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11090052 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10133 S TANTAU AVE CONTRACTOR:VINCENT BURKHART PERMIT NO: 11090052 OWNER'S NAME: VINCENT BURKHART 10133 TANTAU AVE DATE ISSUED:09/07/2011 )WNER'S PHONE: 4083072051 CUPERTINO,CA 95014 PHONE NO: LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIAL License Class Lic.# TEMP PRESSURE VALVE DRAIN OUTSIDE 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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$100 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:37507017.00 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 Issued by: Date: 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 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) 1,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 witthe Cup o Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Se ions 5505, d 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Dater 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,after 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 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, —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 p rmit.Additionally,the applicant understands and will comply a all non-poi sour ulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date ��/ 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: toi-3-3 r[' ,� PERMIT# OWNER'S NAME: PHONE# OfS — -;L- GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: l *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY 1NSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND A L S BCONTRACTORS 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: V 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 Owner/Contractor Signature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 37507017. 00 DATE ISSUED. . . . . . . : 09/07/2011 RECEIPT # . . . . . . . . . : BS000014690 REFERENCE ID # . . . : 11090052 SITE ADDRESS . . . . . : 10133 S TANTAU AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER VINCENT BURKHART ADDRESS 10133 TANTAU AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : VINCENT BURKHART CONTRACTOR LIC # *OWNER* COMPANY VINCENT BURKHART ADDRESS 10133 TANTAU AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1 . 00 41. 00 0 . 00 41. 00 0 . 00 1BCBSC VALUATION 100 .00 1 . 00 0 . 00 1 . 00 0. 00 1BSEISMICR VALUATION 100 . 00 0 .50 0 . 00 0 .50 0. 00 1PPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 1PREPPIPE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 1TRAVDOC FLAT RATE 1 .00 44 . 00 0 . 00 44 . 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 174 . 50 0 . 00 174 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 174 . 50 MC --------------- TOTAL RECEIPT 174 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 302 TUB & OR SHOWER 506 GAS TEST 507 FINAL PLUMBING OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• building5cugertino.oE 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 r splo APN BP# to 5 h 0,V"ER NAM 1' rOWNER ADDRESS ��a_y ` C / �J l� . 101 � fno DESCRIPTION OF WORK: (/ V t 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 (DIRE CTIONS: 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. 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. V3. 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. Arb4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. �5- I 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. V&ZI understand if I am considered an "employer" under state and federal law, I must register with the state and al 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. `97. 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. 1&&'l 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 04/14/10 ID-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 contractors. vnli0i. I 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. L11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. 4orm 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the ation 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 ven ation acce table to the city may be required to be presented when the permit is issued to,verify the property owner's s at Property Owner's Signature: Date: - --------------------------------------------------------------------------------------------------------------------------------------------- (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: Owne7BuilderFonn 2010.doc revised 04114110 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10133 s Tantau DATE: 09/0712011 REVIEWED BY: gs APN: BP#: "VALUATION: $100 R�PERMITTYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Du lex PENTAMATION 1 RPDP USE: p PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Drainage 1PREPPIPE 1 # $44 TOTALS: $44.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: IPPERMIT Other Plumb Insp. E] hrsl $44.00 - NOTE: These&es are based on the preliminary in ormation available and are only an estimate. Contact the Dept for addn7 info, FEE ITEMS (Fee Resolution I.1-053 Isjf. ';'1.-%I) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $44.00 PME Permit Fee: $44.00 Work Without Permit? 0 Yes No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 A Strom Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $133.50 $0.00 TOTAL FEE: $133.50 Revised: 07/04/2011 GENERAL PERMIT APPLICATION MEP L2 COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CIfPERTINO (408)777-3228• FAX(408)777-3333• buildinq(d7cuoertino.org MISC PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS V [ W PROJECT ADDRESS /0 1 t kA Ave ` 7APN # o i l- OWNER NAME C� PHONE 61 �`� E . STREET ADDRESS In� 9 CITY, STATE,ZIP ' J FAX 0)33 CONTACT NAME1 PH NE E-IYIAII Y�OVCJ 1(S, U ! t,(Yy�c��Il- O — — 0 STREET ADDRESS n CITY,STATE, ZIP FAX 19�OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME LIC SE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OFSFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ElYES PROJECT IN ElYES IS THE BLDG AN ElYES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK TOTAL VALUATIO /00,, CZ) 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 behalf. I have read this application and the information I h ve provid d is co have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating buildin ons on'I e representatives of Cupertino to enter the above-identified property for/inspection pu{poses. Signature of Applicant/Agent: Date: SLT11LEMENTAL INFORMATION REQ=D OFFICE USE ONLY OVER-THE-COUNTER Y ❑ EXPRESS U ❑ STANDARD U ❑ LARGE ❑ MAJOR MEPMiscApp_2011.doc revised 06121111