13030011 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10155 ORANGE AVE CONTRACTOR:JOHN A IMPINK PERMIT NO: 13030011
OWNER'S NAME: JOHN A IMPINK 10155 ORANGE AVE DATE ISSUED:03/01/2013
OWNER'S PHONE: 4085069690 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONT'RACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL U COMMERCIAL
License Class Lic.# TO CLEAR CODE ENFORCEMENT CASE: CONVERT
BDRM TO
Contractor Date HALLWAY W/NEW EXTERIOR DOOR&BATHRM
I hereby affirm that I am licensed under the provisions of Chapter 9 EXTENSION/REMODEL(180SQFT)REPLACE KITCHEN
(commencing with Section 7000)of Division 3 of the Business&Professions DOOR
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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$10000
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 APN Number:35716058.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ,/-
costs,and expenses which may accrue against said City in consequence of the /�TG� 3 •�3
granting of this permit. Additionally,the applicant understands and will comply Issued by: ,���/r Date:
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.
8] OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
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
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 HAZARDOUS MATERIALS DISCLOSURE
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. 1 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(a)should 1 store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 505 25533,and 255 4.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:.L//F►�"3
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 California. It after making this certificate of exemption,l CONSTRUCTION LENDING AGENCY
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
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
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-poi s urce regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18. yy �1
Signature Date -LlnAe1✓
CONSTRUCTION PERMIT APPLICATION 0
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 to
CUPERTINO (408)777-3228•FAX(408)777-3333•buildingftcuoertino.org
[:]NEW CONSTRUCTION ❑ ADDrrION ALTERATTON/TT ElREVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS i9t6AIC415 A/ PHO APN a c5' 050'
OWNERNAME V &MAH.
,tiJr d SUG� D l�I rf�u_Jor�>JCCrawfcts�.J�fJ
STREET ADDRESIp' C )STATE,ZIP��T �� FAX
CONTACT NAME PHONE V E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
ErOWNFR ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHr1ECT ❑ENGINEER D DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSENUMBER LICENSE TYPE BUS.LICk
O v
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECTIENGWEER NAME ,�///f. LICENSENUMBER BUS.LICH
COMPANY NAME /j E-MAIL FAX
STREETADDRESS �J CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK -�O /-�A9 r/ol'!'7 r�ON ' GGA✓✓E�r ��TJ�ooM /�✓To , _
/�A«riff i! w /✓�uJ EXT �a �6G/Z �iVi7 �Hr�/LbO� E7'cTE�v X,rV
�£iylG�CL CI�o � - .���A� `ir�.YE��oFt - wiTfz/ �✓/i✓17a cd.
EXISTINGUSE PROPOSEDUSE CONSTATYPE I aSTORD3
USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEWFLOOR DEMO TOTAL '4
AREA AREA AREA ;DIAL
�a
BATHROOM KITCHEN OTHER
RFMODEL AREA �,( REMODEL AREA REMODELAREA
PORCH AREA (DECK AREA TOTALDECK/PORCH AREA GARAGEAREA. DETACH
❑ATTACH
#DWELLING UNITS: ISASECONDiMIT OYES SECONDSTORY AYES
BEMGADDED7 �ti0 ADDITION' Iwo
PRE-APPLICATION DYES FM.PROVIDECOPYOF ISTHEBLDGAN I]YES RECEIVED Y: TOTAL VALUATION:
PLANNNGAPPLN,211O PLANNMGAPPROVALLEITER EICHLERHOMEr ,ffVD � ('J
By my signature below,l certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provi is co ct. lb read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating�//to b 'd' ons c on. authori",e repr entatives of Cupertino to enter the above-identified property for inspection purposes.
SignanneofApplicanttAgent: T Date:
SUPPLEMENTf INFORMATION REQUIRED PLANCHECKTYPE ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit forOVER-THE-COUNTER W BUILDING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building l
permit for new building. ❑ EXPRESS -PLANNINGPLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure El STANDARD d PUBLIC WORKS
Tom if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application. ❑ MAJOR ❑ SANITARY SEWER DISTRICT
❑ ENVIRONMENTAL HEALTH
BldgApp_2011.doc revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10155 Orange Ave DATE: 03/01/2013 REVIEWED BY: Sean
APN: BP#: VALUATION: $10,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Repair
PRIMARY PENTAMATION 1R3SFDREM
USE: SFD Or Duplex PERMIT TYPE: i
WORK To Clear Code Enforcement Case:
SCOPE
fir :� v z .�..a .e�,• r�4rd.,,,, war.
,bfvd). Plan Check Plumb. Plan Check Dec. Plan Check
Meeh. Permil Fee Plumb.Permit Fee: Elec.Permit/Fee:
Oilrea ,M1fcch.Insp. Odrer Plumb Imp. Li
Other Elec. Insp,
Ifech.Insp. Fee: Plumb. brsP. Fee: El". Insp.Fee:
NOTE: This estimate does not include fees due to other Departments(Le,Planning,Public Works,Fire,Sanitary Sewer District,School
District,eta). These fees are based on the prelinddna information available and are only an estimate. Contact the De t for addn'l info.
FEE ITEMS (Fee Resolution 11-053 E . 711112) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 F180 s.f. Remodel,Bath(<=300 sf)
Suppl. PC Fee:. Q Reg. Q OT 0.0 Ins $0.00 $600.00 IREMRESBAT
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. FeelD Reg. O OT O,Q Ins $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Constmelion Tax:
Administrative Fee:
Work Without Permit? G Yes Q No $600.00 0
Advanced Plannine Fee: $0.00 Select a Non-Residential 0
Building or Structure
Trm,el Documentation Fees: A
Strong_Motion Fee: IBSEISMMCR $1.00 Select an Administrative Item
B1da Stds Commission Fee: 1BCBSC $1.00
$602.00 $600.001''" ' 1OTAL�'*. $1,202.00
Revised: 01/01/2013
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AM: 367-16-oS8 �/IA)APPROVE BY:
This set of plans and specifications MUST be kept at the
Job site during construction. It is unlawful to make any
FCOKt�I changes or ut appns of same, B it deviate
herefrom,without approval from the Building Official.
The stamping of this plan and specifications SHALL NOT
be held to permit or to be an approval of the violation
of any Provisions of any City Ordinance or State Law.
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DATE .�• /•l.3
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COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION
CITY HALL
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
C U P E RT I N O (408)777-3228• FAX(408)777-3333
SCOPE OF WORK: Bathroom Remodel.
Project shall comply with the 2010 California Building(Base code 2009 IBC), 2010 Residential
(2009 IRC), Plumbing(2009 UPC), Mechanical(2009 UMC), Electrical (2008 NEC), Fire (2009 IFC)
and Energy Codes (2008 Building Energy Efficiency Standards)
Energy code mandatory lighting measures:
1. All permanently installed high efficacy luminaires shall be switched separately from low
efficacy luminaires. (150(k)(7))
2. Permanently installed luminaires in bathrooms, garages, laundry rooms and utility rooms
shall be high efficacy luminaires OR are controlled by an occupant sensor(s)certified to
comply with Section 119 that does not turn on automatically or have an always on option.
(150(k)(10))
Plumbing plan notes:
3. Water closets shall have an average water consumption of not more than 1.28 gallons per
flush. (CPC 402.2)
4. Shower heads shall have a water flow not to exceed 2.5 gallons per minute. (CPC 402.1.1)
5. Faucets in kitchens, wet bars, lavatories, laundry sinks, etc shall have a water flow not to
exceed 2.2 gallons per minute. (CPC 402.1.2)
6. Shower stalls shall have a clear interior finish area of 7.1 sq.ft. and be able to
accommodate a minimum 30 inch circle at the threshold level. These clearances shall be
maintained up to a height of 70 inches above shower drain. (CPC 411.7)
7. Shower compartments and walls above bathtubs with installed shower heads shall be
finished with a smooth, nonabsorbent surface to a height not less than 72 inches (6 ft).
(CRC R307.2)
8. The maximum hot water temperature discharging from the bathtub, shower and whirlpool
bathtub filler shall be limited to 120 degrees Fahrenheit. The water heater thermostat shall
not be considered a control for meeting this provision. (CPC 414.5 &418.0)
9. A 30-inch clear width for water closet compartment and 24 inch clearance in front of water
closet. (CPC 407.5)
Electrical Plan Notes:
10. The installation of smoke alarms in all of the following areas shall be provided: (R314.3)
a. On the ceiling or wall outside of each separate sleeping area in the immediate
vicinity of bedrooms.
b. In each room used for sleeping purposes.
11. The installation of carbon monoxide alarms in the following areas shall be provided:
(R315.1)
a. Approved carbon monoxide alarms shall be installed outside of each separate
sleeping area in the immediate vicinity of the bedrooms and on every level
including basements in dwelling units that have fuel-fired appliances or attached
garages.
12. At least one 20 amp branch circuit shall be provided to supply bathroom receptacle outlets.
Such circuits shall have no other outlets. (CEC 210.11(C)(3))
13. All receptacles in bathrooms, garages, accessory buildings, outdoors, crawl spaces,
unfinished basements, kitchens(where receptacles serve counter top surfaces), laundry,
utility, wet bar sinks (within 6 feet of the edge of the sink), shall have ground-fault circuit
interrupter(GFCI) protection. (CEC 210.8)
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE- CUPERTINO,CA 95014-3255
GUP ERTI NO (408)777-3228-FAX(408)777-3333- buildinora)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:
SITE ADDRESSAPN BP;#
do Z)eAA) C A X3,57-/6-,os-$
OWNER NAM OWNER IRE
Jndwt r iDi ' On1C�� /t✓ - Wvl
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. 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. 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 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 owners unless they are responsible for
he construction and are not hiring a licensed Contractor to assume this responsibility.
li7 3. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
rotect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
(�naam�e instead of my own.
W✓ 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
m
nubers on permits and contracts.
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 laud.
W6. I understand if I am considered an "employer"under state and federal law, I must register with the state and
eral 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. I understand under California Contractors'State License Law, an Owner-Builder who builds single-family
1 esidential 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.
OrAi
8.'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.
Oiw]el"BuilderFa-iii 2010.doc revised 04/14/10
fjl 9. I understand I may obtain more information regarding my obligations as an"employer"from the Internal
evenue 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.ra.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.
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. Youronly 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 ccep ble to the city ma be required to be presented when the permit is issued
to verifythe roe owner's si at re.
Property Owner's Signature: Date: 1 RRIC 1
(NOTE:
j-;e--
ow--ing--A--u--th--o-ri-z•a-t-i-on--F--o-r--m--i-s--r-e-q-ui-r-e-d-t-o--b-e---c-o -the-p-r-o-p-e--rt-y---o-#--n-
--ne--r-o--n-1-y--w--h-e--n,-d'e-si-g-n-a--t-in--g--a-n-
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 ov✓ner'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:
a imerBuilderForm 2010.doc revised 04/14110