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12070145 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10235 VICRSBURG DR CONTRACI'OR:JOSH PEREIRA&MIN00 PERMIT NO: 12070145 MEHTA O\VNFR'S NAME: JOSH PEREIRA&NIINOO MEI ITA 10235 VICESBURG DR DATE ISSUED:07/182012 O\VNER'S PHONE: 4084999550 CUPERTINO.CA 95014 PHONE NO: ❑ LICENSED CONfRACfOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class Lie.q \1EC11 r RESIDENTIAL r COMMERCIAL Contractor Dale I hereby affirm that lour licensed under the prurisiuns of Chapter 9 JOB DESCRIPTION: INSTALL TANRLESS WATER HEATER (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 penally of perjury one of the following mo 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 perfomrance of the work for which this permit is issued. Sy.Int Fluor Area: \h,luation:$1000 1 have and will maintain Worker's Compensation Insurance.as provided for by Section 3700 of the Labor Code,for the performance of dmc work for which this permit is issued AI'N Number:36907011.00 Occupancy T.Virc: A I'I'LICAN'1'CIiR'I'I FI C..\'PION I certify that I have read this application and state that the above information is correct. l agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK ISNOT STARTED to building construction•and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indcmnifyand keep harmless the&lyOfeupertinoagainstliabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,ani expenses which may acerae against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply r with all tion-points a regulations per the Cupertino Municipal Code,Section Issued by: Date��j ��`Z 9.1& Signature Date']0 (zl RE-ROOFS: OWNER-RUILDER DECLARATION All roofs shall be inspected prior to my roofing material bebg 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 front the Contractor's License Luw for one Of inspection. the following tiro reasons. I,as owner of the property,or my employees with"races as their sole compensation, Signature of Applicant. Date: will do the work,and the structure is not intended or offered for sale(Sec.-7044, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to AL1.ROOF COVERINGS TO RE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). hereby affirm tinder penally of perjuy one of the following three ILAZARDOUS\IATERLU S DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code.Sections 25505.'_5533,and 25534. 1 trill maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the I Icalth& performance of the work for which this permit is issued Safely Code,Section 25532(a)should I store or handlehavyrdons material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally.should 1 use equipment or devices which emit hazardous air Section 3700 ofthe Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance wish the Cupertino Municipal Code,Chapter 9.12 and the Ilealth&Safely Code.Sections 25505,25533.and_5534. 1 certify that in the performance of die 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 Own a t rued:agree_ Compensation laws of Calilm-nia. If,atter making this certificate of exemption•I Date:a1�,�0 V1 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 CONS'I'RIICPION LENDING AGENCY I hereby aff inn that there is a construction lending agency for the performance of work's A IT LICANT CERTI FICATION 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 mid state Imus relating (o building construction,and hereby authorize representatives of this city to enter Lender's Address upon(lie above mentioned property for inspection purposes.(Nle)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 ARCHITECI"S DECLARATION granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records, with all non-point source rehial per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date \b I2U 1 T J b OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228• FAX (408)777-3333• buildina5Cuoertino.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 APN BP# /022' s, G S0U2 t /r Q OWNER NAMOWNER ADDRESS 10 L DESCRIPTION OF WORK: I NI s- >_L_ I'I:C,Ss 0A`fE41- -FtEA-i GP, 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.) Q L_�-_1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an'Owner- Builder" building 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. �i 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. n -- 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. ��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. I5. 1 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 (S500), 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. V 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 performed under contract with a licensed general building Contractor. 9Cs 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. OirnerBuilderForm 2010.doc revised 04/14/10 9. I"understand I may obtain more information regarding my obligations as an "employer"from the Internal ReyenUo Sefvjce, the United States Small Business Administration, the California Department of Benefit Payments, and tnc Caufun0a Dlvialun of Industrial Accidontc. 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. 1 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. U-11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide Lally 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 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 aipermit 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: I 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 ac t ble to the city may be required to be presented when the permit is issued to verify the ro ert owner's si n ur Property Owner's Signature: Date: ) Z ------ - --- ---------­---- --- (NOTE: The 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: 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 Signatuie: Date: OiwnerBuilderForni 2010.doc revised 04/14/10 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10235 vicksburg dr. DATE: 07/18/2012 REVIEWED BY: bobs. 124 APN: BP#: 'VALUATION: j$1,000 *PERMIT TYPE: Plumbing Permit PLAN CIIECR TYPE: Alteration /Addition / Repair PRI�L�RI' PENTAMATION USE: SFD or Duplex PERMIT9'l'PE: PRWHEATR WORT: install tankless water heater. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Water Heater iPRWHEATR 1 # $27 TOTALS: $27.00 Alvah. !Inn Check Plumb. Plan Check 0.0 hrs $0.00 Fl,,,. Plan Chock ,Need. Penna Fee: Plumb. Permit Fee: I PPERAHT Elec.Pe"'arl res: Other Alech.Insp. Other Plumb.I nsp. 0.0 hrs Lnm Other Elce.htvp. Alech.hop. Fee: Plumb. hi.y.Fee: Elee. htsp.Fee.., NOTE: This ewimate does not indutle jeev Clue to other Departments(i.e. Planting, Puhlic Works, Fire,Sanitary Sewer District,School District,etc.). These ees are based on the prelitninan information availahle and are only tat estimate. Contact the Det for athin7 info. FEE ITEMS (Fee Resolution 11-053 6/T 711/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: Sappl. PC Fee PML' Plan Check: $0.00 Pertnit Fee: SuppL !nsp Fee PME Unit Fee: $27.00 PME Permit Fee: $45.00 Construction Tax: Administrative Fee: 1ADMIN $42.00 Work Without Permit? O Yes 0 No $0.00 Advanced Planning Fees: Travel Documentation Fee: ITRAI DOC $45.00 A Stone Motion Fee: IBSFISHICR $0.50 Select an Administrative Item 131c1e Stds Commission Fee: IBCBSC $1.00 SURToTALS: $160.501 $0.00 TOTAL FEE: $160.50 Revised: 07/01/2012 lZol �- S GENERAL PERMIT APPLICATION -7 0M E P Eg COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 M I /� CUPERTINOO� (408)777-3228 • FAX(408)777-3333•building8cuDerlinD.org v\ E PLUMBING �CHANiCAL QELECCRICAL ❑MISCELLANEOUS PR ADD S I APN a _ O 9 - o ( I OWNFA$NAME PHONE E- e G K e, I A 6 O tt rF .c IKD c STREET ADORE55 CCCY, STATE FAX o (cam uar� I)6Z Lu PE f'--T7NO LR W ACT 1 Eq I CTA I PHONE S.rn-AE E-MAIL S M� STREET ADDRESS// =.S7SATE IIP FAX ❑OWNER W OWNS 2 DOFR ❑ Cw AGENT ❑ CONTRACTOR Cl CONTRACTOR AGENT ❑ ARCHITECT ❑ENGJNEEt ❑ DEVELOPER ❑ TENAXT CONTRACTORNAME LICENSE NUMBER LICENSE TYPE I BUS.LIC: COMPANY NAME E-MAIL I FAX STREET ADDRESS I CITY.STATE,ZIP I PHONE ARCHTTECT/ENGLNEER NAME / ^, I LICENSE NUMBS I BUS.LIC p f COa4ANY VANE' E-MAJL FAX STREET ADDRESS CITY,STATE ZIP I PHONE USE OF ❑SFO w OUPLEX ❑ M T I.FA Y PROTECT IN W RJ'L ❑ YFS PROJECT IN ❑ YEs IS THE SLOG AN ❑ YES BUILDING: [3CDMMERCW. I URBANBO'cRFACE AREA Ej NO I FLOODZONE ❑No EICHLER NONE! ❑NO DESCATPTION OF WORK .- f TPaLin IOTI T C 210((Z T SN RLr-1 0', +fr-fl TOTALVALUATION: IV i I RECEIVED BY: �� r By my signature below,I certify m each of d3e following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have 'ded is correct. I have:rad the Description of Work and verify it is accurate. I agu m comply with all applicable local ordinances and saw laws:dating m Idi g corumuctim I author.=representatives of Cupertino to enter the a v -ideatified pr-o-pT .j for inspection pu113oses. Signature ofApplicant/Agenu Data: 8 1. (i SyNLMffNTAL INFORIMATION REQUIRED OFFICE USE ONLY OVER-THE-COUNTER r - ❑ EtiPRE55 s U ❑ STANDARD U Z ❑ LARGE ❑ AWOR AEP:Mac4pp_2011.doc revised 06/31/11