13020159 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 101281MPERIAL AVE CONTRACTOR:JOEANDRUSKO PERMIT NO: 13020159
OWNER'S NAME: JOAN ANDRUSKO 10128 IMPERIAL AVDATE ISSUED:02/28/2013
OWNER'S PHONE: 4088739616 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL LJ COMMERCIAL
REPLACE(E)WATER HEATER,SAME LOCATION
License Class Lic.q
Contractor - Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I 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 Valuation:$1350
performance of the work for which this permitis issued. Sq.Ft Floor Area:
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 for which this APN Number:35722040.00 Occupancy Type:
permit is issued. -
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITIHN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives Of this city to enter AST LLED INSPECTION.
upon the above mentioned property for inspection purposes. (We)agree to save 180 D
indemnify and keep hmmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ued b Date• -2--12-21C
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. RE-ROOFS:
Signature Date 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.
OWNER BUILDER DECLARATION Date:
Signature of Applicant:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,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) - HAZARDOUS MATERIALS DISCLOSURE '
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(x)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Compensation,as provided for by Section 3700 of the Labor Code,for the
. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
performance of the work for which thispermit is issued.
the Health&Safety Code,"ons 25505,25533,and 25534.
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 for which this Owner or authorized age0 Date:
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 CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,atter making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must 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.)
forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Name
APPLICANT CERTIFICATION Lender's Address
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 property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signa[u Date
GENERAL PERMIT APPLICATION n �1 M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION OV
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 f■■ i s ^
CUPERTFNO (408)777-3228• FAX(408)777-3333• buildinarcDcuoertino.ora \ ■v
PLul,s G D MECHANICAL ELECTRICAL DMISCELLANEOUS
PROTECT ADDRESS
Dw�uERNAME v?t�/U0N/N �O! T O � � 7,77
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t0O1M fI 7S E-MAILprhn rwpco
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STREET ADDRESS S 4 me . Kr fines CITY, STATE,ZIP FAX
CONTACT NAME PHONE E-MAIL
STREEFADDRESS CITY,STATE,ZIP FAX
❑ OWNER 0 -BUIIDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACIORAGENT ❑ ARC/DTECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSENUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME E-MAIL FAX
STREETADDRESS CITY,STATE,ZIP PHONE
ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC p
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF or DUPLEX ❑ MULTI-FAMILY PRO]ECTINWILDLAND EI YES PROJECT IN ❑YES ISTHEBLDGAN El YES
BUILDING: ❑CONWERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? El NO
DESCRIPTION OF WORK
(v?s {a l/a�Y'o h 6-F rLe v/ o coq le r h e a 4 r•'
TOTAL VALUATION: /3,J OT 61 RECEIVED BY:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's b f. I have read this
application and the information I e provided is comet 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 g building constru non I authorize repro ntativeS of Cupertino to enter the above-id
/e/nti ell nd prropei&for inspection pu.poses.
Signatureof Appbcant/Aeent: -/.{�� 1/Yp`n�,',� Date: Z6 (1
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
OYER-THE-COUNTER
❑ EXPRESS
U
❑ STANDARD
u
i ❑ LCRCE
❑ AUJOR
1EPd4isc4,DD_. 11.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10128 IMPERIAL AVE DATE: 0212812013 REVIEWED BY: MELISSA
APN: 357 22 040 BP#: 'VALUATION: $1,350
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY PENTAMATION PRWHEATR
USE: SFD or Duplex PERMIT TYPE:
WORK REPLACE E WATER HEATER SAME LOCATION
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater - 1PRWHEATR 1 # $27
$27
S.
TOTALS
ttlech. flan Cheek Plumb.Plan Check 0.0 hes $0.00 Elec.Plan Check
Mech. Per
Pee; Plumb.Permit Fee: IPPERMIT lilec. Penna Pec.:
Other Meeh. Insp, Other Plumb Insp. 0.0 ars $45.00 ocher Elec.Insp.
Alach.Imp. Fee: Phnuh. Lisp. Pee: Flee,Insp Pee.,
NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District etc.). These ees are based on the preliminary in ormation available and are only an estimate. Contact the Dept for addn'l,info,
FEE ITEMS (Fee Resolution]1-053 E . 7(( 11112) FEE QTY/FEE MISC ITEMS
Plan Chock Fete:
Suppl. PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl. lnsp Fee.
PME Unit Fee: $27.00
PME Permit Fee: $45.00
Consiruclion Tax:
Administrative Fee: IADAIIN $42.00 .
Work Without Permit? Q Yes Q No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAVDOC $45.00 A
Strong Motion Fee: IBSEISMMR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
l O $160.50 $0.00 „ TQTALFEE ;`` $160.50
z
\rn` I Revised: 01/01/2013
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO, CA 95014-3255
CUP ERTINO (408)777-3228- FAX(408)777-3333- buildinana cuoertino.ora
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:
SR ADDRESS ` 1 APN BP#
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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.)
��— 1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner-
Builder"building permit that erroneously impiies.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. I understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may
prbtect 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. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
84,_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" 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.
_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.
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.
a vnel'BuilderForm 2010.doc revised 04/14/10
9, I understand 1 may obtain more information regarding my obligations as an"employer"from the Internal
t) tevenue 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. 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
y all applicable laws and requirements that govern Owner-Builders as well as employers.
/)x_12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
jj 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
e
employee of that individual or fine is injured whilworking 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 n tune.
Property Owner's Signature: Date: a2 8
------------------------------------------------------------------------- p-le-t---by-th,----------------------------------------------------
(NOTE: The following Aufhorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply fora 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:
OimerBuilderForm 2010.doc revise 04/14110
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/SUBCONTRACTOR LIST -
JOB ADDRESS: U/o?e /m e r ar Ve e r o PERMIT# ) �Z°:�1 5 cl
OWNER'S NAME: 7_0�2 H h 4,, 4ruvhk6 PHONE# " 0Q g_.73 —9&16>
GENERAL CONTRACTOR: BUSINESS LICENSE#
ADDRESS: CITY/ZIPCODE:,.
*Our municipal code requires all businesses working 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:
t/ SUBCONTRACTOR BUSINESS NAME _ B.USINESS LICENSE #
Cabinets & Millwork $ N6(Lp$ S V IES 20 9
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
Owner/Contractor Signature Date