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12060157 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10520 CASTINE AVE CONTRACTOR:TIETL GARY W AND PERMITNO: 12060157 MARY K TRUSTEE OWNER'S NAME: TIE'rL GARY WAND MARY K TRUSTEE 10520 CASTINE AVE DATE ISSUED:06262012 OWNER'S PIIONE: 4097330414 CUPERTINO,CA 95014 PDONE NO: ❑ LICENSED CONT'RACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class Lic.H r j-"- F- MECH RESIDENTIAL COMMERCIAL Contractor Date hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL GAS LINE IN BACKYARD FOR NEW FIRE PIT (commencing with Section 7000)of Division 3 of the Business&Professions AND 136Q Code and That my license is in full force and effect. 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. 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:$900 permit is issued. APPLICANT CERTIFICATION AIN Number:32644039.00 Occupancy Type: I certifyIhal I have read[his application and state that the above information is cored. I agree to comply with all city and county ordinances and state laws relating to building construction,mid 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments. costs,and expenses which nmy accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS 71M LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issue by: Date: Signature Dale U% XOWNER-RUILDER 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 being 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,mid the Slrc[ure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant Date: I,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"OR BF,TFER I hereby affirm under penally of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's IIA'/.ARDOUS 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 Health&Safely 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 Safely Code,Section 25532(a)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 Qualify Management District l will 1 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 Ilealth&Safely Code,Sections 25505,25533,and 25534. Compensation laws of Cali Poria If.after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,I must Owner a uthorized e e t: forthwith comply with such provisions or this permit shall be deemed revoked. a Dale: 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 cared. 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 properly for inspection purposes.(We)agree to save indemnity and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may acerae against said City in consequence of the granting Of[his permit.Additionally,the applicant understands and will comply with all non-points ce regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. y I understand my plans shall be used as public records. Signature Le/t+ Dale <. Licensed Professional 1 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333- building0cuoertino.oro 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 /Q ['�Q l+d Q vg APN BP# OWNER NAME/' J — ]— /l OWNER A D SS ^I _ 4 A2 DESCRIPTION OF WORK: / 10 O1411 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 ofFlclal 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. 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. A.tt 7�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. AWr4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. r5. 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. 6. I understand if I am considered an "employer"under state and federal law, I must register with the state and ederal 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. &Ot7. 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. B. I 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. OI,'pel'Bldldel"FOIYIl 1010.doc i-erised 04//4/10 9. 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.csib.ca.gov for more information about licensed contractors. tnLf io. I am aware of,and consent to an Owner-Builder building permit applied for in my name, and understand that I Qaam the party legally and financially responsible for proposed construction activity at the site address listed above. /J(N` 11. 1 agree that, as the party Iegally.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. V12. 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 sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court..Itis also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is'lnjured 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 mimbe 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 owners si natur . Property Owner's Signature: Date: Z - -- ------------------------------------------------ -- ---------- ---- ---- -------------------------------------------------------------- - (NOTE: The following Authorization Fo 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: OrrnerBuilderFornr 2010.doc revised 04114/10 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 10520 Castine Ave DATE: 06/26/2012 7REVIEWED BY: Sylvia APN: BP#: 'VALUATION: $900 PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex PENTAMATION 1RPGAS USE: PERMIT TYPE: WORK Install clas line in backyard for new fire pit and BBQ SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Gas <=4 Outlets 1PGASRES 1 # $65 TOTALS: $65.00 Plumb. Plan Check 0.0 hrs $0.00 1:lec. Non(,i%,k 11"J" /l nult J-"" Plumb. Permit Fee: IPPERM/T lilr. 1'rwnlr 14,: )I/);" IL 1' p p. 0.0 Other Plumb Inshrs $44.00 U;Irz 0"'. bup. .Ilr�h. hnp. /- r' Phmrh_ 1",j'. Far: Fier_ NOTE: This estimate does not includejees due to other Departments(ie. Planning,Public Works, Fire,Sanitary Sewer District,School District,etc. . Thesefees are based on the prefinddna information available and are only an estimate Contact file Dept for addn7 info. FEE ITEMS (Fee Resolution /1-053 E2' 711111) FEE QTY/FEE MISC ITEMS Marl Chcck l-ec. Suppl. VC:/ t, :} PME Plan Check: $0.00 PME Unit Fee: $65.00 PME Permit Fee: $44.00 Cuam-n' lion 'Fos: Administrative Fee: IADM1N $41.00 Work Without Permit? 0 Yes 0 No $0.00 I:h„ucr�ll'lunnin, Feet': Travel Documentation Fee: ITRA VDOC $44.00 Strong Mol ion Fce: IBSEISMICR $0.50 Select an Administrative Item Bldg,Sids Commission Fee: 1BCBSC $1.00 SUBTOTALS: $195.50 $0.00 TOTAL FEE: $195.50 Revised: 0 613 0/2 01 2 d (Dl —( GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)T77-3333• buildingCcDcuoertno.ora CUPERTINO misc PLUMM / .BING ❑ ECHANICAL ELECnUCAL ❑NISCELLANEOU�S FROI CTDORFSS 10,520 CAST/NF anar �"s — �,2.(p – 41` - O -may Dov"°`"AME GARY M c' MARY TIE/ATz "HONE 402 733 OJ//Y EM"D GARYTIEVOYA460a M ADDRESS /0520 V N AT VE. CITY. STATE ZIP �U'Ar� I INO C(1 FAX STREET CONTACT NAME A -T II AT PRONE 409-733- 047 E-MAtr.GARYTIk-ne QYA14M. STREETADORFS9 CITY,STATE.ZIP C s nm A //\ FAX OWNFR ❑ OWNER-RUIIDER 13OWNF]IAOENT 1:1 tTINMA=R 13CONTRACTOR AGENf/f 11 13 cHrrECT ❑ENo� ❑ oEvELOPFR ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LLC a COMPANY NAME E-MAB. FAX SIAEEr ADDRESS QTY,STATE,ZCP PHONE ARCHIIECTIENGINEM NAME LICENSE NUMBER BUS.LIC a COMPANY NAME' - E-MAIL FAX TMEETAUDRESS MY.STATE,ZIP PHONE USE OF XSF0wDUPLEX ❑ MULTFFAMD.Y PROIECTIN WI DLAND ♦L ❑,,{ y YES PROTECT[N ❑}YES 15 THE BLDG AN ��0.r YES BUDDING: ❑R]MMAtCLV. URBANINTERFACE AREA ) NO FLOOD ZONE I�INO EICIi)FR HOME/ 19NO DESOUFTION OF WORK O f OKo e O� -Tn -fav d e II /inp, nevi - r / OV f f o / ,z fiAf, x IL /DC iS Of ol 9010 CpC OQO16 NEC, .2(Oldc'ec -) EOTAL VALUATIO - r e O O RECEIVED BY: By tay sigoatum below,I c to each of the following: I am the property owner ar enthorized agent to act on tlt p tmnef's behalf. I have Tend application and the iufottoatioo I have provided is correct have tad the Detaiptioo of Work and verify it is acnaat I agree m comply with all applicabl oc ordinances and state laws miadng to buildinI®thorize representatives of Cupertino to enter the above-ideatified property for inspection p ses. Signaeae of App6tanUent: g [ion Agz4ADate: o/ SUPPLEMENTALUFORMATIUXQUMED V OFFICE USE ONLY OVER-ME-COUNT Ft ❑ EXPRESS Y U u ❑ STANDARD u ❑ LARGE ❑ MNOR dAw MEPMacApp_2011.doc revised 06121111 Ex,,sj M Poo l CUPERTIN Bullding Depertmen rlu'C PLANS 'F - - - - - ¢ JUN 26 2012 1 By® CH�Kw � REVIEWED FOR CODE COMPLIANCE ,rye OAS Reviewed By: rJ✓I✓l �' 1= qWG w - �1t�6 �GRnlpl� oA� _ FICE JurlGYli)a COPY . iRiDfr I��a $�,;GPv $TOaE ll�fJG.H Q • � R O.�s;�. 1_ j _ ; .I I � I I I I � L ' c:_" � �i � � I , ` � 7- - _ I' I i ' �• �i� I .o � ' /, I � .`C' I .. `J�i IJ�.TI I — –�c . I I ' - rl Qe Lu GFI (WA) �,- rZD I _ �!�_ bawl 7 f�M Gnecil� el 5r e %Q'v IWY 4 au,TLEr _goKBru 3/(WGRs {�ndFBarbn�ue; GAS �-.IYIa J ag '164) 40K 8TU I 1� —V < i ,IOV OwrLkT ' 0L p POOL ' 6�NDh9GROQW-D Pun+ f .( ISE: rrR Q ` L.AIV)P AP \II i htis d„cPl F.km�lisDl or dlhl Sw ace . �loWeh ge 4 —_ .—. __ _'1 —---- ------ — ------- --- - --- - — -- ---- JUN 2 IBX: .SID> ,BALK