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12040038CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20771 MC CLELLAN RD CONTRACTOR: ALEXANDER & YE YINING PERMIT NO: 12040038 MARTINOVIC OWNER'S NAME: ALEXANDER & YE YINING MARTINOVIC 20771 hICCLELLAN RD DATE: ISSUED: 04/06/2012 OWNER'S PIIONE: 4084904836 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION r r r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.N MECH RESIDENTIAL COMMERCIAL Contractor Date hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE FURNACE, RELOCAT1: TO ATTIC, REPLACE (commencing with Section 7000) of Division 3 of the Business & Professions ATTIC SUPPLY DUCTS. INSPECTOR TO VERIFY STRUCTURAL. Code and that my license is in full force and effect. SUPPORT OI' FURNACE IN ATTIC I hereby affirm under penally of 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: Valualion: $9794 permit is issued. APPLICANT CERTIFICATION APN Number: 35916012.00 Occupaney Type: I certify that I have read (his application and slate 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 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: / /y �[ %Gf7 Date: OWNEWBUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE -ROOFS: the fallowing two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is I, 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 (Sec.7044, inspection. Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to Signature of Applicant: Date- construct the project (See.7044, Business & Professions Code). 1 hereby affirm under penally of perjury one of the following three ALI, 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, as 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 Ilealth & Safely 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 Ileallh & Safely 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 die work for which this permit is issued, I shall contaminants as defined by the Bay Area Air Quality Management District 1 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, alter making this certificate of exemption, I Health & Safety Code. Sections 25505, 25533, and 25534. become subject to the Worker's Compensation provisions of the Labor Code, 1 must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or au rized a 1: — �_ Dete: 4-/6 /ZOiZ APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I cerdly that I have read [his 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 alf rm that there is a construction lending agency for the performance of work's to building construction, mid 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 indemnify and keep harmless (he City of Cupertino against liabilities. judgments. costs, and expenses which may accrue against said City in consequence of the Lender's Address granting of this permit- Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section ARCHITECT'S DECLARATION 9.18- 1 Signature !T. rM�— Date 4/6/zof� 1 understand my plans shall be used as public records. Licensed Professional CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - building(cDcuoertino.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: SITE ADDRESS ZO?-7f v1CC1_E LAN RO CVPEQTYAlU APN 35q ' 16 Cil2 BPI! OWNERNAME ALt&XANOER MA INO V1 CI N g OWNER ADDRESS 20431 MCCCEL49N SPD , cuPEQT 1/v0, CA 950 DESCRIPTION OF WORK: REPLACE FuQNqc6 15uPPIY DOC -75 K6tZ CATS Fu2"CC -M A771C 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. (DIRECTIONS: Pleaseread and initial each statement below to signify you understand or verify this information.) AM1. 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. AM 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. _AM 3. 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. AM 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. -A,m5. I 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 ($500), including labor and materials, I may be considered an "employer" under state and federal law. _&�8. 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 me to serious financial risk. A�g. I 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. AN 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. ArnerBuilderFOrm 2010.doc revised 04/14/10 _f9. 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. A10. 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. _A�E11. 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. AM 12. 1 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 sustaiq 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 Property Owner's Signature: ature. Date: 9 /6 �20 ------ ----- ----- --- ----- ----- (NTE:OThe 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: Address of Authorized Agent: Tel No 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: OWnerBuilderForm 1010.doc revised 04114110 6 ITEMS OF 6 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 35916012.00 DATE ISSUED.......: 04/06/2012 RECEIPT #.........: BS000016477 REFERENCE ID # ...: 12040038 SITE ADDRESS .....: 20771 MC CLELLAN RD SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OPERATOR: patg COPY # : 1 OWNER ............: ALEXANDER & YE YINING MARTINOV ADDRESS 20771 MCCLELLAN RD CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: ALEXANDER MARTINOVI METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 260.98 --------------- 260.98 VOICE ID DESCRIPTION -------- ---------------------------- 505 FINAL ELECTRICAL 508 FINAL MECHANICAL REFERENCE NUMBER -------------------- VISA VOICE ID DESCRIPTION -------- ---------------------------- '507 FINAL PLUMBING CONTRACTOR .......: MICHAEL LEE LIC # 28867 COMPANY ..........: SANDIUM ADDRESS ..........: 4223 VERDIGRIS CIR CITY/STATE/ZIP ...: SAN JOSE, CA 95134 TELEPHONE ........: (408) 894-9072 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 9,794.00 1.00 0.00 1.00 0.00 1BSEISMICR VALUATION 9,794.00 0.98 0.00 0.98 0.00 1MFR=<100 UNITS 1.00 130.00 0.00 130.00 0.00 1MPERMITFE 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 ---------- 260.98 ----- 0.00 ------ 260.98 ---------- 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 260.98 --------------- 260.98 VOICE ID DESCRIPTION -------- ---------------------------- 505 FINAL ELECTRICAL 508 FINAL MECHANICAL REFERENCE NUMBER -------------------- VISA VOICE ID DESCRIPTION -------- ---------------------------- '507 FINAL PLUMBING CITY OF CUPERTINO I/JI FEE ESTIMATOR -BUILDING DIVISION APPLIANCE/ EQUIP TYPE ADDRESS: 20771 McClellan Rd. DATE: 04/06/2012 REVIEWED BY: jsg UNITS APN: 35WIPMZ BP#: ?pq(SD VALUATION: $9,794 *PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: # PENTAMATION FURN/AC PERMIT TYPE: WORK Re lace furnace relocate to attic replace attic supply ducts. Inspector verify structural support of SCOPE furnace in attic. APPLIANCE/ EQUIP TYPE FEE ID Phnrrh. /'Inn Check QTY UNITS BP FEES lilac. Pc"nif 1-ve.: Furnace, Forced -Air 1MFR=<100 Ocher Oec. ln,sp.Ej 1 # $130 Perini! Fcc: Suppl.hrap Fcc PME Unit Fee: $130.00 PME Permit Fee: $44.00 Crurslrrurlion Tac: Administrative Fee: (ADMIN $41.00 Work Without Permit? O Yes 0 No $0.00 TOTALS: Travel Documentation Fee: ITRAVDOC $130.00 Strong Motion Fee: 1BSEISMICR NOTE: This estimate does not includejees due to other Departments (l.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc). These lees are based on the Preliminarrinformation available and are only an estimate Contact the Dept for addn7 info. FEE ITEMS (Fee Resohtiion 11-053 E/T 711111) Mech. Plan Check 0.0 hrs $0.00 Phnrrh. /'Inn Check Eh%:. Man Ch,rk Mech. Permit Fee: IMPERM/T Plnmh_ Perna Fee: lilac. Pc"nif 1-ve.: Other Mech. Insp. 1 0.0 hrs $44.00 Orbta• Plumb Insp.El Ocher Oec. ln,sp.Ej ,ble(h. Gt,p. Fee: Ylunrh. Irr..p. rue: Elec. Insp. Fee: NOTE: This estimate does not includejees due to other Departments (l.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc). These lees are based on the Preliminarrinformation available and are only an estimate Contact the Dept for addn7 info. FEE ITEMS (Fee Resohtiion 11-053 E/T 711111) FEE QTY/FEE MISC ITEMS Plan Chuck Fcc: Supp/. PC Fee PME Plan Check: $0.00 Perini! Fcc: Suppl.hrap Fcc PME Unit Fee: $130.00 PME Permit Fee: $44.00 Crurslrrurlion Tac: Administrative Fee: (ADMIN $41.00 Work Without Permit? O Yes 0 No $0.00 Ardrnnced Planning Fees. Travel Documentation Fee: ITRAVDOC $44.00 Strong Motion Fee: 1BSEISMICR $0.98 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $260.98 $0.00 TOTAL FEE: $260.98 Revised: 04/01/2012 CUPERTINO GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 G160 M I (408) 777-3228• FAX (408) 777-3333 • buildinaCcDcuDertino.orD (� RPLUMBING FrmECHANICAL RELECTRICAL RMISCELLANEOUS PROJECT ADDRESS 20431 MCCLGLLAN 20,CUPt2TIN0 APN0 3S 1 ILS - of OWNER NAME. ALE XANOL2 MA2TINOVIC PHONEoff_ qa-4x36 4 4 E-0IAIL J ALEXANOE R. MAR TIN OV I C Q QMAIL.COM STREET ADDR17SS Za-471 MCCLELLAN P.D CITY, STATE, ZIP CUFE2TJN0, CA gSCJi4 FAX CONTACT NANIF. PIIONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR 11 CONTRACTOR AGENT ❑ ARCIIITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME S A N p I V h'� INC LICENSE NUMBER p pp 1 1 p 0 0 0 1 LICENSE TYPE. BUS. LIC u COMPANY NAME SANp1UM INC. E -MAI I. MIIcELEELSAnJOIVM.COM FAX 650-(illtt-OSGS STREET ADDRESS 4-40 N. WOLFE 2D 1� CITY, STATE, ZIP SVNNYVALE, CA ")408'.5 PHONE 4.O89 w-90� ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS, LICA COMPANY NAMI. EMAIL FAX STREET ADDRESS CITY. STATE, ZI P PHONE USE OF EgSFD or DUPLEX ❑ NIULTLFAMILY BUILDING: ❑COMMERCIAL I PROJECT IN WILDLAND ❑ YES URBAN INTERFACE AREA �NO PROJECT IN❑ FLOOD ZONE ES �O ISTHEBI.DGAN ❑ YES EICI ILF.R I TOME? GY\O DESCRIPTION OF WORK REPLACEMENT OF FU2NAOE REPLACEMENT OF ATTIC SUPPL`e DUCTS RELOCATE 1=UfLNACE TO ATTIC TOTAL VALUATION: C.l-4Ci4 RECEIVED BY: L=tC „JaArj By my signature below, 1 certify to each of the following: 1 am the property owner or authorized agent to act on the property ol/wn 's behalf. I have read this application and the information I have provided is correct. I 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 coast ru�cti/o9II III representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: z WL/( Date: 41/6./ ZO 17- 2SUPPLEMENTAL SUPPLEMENTALINFORMATION REQUIRED orrtcE use orvt.r. ❑ OVEIRTHE-COUNTER _ 6 id ❑ EXPRESS' _ ❑ STANDARD V ❑ LARGE 6' ❑ MAJOR MFMiliscApp_201 I.doc revised 0621111