13010044CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:. 19706 ALDERBROOK WAY I CONTRACTOR: JAMES STEVEN BURNS I PERMIT NO: 13010044
OWNER'S NAME: JAMES STEVEN BURNS, 19706 ALDERBROOK WAY DATE ISSUED: 01/08/2013
OWNER'S PHONE: 4087656953 - - CUPERTINO, CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL
License Class Lie. # REMOVE & REPLACE 10 (E) WINDOWS (EGRESS
REQUIREMENTS WILL APPLY) & 1 SLIDING GLASS DOOR
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 o the Business & Professions
Code and that my license is in full force and effect
I hereby affirm under penalty of perjury one i 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 3760 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, and hereby authorize representatives of this city to enter
upon the above mentioned properly.forinspection purposes. (We) agree to save
indemnify and keep hamrless 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 will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
V 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 & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I 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, 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.
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
Compensation laws of Califomia. If, after making this certificate of exemption, I
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.
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 wanly ordinances and state laws relating
to building construction, and 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 will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18. t j — .
Sq. Ft Floor Area: I Valuation: $4429
APN Number: 36921047.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM'EX&PtALLED INSPECTION.
t B
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 Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 255 3, and 25 3;; 4.
Owner or authorized agen (Vu „� Da�t� -e: m
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.) -
Lender's Name
Lender's
I understand my plans shall be used as public records.
Licensed
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION o
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 0\
CUPERTINO
(4 08) 777 -3228 FAX (408) 777 -3333 • building ancupertino.org \
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PROJECT ADDRESS
APN #
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OWNERNAMB Jeh
PHONE
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CONTACT NAME ..
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FAX
❑ OWNER OWNER - BUILDER ❑ OwTTER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME
LICENSENUMBER
LICENSETYPE
BUS, LTC#
COMPANY NAME
E -MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHRECT/BNGWEER NAME
LICENSENUMBER
BUS. LTC K
COMPANY NAME
&MAIL
FAX
STREET ADDRESS
CRY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
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lace IO w1olejows ot not
EXISTING USE
PROPOSED USE
CONSTB TYPE
NSTDBMS
USE
TYPE
OCC.
SQ.FT.
VALUATION (S)
EKISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NETAREA
BATHROOM KRCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCHAREA DECKAREA TOTAL DEC'K/PORCH AREA GARAGE AREA
DETACH
I
ATTACH
#DWELLINGUNRS:
IS A SECOND UNr' OYES
SECONDSTORY OYES
BEING ADDED!, ONO
ADDITION! ONO
PRE - APPLICATION OYES IF YES, PROVIDE COPY OF
PLANNING APPL# ONO PLANNN'GAPPROVAL LEffBR
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OTAL VALUATION:
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By my signature below, l certify to each of the following: I Rm the property owner or authorized agent to act on the p party owner's behalf. I have read this
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 relatin o building cons coon. I authorize representatives of Cupertino to enter the above -i entified property for inspection purposes.
Signature of ApplicanttAgent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
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New SFD or Multifamily dwellings: Apply for demolition permit for
conNTE'ni r
r Waisliatiu�+Ge
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existing building(s). Demolition permit is required prior to issuance of buildingkrit
1il r a
a <I+
permit for new building.
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Hazardous Materials Disclosure
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Commercial Bldgs: Provide a completed
&AARD 4a `•'r
_
form if any Hazardous Materials are being used as part of this project.
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�,❑Get,,a? ;�
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_ Copy of Planning Approval Letter or Meeting with Planning prior to
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submittal of Building Permit application.
"ENVIRONM1mN7'AMU;
❑': TITfr.
BldgApp_2011.doc revised 06121111
Orr /
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
50
ADDRESS: 19706 ALDERBROOK WY DATE: 01/08/2013
APN: BP #:
REVIEWED BY: MELISSA
*VALUATION: $4,429
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD Or Duplex
USE:
Alech. Perini[ Fee:
PENTAMATION 1GENRES
PERMIT TYPE:
WORK
REMOVE & REPLACE 10 (E )WINDOWS EGRESS REQUIREMENTS WILL APPLY )& 1 SLIDING
SCOPE
GLASS DOOR
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc). These fees are based on the preliminary information available and are only an estimate. Contact the Deptfor addn'l info.
FEE ITEMS (Fee Resolution 11 -053 Efl 711112)
FEE
QTY/FEE
Ifeed. Plan Check
Plumb. Plan Check
Elec. Plan Check
Alech. Perini[ Fee:
Plumb. Permit Fee:
F,lec. Permit Fee:
Other A9ech. Insp.
Other Plumb Insp.
Other Elcc. Insp.
Wech. Insp. Fee:
Plumb. hap. Fee:
Elec. Insp. Fire:
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc). These fees are based on the preliminary information available and are only an estimate. Contact the Deptfor addn'l info.
FEE ITEMS (Fee Resolution 11 -053 Efl 711112)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
= #
$533.00
Window / Sliding Glass Door
1WINREP Replacement
Suppl. PC Fee: Q Reg. Q OT
fO.OThrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. FeelD Reg. 0 OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Consi uclion Tax.
Administrative Fee:
0
Work Without Permit? O Yes O No
$0.00
Advanced Planning Fee:
$0.00
Select a Non - Residential
Building or Structure
O
0
i
Travel Documentution Fees:
Strong Motion Fee: IBSEISM/CR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
$1.50
$533.00
�T.O1 AL FEE;;
$534.50
Revised: 10/01/2012
CUPERTINO
�7���1 `► I� £�1I�7:T�1 �3���•�iU :7 7�7 :711
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 • building ancuoertino.org
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 ADD ESS
o r W4t
APN
BP#
OWNERNAME
es 5-h%jen u
OWNER ADDRESS
br k Ca st
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.)
��kQL1. I 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. 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 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.
& 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.
& 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.
64. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
�v 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.
dA& 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
mp�to serious financial risk.
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
is performed under contract with a licensed general building Contractor.
OV8 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 04114110
146 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.cslb.ca.gov for more information about licensed
tractors.
�} 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.
?11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
/byy all applicable laws and requirements that govern Owner - Builders as well as employers,
�rC1 Y� 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
VVV 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: me"\,O, 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
I Property Owner's Signature: 1,*Ayan &ZQ2 /L QfZ2'Y114 Date: J I Z / I D j
(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 AGE T TO'Ar& dWPROPERTY 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
OwnerftilderForm 2010.doc revised 04114110
JAN 0
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Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014 -3255
Tclephune'. 41A-177.3229
Fax: 408-777-3333
JOB ADDRESS: M
SUBCONTRACTOR'
BUSINESS NAME
Wq
PERMIT #/_30100L/1-/
OWNER'S NAME:
_; V
PHONE # %— 7(o— 3
GENERAL CONTRACTOR:
Cement Finishing
BUSINESS LICENSE #
ADDRESS:
CITY /ZIPCODE:
vU1 u.a...ciPal cuue requires anpusmesses woriung in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable. subcontractors and complete the following information:
1
Date
SUBCONTRACTOR'
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork.
Cement Finishing
Electrical
Excavation
Fencing
Flooring /Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
1
Date