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11090017 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20395 PACIFICA DR STE 104 CONTRACTOR:JM CONSTRUCTION PERMIT NO: 11090017 OWNER'S NAME: WHITTAKER DENNIS S AND ELIZABE 562 DIVISION ST DATE ISSUED:09/02/2011 ``VNER'S PHONE: 4082553212 CAMPBELL,CA 95008 PHONE NO:(408)379-9852 u LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL License Class Lic.# 7 5 6Q 56 REPAIR 32 SQ FT OF SHEETROCK SIDING,FRAMING, SUSPENDED CEILING DUE TO CAR ACCIDENT Contractor J.(�. C�o n��r��(n ADate �I l� 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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$3500 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 /I � APN Number:36940025.00 Occupancy Type: permit is issued. yat 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 tr comply with all city and county ordinances and state laws relating WITHIN 1 DAY F 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 DA FROM LA CALLED INSPE T N. indemnify and keep harmless the City of Cupertino against liabilities,judgments, 21 costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: with all non-point source regulations pe�the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date a l 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 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 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) 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. 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(a)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 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,Section 5505,25533, nd 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: 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 Compensation laws of Califomia. If,after making this certificate of exemption,I 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION ts,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. ting of this permit.Additionally,the applicant understands and will comply ...,h all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date CITY OF CUPERTINO 4 ITEMS OF 10 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 36940025 . 00 DATE ISSUED. . . . . . . : 09/02/2011 RECEIPT #. . . . . . . . . : BS000014664 REFERENCE ID # . . . : 11090017 SITE ADDRESS . . . . . : 20395 PACIFICA DR STE 104 SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : WHITTAKER DENNIS S AND ELIZABE ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO CA, 95014 RECEIVED FROM . . . . : JM CONSTRUCTION CONTRACTOR . . . . . . . : EDENS, JIM LIC # 20955 COMPANY . . . . . . . . . . : JM CONSTRUCTION ADDRESS . . . . . . . . . . : 562 DIVISION ST CITY/STATE/ZIP . . . : CAMPBELL, CA 95008 TELEPHONE . . . . . . . . : (408) 379-9852 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 3, 500 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICO VALUATION 3, 500 . 00 0 .74 0 . 00 0 . 74 0 . 00 1SIDEOTHER SQ FEET 32 . 00 392 . 00 0 . 00 392 . 00 0 . 00 1STINSP UNITS 1 . 00 130 . 00 0 . 00 130 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 523 . 74 0 . 00 523 . 74 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 1, 049 .24 49028 --------------- TOTAL RECEIPT 1, 049 .24 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228- FAX(408)777-3333- building(lcupertino.oL 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 ��O ,� ` � APN BP# OWNER NAME ---% 1v OWNER ADDRESS 6 DESCRIPTION OF WORK: e^r a 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.) S, 1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Bui1der" 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. "�_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. 4(') 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. 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers 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 law. '(5_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. 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. OwnerBuilderForin 2010.doc revised 04114110 CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION ADDRESS: 20395 pacifica dr. DATE: 09/02/2011 REVIEWED BY: bobs. SUIAPN: BP#: "VALUATION: 1$3,500 'PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION 1GE S USE: PERMIT TYPE: WORK Commercial repair do to car accident includes 32 sq ft. sheetrock siding, framing suspended ceilin . SCOPE NOTE. Thesefees are based on the prelindnary information available and are only an estimate. Contact the Dept-for addn 7 info. FEE ITEMS t/'�e Resolution I1-053 I f 7,l-"11) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = s.f. Siding Suppl. PC Fee: E) Reg. 0 O-170-0-1 hrs $0.00 $392.00 ISIDEOTHER All Other PME Plan Check: $0.00 Permit Fee: Hourly Only? Q Yes E) No $0.00 Suppl. Insp. Fee ` Reg. OT 0.0 Ihrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Acoustical Fee: 0 Yes G No $0.00 Q Work Without Permit? Q Yes (D No $0.00 I'(anning Fee: $0.00 1 hours Inspections E) $130.00 1sT11vsP Inspection,Hourly Strong Motion Fee: IBSEISMICR /50 Select an Administrative Item Bld> Stds Commission Fee: 1BCBSC $1.00 1 SUBTOTALS: $1.501 $522.00 TOTAL FEE: $523.50 Revised: 07/04/2Q1 I ' V� " 7` CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• buildinp(aDcupertino.ora i I ()QA ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS 0 i ✓"O d APN# J ?J(.0 Ci 0 CSU OWNER NAME PHONE Z. E-MAIL STREET ADDRESS _�LU ZIP FAX uc. ZC CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENTCONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME J 9 '. 1 t LICENSE 3/NUM OBER LIC SE TYPE BUS.LIC# COMPANY NAME ` / E--MAILFAX STREET ADDRESS CITY]STATE,Z P �� QO PHONE J � `` J v C , a e_% I C4 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK e Y-.n�� 1 �} S he��r��'. C S SI •w ,r" 1 EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA - O _ BATHROOM KITCHEN OTHER v REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA I GARAGE AREA: DETACH []ATTACH #DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? ❑NO ADDITION? []NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: /I T0W—C) V ATIN: PLANNINGAPPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO 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 behalf. I have read this application and the information I have pro ded 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 relating to uil g construe' n. I au rize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENT ORMATION Q D PLAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demaddorf permit for OVER-THE-COUNTER G PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building I permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD C1PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIItE 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 06/21/11