Loading...
12070142 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20800 VALLEY GREEN DR CONTRAC'MR:20800 VALLEY GREEN DR PERMUTING: 12070142 OWNER'S NAM Ii: 20800 VALLEY GREEN DR PO 1305 1368 DATE ISSUED:07/18/2012 OWNER'S PHONE; 4082530200 CARLSBAD.CA 92018 PHONENO: ❑ LICENSED CON"FRACI'OR'S DECLARATION BUILDING PERNwr INFO: BLDG r ELECT r_- r.— License License Class Lie..N DIEC11 r RESIDENTIAL r COMMERCIAL Contractor Date hereby affirm that I am licensed under the provisions of Chapter 9 •1013 DESCRIPTION:APT 448-WASHER/DRYER HOOK UP (con] tcith Section 7000)of Di%ision 3 of the Business\ Professions Code and that me license is in full force and effect. 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 Ibr by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued Sq,Ft Fluor Area: Valuation:$500 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 Imnvhich this permit is issued APN Number:32609040.00 Occup:mcy'rype: n rr1.lC�xr cr•.R r1 r•Ic,crum I certify than I have read this application and state that the above infomation 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,mad 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply �1 with all non-point source regulations per the.Cupertino Municipal Code,Section Issued by- Date? 9.18. Signature Date Rh:ROOFS: -u O%%'NER-BIIILDER DECLARATION 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 1 hereby affirm that 1 am exempt from the Contractor's License Law for one of inspection. the rationing ton reasons: 1,as owner of the property,or my employees with%ages 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 R Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to ALI,ROOF COVERINGS TO BE CLASS"A"OR BF,9-I'ER construct the project(Sec.7044,Business K Professions Code). I hereby affirm under penalty of.perjury one of the fallowing three IIAZARDOUS MATERIAIS 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 Ilealth,Safes.Code.Sections 25505,25533,and 25534. 1 will 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 Health S performance of the work for which this permit is issued. Safety Code.Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of[he Labor Code,for the performance of the work for which this cons rlinants as defined by the Bay Area Air Quality Management District 1 mill maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. []eallh S Safely Code.Secti as 25505,25533,and 25534. I certify that in the performance of the 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 (1 ter or oath izeJ it Compensation favus ofCalifomia. If,after making this certificate of exemption,1 l Date: 7 la Z 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 CONSfRIff-flON LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLIC\N'I'CERTIFICATION for which[his 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 and state laws relating to building construction,and hereby authorize representatives of this city to enter Lender's Address 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 ARCHITECT'S DECLARATION graming 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 regulations per the Cupertino Municipal Code,Section Licensed Professional Signaler Date ��CJ Z OWNER-BUILDER DISCLOSURE FORM C COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING'DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 C U P ERTI tJ 0 (408)777-3228 • FAX(408)777-3333 • buiidinor cuoarino.ora Dear Property Owner(s): An'applicatibn fora building permit has been submitted in your name listing yourself as the builder of the'property . •. . improvements specified at: SITEADDRESS J"V, II�L'P!'1 �//'L1 APN /Z 14 1D IBP OWNER NAME C 01'x©ADDRE / / J .� DESCRIPTION OF WORK: 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.) :S!/ 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. 2. 1 understand building permits are not required to be signed by property ov+ners 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. 5 1/ 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. 516.5. 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 ($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 understate and federal Ia�v; I must register with the state and '. federal gove'rnment;'wifhhold payroll taxes provide workers' compensation disability I sura ce and contrbute to unemplo'anent compensation for each "employee:'"I also understand my failure to abide by these'laws may subject me to serious financial risk. ---- 511--7.-1 understand under California Contractor-"State,L-icense Cg%v,ariOwner-Build6r ho.builds'single=family—_ residential structures cannot legally build them with the intent to offer them for sale, unless a//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. �!1 _ 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. OwnerBuilderForm 2010.doc revised 04/14/10 1 Iia , l�9. I understand 1 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 1-80d-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed ';contractors. - 1 S 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. S / 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. 5_�_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 a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not .;those Contractors are properlylicensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS:Please complete the following construction lending agency information.) I 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 proeerty owner's signature. Property Owner's Signature: / 7, /GAJ Date: — = ------ --------------------- (NOTE: The following X wtt;6 riza-tho n-F-o- orm is-r-&-q-ahre-d 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: I 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 I signature. Property Owner's Signature: Date: - OuhrerBvilderFornn+ 201 D.doc revised 04/14/10 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION 12 ADDRESS: 20800 VALLEY GREEN #448 DATE: REVIEWED BY: Sylvia APN: 13P#: 'VALUAT[ON: $500 *PERMITTYPE: Mechanical Permit PLAN CIIECK TYPE: Alteration/Addition / Repair PRIMARY1'ENTANIATION USE: SFD Or Duplex PERNI IT T1 PE: 1 RMAP WORK Washer/Dryer Hook u SCOPE APPLIANCE/EQUIP TYPE FEE ID Q't'Y UNITS BP FEES Other Appliance/Equip 1BAPPLOT 2 # $134 TOTA LS: $134.00 Mech. Plan Check 0.0 [its $0.00 Phaah.Plan Check- Flee. Plan Check Ntech. Perini t Fee: IMPF.RMIT Plumb. Permit Fee: Flec. Permit Fee: Other Mech. Insp. 0.0 [its $45.00 Other Plumb/asp. 7 ElOder Elee./asp. El ,11cch./nap. ree: Plumb. to..p. ree: Elec./nsp..ree: A'OTF: This estinuue does not incPude fees elite to otter Departments(i.e. Planning, Public Works, Fire.Sanitary Server District,Schaal District,etc.). These eev are hosed on the prelindnart information available and are onb,an estimate. Contact file De t or adtln'I info. FEE ITEMS (Fec Resolution I1-053 ED 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check F'ee: Suppl. PC Fee PME Plan Check: $0.00 Permit Fee: Suppl. Insp Fee PME Unit Fee: $134.00 PME Pennit Fee: $45.00 Consmtction Tax: Administrative Fee: 1ADMIN $42.00 Work Without Permit? O Yes Q No $0.00 Advonced Planning Fces: Travel Documentation Fee: ITRA VDOC $45.00 Strong Motion Fee: IRSEISMICR $0.50 Select an Administrative Item 131dg Stds Commission Pec: IRCRSC $1.00 SUBTOTALS: $267.50 $0.00 TOTAL FEE: $267.50 Revised: 07/01/2012 1 (iU p-e/v �r -o CONSTRUCTION PERMIT APPLICATION .r''. COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 ts , CUPERTINO (408)777-3228 • FAX(408)777-3333 •buildinGGncuoertino.ora ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTER4TION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT'. PROTECT ADDRES•`r7 /1 !`/Lel kAPN OWNER NAME I ' R S /1 /L �1� r.C.XXX������(((��_///��' ./� V -J I PHONE �'5_V20O EMAB. STREET ADDRESS Z !Z /V• I JY e/7 r- Cm, STATE Z@ Jd FAX COMACI NAME PHONEF V E-MAn- i t STREET ADDRESS ^�. ,/ (� Cm,STA Zs FAX OW"aR ❑ ORNELBUIIDER ❑ OwNEILAGENT ❑ CONTBACTOR ❑CONTBACrOAAGENT ❑ AACFIl'IEm ❑ENGNEER ❑ DEVFZOPEA ❑TENANT CONTRACrOR'NAIE' - LICFNSENUtfl)EA Z.' - v�' � 'CfCENSETYPE ,�i� -_ HITS.LICA - - - 1 1 COMPANY NAME12� E-MAIL FAX STR r ADDRESS _� ! I1• �r.z AQ! 1 u Cm,STATE,Z� "ONE ARCHrtECr/ENGR'EEk NAME LICENSENUhIDER BUS.LIC A COIWANYNAME --. •..• •.• E-hL1II.- FAX STB=ADDRESS Cm.STATE ZIP PHONE DESCRIPTION OF WORK P rt EXISTING= PROPOSED USE CONSIR TYPE 0SrOR16 . t•'3,1� l�sdjy L-A ' r'a-"y AREA G AREA AREA NETAAEA t —~!MS ^f: _ a BATHROOM KITVIDt OTHER vw .REMODEL AREA REMODEL AREA REMODEL AREA PORCHAREA DECKAREA TOTAL DECP.IPORCH AREA GARAGE AREA-13 DETACH ❑ ATTACH L'$S DWD1alnUNQ3 6AS000I UNT17 ❑YES I s1cota)STORY ❑Yas a aCINCADDCa] EJNo ADDrnIX1! ❑FO - 3�fil� i pi +. e .'- ^ I•�••Y-•. PrtSMPPI.Qa'LION ❑M a'YFS.PROVIDE COPYOF PWMER•s NRH£ WE Yj>- ` _ AL 5Ou `r d fl-WNPlo AFl1I ❑}q p1aJ.'NpgAPPROVAL[EITu! T 3 ! N By my signature below,I certify to each of the following: I am the property owner or aut rite eat to act on the property owner's behalf. I have read this application and the informi.tion I have provided is correct I have read the Description ofd verify it is accuram. I agree m comply with all applicable local ordmarim and state laws relating to b ding construction. I au .OrIZC representatives of Cu uno to enter the a-boove-identified property for inspection purposes. .Sig,wmmofAppli=t/Agenb ' '-J Dam: . ..... SUPPLE.�fED7TAL'LYFOR�fA]'ION REQ _ ._- -- _ •. . i P HEG6t'C,HEE I' .. -F'}' A4t1T __IP.i ..P $z2• . New SFD orbluldfamily dwellings: Apply for demolition permit for - - existing building(s). Demolition permit is required prior to issuance ofbuilding <- _ ,y • - , -c` - permit for new building. s._ _ �� ar�i y. . .1 As•IE<v - _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure - form if any Hazardous bfaterials are being ued as part of this project - _ %ac Q tTAEI cei — Copy of Planning Approval Letter or bfeeting with Planning prior to - �' "`• ' submittal ofBuEding Permit application. �' LABOR„ AA1T\ r 'iEAnts-rIG6T, BldgApp_2011.doc revised 03/1 d111