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12060178CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 23500 CRISTO REY DR UNIT 203C CONTRACTOR: SOUTI I BAY MARBLE & PERMIT NO: 12060178 SHOWER DOOR OWNER'S NAME: MCDANIEL ELOISE C TRUSTEE 870 BRANST17N RD DATE ISSUED: 06/29/2012 OWNER'S PHONE: 6509440100 SAN CAR LOS, CA 94070 PHONE NO: (650) 592-7416 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RF.SIDFNTIAI. COMMF.RCI,U. License Class Lic. q REPLACE SHOWER PAN AND WALLS IN UNIT 203C **SEE NOTES** Contractor Dale 1 hereby affirm that I am licensed under the provisions of r 9 (commencing with Section 7000) of Division 3 of the Businessess & Professions 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 Sq. Ft Floor Area: Valuation: $4239 performance ofthe work Ibr 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 permit is issued, APN Number: 34253039.00' Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT E ORK IS NOT STARTED correct I agree to comply with all city and county ordinances and state laws relating WITHIN 1 OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAY LAST CALLED INSP CTION. indemnify 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 permit. Additionally. the applicant understands and will comply Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code, Section 9, 18. RF: ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed [fit roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. ❑ OW'NF.R-BUILDER DECLARATION Signature of Applicant Date, 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: AL1, ROOF COVERINGS TO BE CLASS "A" OR BETTER 1, as owner of the property, or my employees with wages u their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) I, as owner ofthe property, am exclusively contracting with licensed contractors to H A7.ARDOUS MATERIALS DISCLOSURE: construct the project (Sec.7044, Business & Professions Code). 1 have read the hazardous materials requirements under Cha pier 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. ]will 1 hereby affirm under penally of perjury one of the following three maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should 1 store or handle hazardous I have and will maintain it Certificate of Consent to self-insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Qualify Management District performance ofthe work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Ilealth & Safely Code, Sections 25505, 25533, and 25534. Section 3700 ofthe Labor Code, for the performance of the work for which this permit is issued Owner or authorized agent: I certifyThat in the performance ofthe work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, 1 must 1 hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked- work's for which this permit is issued (Sec. 3097. Civ CJ Lender's Name APPLICANT CERTIFICATION Lender's Address 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 stale laws relating to building construction, and hereb)' 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, ARC111T'F.CT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting ollhis permit Additionally, the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. �y �/1 Signature / /Z Date 6 ITEMS OF 6 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp:, Rng: Sub: Blk: Lot: APN ........: 34253039.00 DATE ISSUED........: 06/29/2012 RECEIPT.#.........: BS000017201 REFERENCE ID # ...: 12060178 OPERATOR: patg COPY # : 1 SITE ADDRESS......: 23500 CRISTO REY DR UNIT 203C SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 192.50 ---------192.50 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER REFERENCE NUMBER --------- MC VOICE ID DESCRIPTION --------------------------- 202 UNDERFLOOR PLUMBING 301 OWNER ............: MCDANIEL ELOISE C TRUSTEE TUB & OR SHOWER 502 FINAL PLUMBING ENERGY 506 ADDRESS ..........: 23500 CRISTO REY DR UNIT 203C 512 FINAL HANDI-CAP CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED,FROM ....: JESSIE PERKINS CONTRACTOR ......-.: RICKY R. SUTTON LIC # 28912 COMPANY ...........: SOUTH BAY MARBLE & SHOWER DOOR ADDRESS :......... : 870 BRANSTEN RD CITY/STATE/ZIP ...: SAN CARLOS, CA 94070 TELEPHONE ........:'(650) 592-7416 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 4,,239.00 1.00 0.00 1.00 0.00 1BPFIXTURE NO OF FIXTURE 1.00 18.00 0.00 18.00 0.00 1BSEISMICR VALUATION 4,239.00 0.50 0.00 0.50 0.00 1PPERMITFE FLAT RATE 1.00 88.00 0.00 88.00 0.00 1TRAVDOC FLAT RATE 1.00 44.00 0.00 44.00 0.00. TOTAL PERMIT -- ---------- 192.50, ---------- 0.00 192.50 ---------- 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 192.50 ---------192.50 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER REFERENCE NUMBER --------- MC VOICE ID DESCRIPTION --------------------------- 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 302 TUB & OR SHOWER 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL'PLUMBING 512 FINAL HANDI-CAP CITY OF CUPERTINO FEE ESTIMATOR -BUILDING DIVISION NOTE: This estimate does not includ0ees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.. These fees are based omdie prelimina information available and are only an estimate Contact the Dept for addn'l info. FEE ITEMS (Fee Resohdion 11-053 EfF.7/1%11) ADDRESS:,235000RISTO.REY'DR#203C DATE: 06/29/2012 APN: BP#: REVIEWED BV: SEAN 'VALUATION: $4,239 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY Multi -Family Dwelling . USE: Buildina is 3 Stories O Yes a No PENTAMATION 1 RPFIX PERMIT TYPE: WORK REPLACE SHOWER.PAN�ANb WALLS IN UNIT 203C. SCOPE Pharrh. he>p. Fee: NOTE: This estimate does not includ0ees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.. These fees are based omdie prelimina information available and are only an estimate Contact the Dept for addn'l info. FEE ITEMS (Fee Resohdion 11-053 EfF.7/1%11) .N, -cd. Pion Check Plumb. Plan Check 0.0 1 hrs $0.00 Ouc. flan Ch, ck Gtech. Pernik Fee 4 -Plumb. Permit Fee: IPPERMIT lilac 1'e mii Fra: odu" Ihrrh. In.sp, Other Plumb Insp. 0.0 hrs Lwm oche l:Ic,. hrsp. .167(h. Imp, Far': Pharrh. he>p. Fee: li(dr. ln.,p. 1.ire: NOTE: This estimate does not includ0ees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.. These fees are based omdie prelimina information available and are only an estimate Contact the Dept for addn'l info. FEE ITEMS (Fee Resohdion 11-053 EfF.7/1%11) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = # $9.00 Plumbing /BPFIXTURE I Fixture set on One Trap Suppl. PC Fee: Q Reg. 0 OT 0.0 hrs, $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. Q OT 1 6:0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $44.00 Cone nrtion Tax: Administrative Fee: 1ADMIN $41.00 O E) Work Without Permit? oNes 0 No $0.00 Advanced Planning Fee. - $0.00 Select a Non -Residential Building or StructureCl Travel Documentation Fee: ITRAVDOC .0 $44.00 Slront! Motion Pce: IBSEISMICR $0.50 Select an Administrative Item Blde Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: ,,.$130.50 $9.00 TOTAL FEE: $139.50 Revised: 06/3 012 01 2 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408)777-3228• FAX (408) 777-3333 " buildineraDcuoertino.oro Dear Property Owner(s): An application for a building permithas been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS q � % �yi� CYr'i rrC APN BP# O NAME (r� ' OWNER ADDRESS DESCRIPTION OF WORK: II __ 5 L. -Cr lG[_ck 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 thislpermit 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 officialaddress indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. (DIRECTIONS: Please signify you understand or vedfy this information.) r -it 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 homeowners 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. Eat. 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. _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. Lik_4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts: EY -5. 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. Fa- 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. FH 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. E= 8. 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. avnerBuildel'Forvn 2010.doc revised 04/14/10 T44 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.csib.ca.gov for more information about licensed contractors. YAL10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the parry 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. T�_12. I 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. 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 si nature. Property Owner's Signature: Date: /Z — ----------- ----- --- --- --- --- -- ------ ----------------- ------ ------- ------------- —r- - y- hen- g----.. (NOTE: The following Authorization Form is required to be comple(ed 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 Owne, BudderForm-201 0. doe rerised 04114/10 CUPERTINO ❑v rnN.q tT=nNr 12v(,cam 1-7e CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinD(ai)cuoerUra.ora ❑ ADDMON S ALTER ATION / TI ❑ REVISION / DEFERRED ORIGINAL PERS!' PROJETOO B o3C APN4 3 ,- 53,03 ,� Z. OWNER NANE T\ -\e— M_0 'Q'OO EMAII. STREET ADDRE55 2 500 ri�{a �•QVCt2 CITY, STATE tNo Cin sal FAX C z -0/ CONTACT NAMEr pt 1 Z C` PHONE ^ O � � E e 411u v�rleL Q7 l jw r,ru STREET ADDRESS CITY, STATE Z1P FAX ❑ OwNER ❑ OWNER.BUILDER-KERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCi¢TECT ❑ ENGINEER ❑ DE OPER ❑ TNANT CONTRACTOR NAME LICENSE NUMBER. LICENSE TYPE Bus. LIC k COMEANYN� V\ E-MAIL FAX STREET ADDRESS,STATE Ile 0 bc4skom wa ah Sc, . C-0 Qs�i i PHONE 09) 3 - ARCHTTECr/FNGWEER NAME IICENSENUMBER BUS. UC k COMPANY NAME E -MAH. FAX STREET ADDRESS CITY, STATE ZtP PHONE DESCRIPTION OF WORK RAMI Ct EXISTING USE PROPOSE USE CONSTL E NSTORM; y. p r /J �` 1/� Y USE TYPE OCC. SQ.FT. VALUATION(S) =ter NEW F0000. EMO TOTAL AREA AREA AREA NETAREA - BATHROOM KrCNEN OTHER REMOOELARFA REMODEL AREA REMODEL AREA PORCH AREA PECK AREA TOTAL DECK/PORCHARFA GARAGE MFA: DETACH ATTACH k DwELL1NO UNM; IS A SECOND UNIT YES SECOND STORY YEs BEINGADDED? [:INDADDITIOM []NO PRE-APPUCATION ❑ES YT YES PROVIDE COPY OF IS TBE BLDG AN ❑YES RECEIVETjBY: TOTALV UATION: PLWNIJG APPLd ❑NO PLANNING APPROVAL LEITER EICHLER HOME? 14'NO % L pc) By my signature below, I certify to each of the following-. I am the property owner or authorized agent m act on the pr(perty owner's oehalf. 1 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 Slate laws relating to building con coon. I aud?rntatiVCS of Cupertino to enter the above -id ti5ed perty for inspecrion purpmes. Signature of Applicant/Agent Date: 29L t ` SUPPLEMENTAL INFORMATIONREQUERED P[ANCHECK TYPE ROUTLNGSLIP OVER-THELDONTER BUUXENG PLAIN REVUIW 21 - New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permitfornewbuilding. ❑ CRESS ❑ PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS _ form if any Hazardous Materials are being used as part of this project. ❑ ❑ LARGE Fina DEPT _ Copy of Plavving Approval Letter or Meeting with Planning prior to ❑ NA.IOR - ❑ SA.NfTAAY SEWER DISTRICT submittal ofBuilding Permit application. ❑ ENVDRONMENTAL I EAI TH d/deApp_2011.doc revised 06/21/11 cM K 1ZSq•