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12070116CITY OF CUPERTINO 13UILDING PERMIT BUILDING ADDRESS: 10270 ALPINE DR OWNER'S NAM E: PAULSON KIRK I TRUSTEE& ET AL OWNER'S PlIONE: 6066899880 ❑ LICENSED CONI- RACI'OR'S DECLARATION License Class Lie.9 Contractor Dam hereby affirm that I am licensed tinder the provisions of Chapter 9 (commencing tenth Section 7000) of Division 3 of the Business & Professions Code and that me license is in full force and effect. I hereby affirm under penalty of perjury tine of the following to,, 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 permit is issued. APPLICANT CERTIFICATION 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, mid 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, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and a ill comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Dme OWNER- BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business S Prolessions Code) I, as owner .of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code), hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, is provided for by Section 3700 ol'thc 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 perfonmmec of Ibe work for which this' permit i5 issued. I certify that in the performance of the work liir which this permit is issued I shall not employ any person in tray mmnner so as to become subject to the Worker's Compensation laws of California. II', after making this certificate of exemption, I become subject to the Worker's Compensation provisions ofthe Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. . \I'I'LIC. \N'I' C :P :12'1'IRIC, \'1'111\ 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 haws 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 indemnify and keep harmless the City ol'Cupertino against liabilities,judgmens, costs, and expenses which may necme against said City in consequence of the granting of this permit. Additionally, the applicant undersands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. , Date I n le--,A7 IG')- CONI'RAC'FOR: PAULSON KIRK I TRUSTEE I PERMIT NO: 12070116 &Gf AL 7765N SILVER CREEK RD PARK CITY. Iff 84098 DATE ISSUED:07/17rz012 PHONE NO: BUILDING PERMIT INFO: BLDG r ELECT F- PLUMB r DI EC II r RESIDENTIAL r COMMERCIAL r- .10 B 1) ESC R I P110N: UNITS 14- RI COMPLEX WINDOW REPLACEhIENT NON- STRUCI'URA L. REPLACE 22 WINDOWS AND 5 SLIDERS Sit. Ft Floor Area: I Yalunlion:$10800 AI'N N u ether: 32615106.00 ) Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAPS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: . ....... � Dater �� RE- ROOFS: All roofs shall be inspected prior to any roofing material being installed If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Date: ALL ROOF COVERINGS'1'0 BE, CLASS "A" OR BE'17ER IL\/,ARDO11S \IATIIRLV S DISCLOSURE have rend the hazardous materials requirements under Chapter 695 of the Ca lifurnia 1 Ica hh & Sit rely Code, Sections 25505, 25533, and 25534. I will maintain call%plia lice aiIll the Cu perk no Municipal Code, Chapter 9.12 and the Ihealth & Safely Code. Section 25532(m) should I stare or handle hazardous material. Addi lions lly, should I use ell III [intent or devices which emir hazardous air contaminants as defined be the Bay Area Air Quality Management District I will maintain coal pull lice with the Cupertino Municipal Code. Chapter 9.12 and the lleilth & Safety Code, Sections 255115, 25533, and 25534... I hence all mrize)I agent: CONS'1'It11C110N LEINDING AGENCY I hereby of firm thm there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Leader's Name Leader's ARCIIITECI "S DECLARATION I understand my plans shall be used as public records. Licensed CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION NOTE: This estimate aloes not include jecv due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). These fees are baser/ on lite prelinfinan information available and are only an estimate Contact the De t or atldn'7 in o. FEE ITEMS (Fee Resohuion 11-053 Eff 7 /l /l U 10270 alpine dr. DA'Z'E: 0711712012 REVIEWED BY: bobs. iaADDRESS: APN: 13P #: *VALUATION: $10,800 *PERMITTYPE: Building Permit PLAN CIIECK TYPE: Alteration / Repair PRIMARY SFDorDulex USE: p Elec. Insp. Few: PENTANIATION PERbUTTYPE: 1GENRE'd WORK R -!' complex window replacement non structural. Replace 22 windows and 5 sliders. SCOPE $0.00 NOTE: This estimate aloes not include jecv due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). These fees are baser/ on lite prelinfinan information available and are only an estimate Contact the De t or atldn'7 in o. FEE ITEMS (Fee Resohuion 11-053 Eff 7 /l /l U Nlech. Plan Check Plumb. Plan Check Elec. Plan Check Mee%. Perm11 Fee: Plumh. Permit Fee: Glee. Permit Fee: Other Mech. Insp. Other Plumb Insp, Other Elec. lap. Mrsch. btep. Fee: Plumb. /n.qt. Fee: Elec. Insp. Few: NOTE: This estimate aloes not include jecv due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). These fees are baser/ on lite prelinfinan information available and are only an estimate Contact the De t or atldn'7 in o. FEE ITEMS (Fee Resohuion 11-053 Eff 7 /l /l U FEE QTl' /FEE MISC ITEMS Plan Check Fee: $0.00 = # $799.00 Window / Sliding Glass Door 1 Nl1'REP Replacement Suppl. PC Fee: Q Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee@ Reg. 0 OT FO-OT hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Constrmciion Tax: Administrative Fee: 0 G Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Fee: $0.00 Select a Non - Residential Building or Structure E) 0 A Travel Documentation Fees: Strong Motion Fee: 1BSFISMICR $1.08 Select an Administrative Item Bldg Stds Commission Fee: /BCBSC $1.00 SUBTOTALS: $2.08 $799.00 TOTAL FEE: $$01.08 Revised: 07/01/2012 OWNER - BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014 -3255 GUPERTINO (408) 777 -3228 - FAX (408) 777 -3333 - 6uiIdinq((DcuDertino.Orq 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: S� E ADDRESS lOZ Ti o C qSo� APN BP# OWN RN ME I�G�ToRS Chi OWNER ADDRESS 3o rnsslaa UntBTr 1ittJk�Uyco Cdr DESCRIPTION OF WORK: rT`cr 1�9��� fl( aLl ✓cF-�- NQS 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, Initiated 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. read and Initial each statement below to signifyyou understand or verify this information.) 4� 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Bulider' building permit that erroneously Implies that the property owner is providing his or her own labor and material personally. 1, 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. �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. Aa3. I 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. "1--i4.1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. ­'P 5. 1 understand if 1 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. -(� 6.1 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. I-aT I understand under,Califomia 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. -'D 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. OiwI rBuilderForm 1010.doc rm ised 04 /14/10 Name of Authorized Agent: Address of Authorized Agent: I HI INV .. t. 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. -J�%1o. I am aware of and consent to an Owner - Builder building permit applied for in my name, and understand that am the 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 all applicable laws and requirements that govem Owner - Builders as well as employers. -J;�_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 sustain as a result of a complaint. Your only remedy against unlicensed Contractors maybe 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.) 1 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 signatWQ Property Owner's Signature: Date: 1 -7 12 •-- p-roperty ----••---- --owner •---only -- --•when ----------------designating -----an ----- (NOTE: The following Authorization Form is required to be completed by the 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: 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: Data: 0wnuBuilduFann_2010.doc revised 04114110 CONSTRUCTION PERMIT APPLICATION j Z0-7 O 4 l (o COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (40� -3333 • buildin g(aiicuoedino.org F MDITI(1N At TER, -riow /TI F RRVISIDN / DIiFFRRFD DRiGINAI. PERMIT N i PROJECT ADDRESS APNA 2� — r 3 — lD 71(7 fl I . ClAK -V-71 0 QA o LYtT_1 1- OWNER NAME J FSToKS �C PHONE I -ro -g8 b DreSASakS & IL C t�k� l , Cw1 s 9 TREaT ADDRESS misSlolJ ST• UavcvIZ& cL7�' STATE, ZIP rt1NS Fy_flNUSCO CPtt 1os FAX CONTACT N ME �E PHONE ( (0S9_ 0j& S O E -MAIL I SRS -16 - 16 f en2SC sct� i .tom ST ADDRESS � S S • U T 4-1� CRY, STATE, ZIP FAX i N CASCO -4S —3-T+� X3`15 0 OWNER M `OWNER-BUILDER ❑ OWNERAGEM ❑ CONTRACTOR 11 CONTRACTOR AGENT 0 ARCIGIDCT ❑ ENGINEER 0 DEVELOPER ❑ MNANF CONTRACTOR NAME © LICENSE NUMBER LICENSE TYPE BUS. LICA COMPANYN \\ E -MAIL FAX N �\ STREET ADgIiPSa 20 lP n1 C kFES BL . CITY, STATE, ZIP m 4EU. 1 N 7c9-°IC0'd ARCHITECT/ENGRiEER NAME /� �j LICENSE NUMBER BUS. LICA COMPANY NAME 6,%WL FAX STREET ADDRESS CITY,STATEZIP PHONE DESCRIPTION OF WORK aXLSTsNG USE PROPOSE)USE CONSTt.TYPE On REEF /7 _2 L USE TYPE OCC.. SQ.PT. VALUATION (S) AREA AREA NEW FLOOR AREA AREA AREA TOTAL NET AREA �2 � VQ �—,L OK BATmOOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKJPORCH AREA GARAGE AREA: DETACH ❑ATTACH P OWE! ,I.No Elms: ISASDCONDUNR ❑YES SECOND STORY ❑YES BEING ADUKDT 0 N ADDITION! GNO PRE - APPLICATION GYES IF YES, PROVIDE COPY OF IS III BLDG AN GYU &CEunguY "p"" "` ' � -''' S''T" TOTAL. VALUATION: PI,ANNmG APPLA [NO PLANNMG APPROVAL LETTER EICHLKRUOMEr [NO 11 W Orpx.,C) By my signature below, l certify to each of the following: 1 am the property owner or authorized agent ro act on the property owners behalf I have read this application and the information I have provided is correct. 1 have read the Description of Work and verify it is accurate. 1 agree to comply with all applicable local ordinances and state laws misting to buillddiiny mtmctio-n.auth`orrize representatives of Cupertino to enter the above - identified property for inspection purposes. / (% 1 —)-9 Signature of Applicant/AgenL' Date: SUPPLEMIiNTALINFORMATION REQUIRED S — �Pr��clier•ICrrve0040�'���- Rognnr.sLtP �t�-�, New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building ?�"JiBII' R.TIfE LO ER n.0 tkls'f ;aDUtNHJ�t1G P, RL , Fre permit for new building. }" Commercial 61dgs: Provide a completed Hazardous Materials Disclosure � STANDARII O_PISBb7,C�.' ORILS_ ! _ Tom if my Hazardous Materials are being used as part of this project. ��T;�� q (+ �' J 'i — 3 - J - -=G a f - _ Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. ❑at�rAaoR ':.; I r FM:DEP'R n+s��.�. O =sA n�' F.wl!R.DJSrJUCr .g ��G.t s. - ,. SY�' _gin." EM 0 Ell; -