12110102 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7491 TIPTOE LN CONTRACTOR:MARK R SIIELLIH PEGRCY PERMIT NO: 12110102
OWNER'S NANIE: MARK R SFIELLIE PEE RCY 7491 TIPTOE.LN DATE ISSUED: 11/162012
OWNER'S PHONE: 4087253623 CUPERTINO.CA 95014 PHONE NO:
❑ LICENSED CONI'RACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lie.q
' DIECII r RESIDENTIAL(— CODfAIERCLAL -�
Contractor Date
hereby affirm that l am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL 50 GAL GAS WATER HEATER
(commencing with Section 7000)of Division 3 of the Business S Professions
Code and that my license is in full force and effect.
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 pemtit is issued. Sq.FI Floor Area: Valuation:$1100
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for die performance of the work for which this
permit is issued. AI'N Number:35928007.00 Occupancy Type:
APPLICAN 1'CERTIFICATION
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 IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon die above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and
ep harmless swhichmaya crueagty of Cupertino idCityinconst nseq liabilities,judgments, 180 D YS FROM LtyB-'YCALLED INSPECTION.
costs,and expenses which may acerae against said City in consequence of the
granting of this pemtit. Additionally,the applicant understands and will comply -I//S , ) L
with all non-point source regulations per the Cupertino Municipal Code,Swim Issued by: / / �j / Date:
9.18.
Signature Date
RF;ROOFS:
❑ OWNER-RI11LDER DECLARATION All roofs shall be inspected prior to any roofing material beimg installed.If a roof is
installed without fust obtaining an inspection,1 agree to remove all new materials for
1 hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as ow'ncr of the property,or my employees with wages as their sole compensation, Signature of ApplicmC 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 BE ITER
construct the project(Sec.7044,Business R'.Professions Code).
hereby affirm under penalty of perjury one of the following three IIA%ARDOUS MATERIALS DISCLOSURE
declarations: 1 have read the hazardous materials requirements under Chapter 6.95 of the
1 have and will maintain a Ceni Bcate of Consent to self-insure for Worker's California Health S Sufety 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(x)should I store or handle hazatrdous 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 of the Labor Code,for the performance of die work for which this canuaminants as defined by the Ray Area Air Qualit•Management District I will
maintain compliance with the Cupertino Nlunicipal Code.Chapter 9.12 and the
permit is issued. Health S Safety Code,Sections 25505.25533,and 25534.
1 certify that in the performance of die work for which this permit is issued,1 shall
not employ any person in tiny nmanner so as to become subject to the Worker's Owm a or hnze s
Compensation laws of California. If,alter making this cenifacate ofexemption,I ,� t nLage�Date:
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. CCLNS'IRl1Cl'ION LENDING AGENCY
I hereby affirm that there is a construction lending a- my for the performance of work's
APPLIC,\NI'CFR'I'IFICATION 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 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, .\Rflll'1'IiCI"S DECLARATIONcosts,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands mond will comply' I understand my plans shall be used.a public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. ty7 I , I Licensed Professional
Signatur ,L(:LM! Date l
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO. CA 95014-3255 I
CUPERTINO (408) 777-3228• FAX (408) 777-3333• buildinga()cupertino.org
SC
[]PLUMBING ❑MECHANICAL. ❑ELECTRICAI. MISCELrL—A�NEOUS
PROJECT ADDRT•SS 7 1 1 / I / L- - /L� APNd .Z q 2, O,�
OWNER NAME 6� lT/t 1h, I,� I(rJ[k/ Peerr-y PDONE�,IDa`7a5-362-3 E-MAIL CJ
STREETADDRESS �`' �/VIR CITY,STATE,ZIP lh%Ao `^,AQC^I4 FAX
CONTACT NAME 1 PIIONE El-MAI ILL
I
STREET ADDRESS CITY,STATE ZIP FAX
N'NER D OWNER-BUILDIiR ❑ OWNER An D CONTRACTOR OCONTRACTORAGPNT ❑ ARCI111 ECr ❑ENGINEER ❑ DEVELOPER D TENANT
CONTRACTOR NAME LICENSHNUMDIi0.r LI Zj�� LICIiNSE'I'YI'li BUS.LICk
COMPANY NAME /II' erhfio �u-mbi E-MAIL (O ) 1 FAX
STREET ADDRESS I \111 �e � •/ /1/ CITY. ATE,ZIP I '+ ^15� PHONE
�'�5 3-
Cb 1-5
ARCHITECT/ENGINEER NAME Il ��(,(�' ` LICENSENUMBER `� BUS.LICK
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,SI'Al E,ZI P PHONE
USE OF 0S a DUPLP_X DMUI.TI-FAMILY PROJECT IN WILDI.AND El YES PROJECTIN ❑ YIS ISTHRULDGAN ❑ YES
BUILDING: COMMERCIAL URBAN INTERFACE:AREA D NO FLOOD ZONE D NO EICBLER IIOMER ❑ NO
DESCRIPTION OF WORK
ins+al S 1 g,'WOer t
TOTALVALUATION: 1.Y ' 00 RECEIVi:D BY: P
By my signature below.,l certify to each of the following: I am the property owner or authorized agent to act on the property os is behalf. 1 have read this
application and the information I have provided is correct. 1 have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building consuuction. I authorize representatives of Cupertino to enter the above-identified propeny for inspection purposes.
Signature of ApplicandAgent:
SUITLEMEN'TAL INFORMA'I'I REQUIRED OFFICE USE ONLY
❑ OVERAIi ErCOUNIER
r
❑ F-XPREes
- ❑ NIANDARD
❑ LARGE
❑ MAJOR
MEP,l fiscApp_201/.doe revised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 7491 tiptoe lane DATE: 11/16/2012 REVIEWED BY: larrys
APIN: RP#: 'VALUATION: $1,100
"PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PF.NTAMATION PRWHEATR
USE: PERMIT TYPE:
WORK install 50 gallon replacement water heater
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTl' UNITS RP FEES
Water Heater 1PRWHEATR 1 # $27
TOTALS: $27.00
:1�•rfr. /'!an Check Plumb. PlanC heck 0.0 hrs $0.00 Elec. Ph.C/racA
dfech.Permit Fee: Plumb. Permit Fee: 1PP1,R,w17' Flee.Permit Fee:
Other M•eh. Insp. Other Plumb InsP. 0.0 hrs $45.00 O/her vee.insp. Ll I
'
;%lach.bap./:e: Phunh.insp.G e: Elec. Insp. Fee:
A'OTF: This estimate doer not include fees due to other Departments(i.e. Planning, Public 11'orks, Fire,Sanitary Server District,School
District,etc.). These ees are ha.sed on the relirninan information aw ilable and are Dull'an estiau»e. Contact the Dept for addn'I info.
FEE ITEMS (Fee Resolution 11-053 F(f 7/1/13) FEE QTY/FEE MISC ITEMS
Plat Check Fee:
SuppL.PC'Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. Pnsp Fee
PME Unit Fee: $27.00
PME Permit Fee: $45.00
Construction Taw
Administrative Fee: 1,11)MIv $42.00
Work Without Permit? C) Yes (F) No $0.00
Advunced Planning Feer
Travel Documentation Fee: 17'Rd[DOC $45.00
Shone Motion Fee: IBSFISHICR $0.50 Select an Administrative Item
Elde Stds Commission Fee: IBCFSC $1.00
SURTOTALS: $160.501 $0.00 TOTAL FEE: $160.50
Revised: 10/01/2012
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE -CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228- FAX(408)777-3333 • buildinard)cuoertino.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 7Ha 1
�. ��{ �/1f-, CLt �Ir�9 APN BP#
�f". 1
OWNER NAMESI-.Illt Qygl JuDfF ref OWNER ADD ESS I`.Q &J&,-It/10/. n
DESCRIPTION OF WORK: f I ' h1ct Pf�2., r'
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.)
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 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.
1�_V2. 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.
ZA4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
�_P5. 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.
" ��. I 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.
1 7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family
dsldential 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.
8 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
an 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 reviser/04114110
.� I 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.cslb.ca.gov for more information about licensed
contractors.
'10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
/�a�m/t�he party legally and financially responsible for proposed construction activity at the site address listed above.
Ill W1 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
W11 11 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 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: /
-------- w- i-n- ------------------------------- -re-------------------------------------------------------------------------------
(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:
O1Clte1'BnilderFOrnl 1010.doc revised 04/14/10