629 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC - NEW BAL ------ ---------- 0 . 00 ---------- ---------- 0 . 00 1 . 0 4, 000 . 00 1 . 00 1BCBSC VALUATION 0 . 50 0 . 00 0 . 50 0 . 00 1BSEISMICR VALUATION 4, 000 . 00 0 . 00 1, 300 . 00 980 . 00 0 . 00 980 . 00 1SIDEOTHER SQ FEET ________ ---------- ---------- --------- 0 . 00 981 . 50 0 . 00 TOTAL PERMIT 981 . 50 AMOUNT REFERENCE NUMBER METHOD OF PAYMENT ----- ------------ CREDIT CARD 981 . 50 VISA C --------------- TOTAL RECEIPT 981 . 50 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333- buil (a� dingcupertinO—Or- CUPERTINO 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: 1�)� SITE ADDRESS �� f��� APN OWBP# 6'l�3 G Jl / OWNER AD S —6,t E OWNER NAME /!/ ' a �!/ 16 DESCRIPTION OF WORK: C fi 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. I 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. GV3. 1 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. //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. I understand if I employ otherwise hundred dollars($500), including labor andmate other than California licensed Contractors,may beand the total value of my construction sat leas 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 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. X7. 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. s issued, I may Vny . I understand as an Owes sBtonedfby all the property for ny subsequent ownelch this r(s)thapeesulltlfrom any latent bonstrudctioble for nancial or personal ink defects in the workmanship or materials. aa>nerBuilderFor17i_2010.doc revised 04/14/10 e9. I understand I may obtain more information regarding my obligations as an "employer"from the Internal e—v—enue 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. /_10. 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. 4K 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. 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the i formation 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.) 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 issuinga permit. Note:A copy of the property owner's driver's license, form notarization, or other verification ceptable. the 1ty may be required to be presented when the permit is issued to verify the property owner's si nat Property Owner's Signature: Date: i ------------------------------ laiti6- ------- ------------ -- - - - - -- --- (NOTE: The following Authorn 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: 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: OHnaerBuilderForns 2010.doc revised 04/14/10 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 6113 Bollinger rd. DATE: 02/2112012 REVIEWED BY: bobs. AFN: L5 � BP#: p� VALUATION: $4,000 lJU PLAN CHECK TYPE: Alteration / Repair PERMIT TYPE: Building Permit PENTAMATION 1GENRES PRIMARY SFD or Duplex PERMIT TYPE: USE: WORK re lace existing siding with new siding. SCOPE nitary NOTE: This estimate does not include fees due to other Departments(i a Planning,Pum an estismate.eCa tact the Deptr District, addn'l info. District,etc.). These fees are based on the relimina in ormation available and a t�f,4 �,, ar=;=;=f _> 1,'-€, ; FEE QTY/FEE MISC ITEMS FEE ITEMS $0 Plan Check Fee: .00 1,300 s.f. Siding All Other Suppl PC Fee: Q Reg. ::110'11 0.0 hrs $0.00 $980.00 1SIDEOTHER PME Plan Check: $0.00 Permit Fee: $0'00 Suppl. Insp.Fee:Q Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 0 Work Without Pert-nit? 0 Yes Q No $0.00 Select allon-Residential $000 Building or Structure Q 1 BSEISAKCR $0.50 Select an Administrative Item. 00 :._.m..� ...�__._.,._..__..__...._._. CBSC TOTAL FEE: $981.50 SUBTOTALS: $1.501 $980.00 Revised: 1/19/2012 t,�,rxz PLOT PLAnb CONSTRUCTION PERMIT APPLICATION CHMIKED Bx COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISIM'n La/Z 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333• building(@cupertino.org PLANNING DOM �roOveX s1,00 GUPERTIN0 C. ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISIOs�N�/-D7 EFERRF�'i '�' RIGINAL PERMIT PROTECT ADDRESS / //� �0 0109 TA_PN# 1 '/ �• OgAIL OWNER NAME PHONE l /'f/ (� FAX STREET ADDRESS ll/ I� �l/vlll�� STa '/// /� C,GL �✓v/ / PHONE E-MAIL CONTACT NAME CITY.STATE,ZIP FAX STREET ADDRESS ❑ CONTRACTOR ❑CONT?ACTOR ❑ ARCHITECT ❑E'IGDME ❑ DEVELOPER ❑TENANT WNER ❑ OWNER-BUILDER OWNER AGENT LICENSE NUMBER LICENSE TYPE BUS.LIC# CONTRACTORNAME j� �� (1 /, FAX . E-MAST. COMPANY NAME CITY,STATE,ZIP PHONE PSTF= RESSBUS.LICIENGINEER NAME �I . LICENSE NUMBER V FAX E-MAIL COMPANY NAME CITY,STATE,ZIP PHONE STREET ADDRESS / DESCRIPTION OF WORK `` 3 �L`J EXLSTING USE PROPOSED USE CONSTR.TYPE #STORLES USE TYPE OCC. SQ.FI. VALUATION NNj)(S) EXISTNEW FLOOR DEMO TOTAL' yw AREA AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA TOTAL DECKIPORCH AREA GARAGE AREA DETACH PORCH AREA DECK AREA ❑ATTACH #DWELLING UNrfS: IS A SECOND UNIT YES SECOND STORY ❑YES BEING ADDED? ❑NO ADDITION? ❑NO TOTAL VALUATION: > IS THE BLDG AN l<ES RECEIVED BY: PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF EICHLER HOME. ❑NO r (/G PLANNING APPL# [:]NO PLANNING APPROVAL LETTER ' ':/-- By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prrperty owner's behalf.'I have read this application and the information I have provided is correct. I have ad the escription of Work and verify it is accurate. I agree tPmpl foth�applicableoses� ordinances and state laws relating to building can ction. I an ze resentatives of Cupertino to enter the abor a-i� fied property P Pulp Date:2- �` Signature of Applicant(Agent SUPPLEMENTAL INFO TION REQ PLAN CFS TYPE �/AO7JTING SLIP _New SFD or Multifamily dwellings:`'Apply for demolition permit for -COUNTER 9� B�ING P��R' existing building(s). Demolition permit is required prior to issuance of building ❑ EXPRESS `' PLANNING PLAN REVIEW permit for new building. C] PUBI.Ic woRxs _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure [1 STANDARD [I FIRE DEP form if any Hazardous Materials are being used as part of this project. ❑ LARGE _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ r AJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH B1dgApp_2011.doc revised 06/21/11