12090251 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRISSS: 10423 HENEY CREEK PL CONT'RACT'OR:RINERSON DARRELL PERMITSO: 12090251
OWNER'S NAM E: RINERSON DARRELL 1042311ENE1'CRF,F,K PL DATE ISSUED:09272012
OWNER'S PHONE: 4088587033 CUPERTINO.CA 95014-0828 PHONE NO:
❑ LICENSED CON'I'RACFOR'S DECLARA'T'ION BUILDING PERMIT INFO: BLDG r ELECT r, PLUMB r
License Class Lic.d
D1EC11 r RESIDENTIAL _ COMMERCIAL -
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE EXISTING FURNACE AND A/C UNIT WITH NEW
(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 penalty 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.
I have and will maintain Worker's Compensation Insurance,as provided for by
Sq.Ft Floor Arca: Valuation:54500
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:34248020.00 OccupanqType:
API'LIC,\N"1•CER'1'IFICA'1'ION
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 aphis city to quer PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep hamuessthe City of Cupertino against liabilities,judgments, WITHIN ISO DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
grunting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: /Z� Date:
Signature Date
l�f OWNER-BUILDER DECLARATION RE-ROOFS:
'l All roofs shall be inspected prior to any roofing material bcimg installed.If a roof is
hereby affirm thin I am exempt from the Contractor's License Lair for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the simeture is not intended or offered for sale(Sec.7044, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contactors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS^n"OR nr:rrER
hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIAI S DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25.534. 1 will maintain
performance of the work for which this pernnit is issued. compliance with the Cupertino Nlmiicipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of One work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air QualityManagement Districtsw
I ill
maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued.I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in my manner so as to become subject to the Worker's
Compensation laws of Califamia. If,after making this certificate of exemption,I Owr authorjzedoPItent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a constmaion lending agency for the performance of work's
I certify that I have read this application toad state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may aceme against said City in consequence of die
granting of this permit.Additionally,the applicant understands and will comply ARCH I I'I'FCI"S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
19ry �7 licensed Professional
Signature��"""� Date—1-19'?— �C
12,09 (JZ-_-� 1
GENERAL PERMIT APPLICATION M E r®
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO. CA 95014-3255 M I
sc
CUPERTINO (408)777-3228• FAX(408)777-3333 • buildina(cDcuoerino.orD
❑PLUMBING /CHAMCAL
❑ELECTRICAL -/ ❑EMISECCELLANEOUS
PROJECT ADDRSS AIN& yo /0Z
O
OWNERNANIPHO�OUl_yISC).,t
'�) �/
STREETADDRESS CrrY. STATE ZIP I FAX
CONTACT NAME PHONE E-MAIL
STREETADDRESS CIN,STATE. ZIP FAX
❑OWNER ❑ OWNER-BU'BDER ❑ OAWEAAG ❑ CONTRACTOR DCO NiRACTORAG'c F ❑ MCFTr.CT ❑ENGD+EER ❑ DEV OPM ❑ TENANT
CONTRACTOR NAME UCENS NUMBER UCENSE TYPE BUS.0C
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY.STATE,ZtP PHONE
ARCHrTECTIENGIN=NAME LICENSE NUMBS I BUS.UC i
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CIT,(.STATE,ZIP PHONE
USE OF ❑SFD v DUPLEX ❑ MVLTI-FAMILY PROJECT N WILDLAND ❑ YEs PROJECT N [I YES IS THE BLDG AN ❑ YES
BUILDDIG: E]co MRC URBAN NTERFACE AREA NO FLOOD ZONE ❑ NO EICTG_R HOME. ❑ NO
DESCRIPTION OF WORK
TOTALVALUATION: RECEIVED BY: f
By my signature below,I terrify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read chis
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 state laws relati to building au[hotiu representatives of Cupertino to enter the above-ideenntified pro crty forinspection puf*�oses.
re
Signatuof Applicant/Agent Dare:
SUPPLEMENTAL DTFORI�(ATION REQUIRED OFFICE USE ONLY
v VER-THE-COUNTER
t
❑ EXPRESS
u
❑ STANDARD
U
L ❑ LARGE
J
❑ IWOR
MEPMuc4pp_2011.doc revised 06/21/1l
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 10423 honeycreek pl. DATE: 09/27/2012 REVIEWED BY: bobs.
APN: BP#: 'VALUATION: $4,500
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY PENTAMATION
USE: SFD Or Duplex PERMITTYPE: FURN/Al;
WORK replace existing furnace and ac unit with new.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTl' UNITS BP FEES
A/C Units (<=10K cfm) 1BREMAIR 1 # $67
Furnace, Forced-Air 1MFR=<100 1 # $133
TOTALS: $200.00
Mech. Plan Check 0.0 hrs $0.00 Phoub. Plan Check Elec.Plan Check
Mech. Permit Fee: LNPER,IHT Plumb. Permit Fre: Flec.Permit Fee:
Other Mech. Insp. 1 0.0 hrs L $45.00 Ocher Plumb Insp. Ll Other Elec.Imp.
Adech,trop.Fee: Plumb. Insp.Fee: Flee.Insp.Fee:
!TOTE: This estimate does not include jeev due in other Departments(i.e. Planning, Public II'orks, Fire,Sanitary Sewer District,School
District, etc.). These fees are baser/on the preliatinan information available and are only an estimate. Contact the Dept for audit?info.
FEE ITEMS (Fee Resohuion 11-053 Elf 7111111 FEE QTY/FEE MISC ITEMS
Plan Check r«:
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. Insp Fee
PME Unit Fee: $200.00
PME Permit Fee: $45.00
Construction Tar:
Administrative Fee: MDAHN $42.00
Work Without Permit? O Yes 0 No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRA VDOC $45.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee•. IBCBSC $1.00
SUBTOTALS: $333.501 $0.001 TOTAL FEE: $333.50
Revised: 07/01/2012
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
(408)777-3228" FAX(408)777-3333• buildina ancuoertino.ora
CUPERTINO
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 ADDRESSAPN
/oY23 eve rre1_.�� lZp�021
OWNER NAS OWNER ADDRESS
rrE/( D
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 verily.this information.)
�1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
BuildeP building permilt hat 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.
rbL2. 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.
TL3. 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.
9)V4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
<1 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.
rDE-6. I understand if I am considered an "employer" under state and federal law, I must register with the slate 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.
rDL7. 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.
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.
OwnerBuilderFOrm 2010.doc revised 04/14/10
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.
_U_1_ 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.
1. 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.
TL12. 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.) r
Lender Name: /v /A— 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 sl ure.
Property Owner's Signature: Date:
(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 Signature: Date:
C -nerBuilderFornl 2010.doc revised 04/l4/l0