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11090184 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11650 WILDFLOWER CT CONTRACTOR:LECLAIRE RANDY RAND PERMIT NO: 11090184 DEBRA OWNER'S NAME: LECLAIRE RANDY R AND DEBRA 11650 WILDFLOWER CT DATE ISSUED:09/26/2011 'NER'S PHONE: 4084067763 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT PLUMB License Class Lic.# MECH F RESIDENTIAL r COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE GAS FIREPLACE,ADD NEW GAS LINE (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:$1500 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. APN Number:36619057.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. 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 Issued by / '�—Z Date: 2�` 9.18. �— Signature Date RE-ROOFS: OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(See.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will maintain compli a with th Cup tino Municipal Code,Chapter 9.12 and the permit is issued. Health&Sa ode,Se ons ,25533,and 5534. 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 Owner z g Compensation laws of California. If,after making this certificate of exemption,I Date: 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. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save ins'---unify and keep harmless the City of Cupertino against liabilities,judgments, c and expenses which ma a against said City in consequence of the ARCHITECT'S DECLARATION gra...mg of this permit. itional ,t ap icant understands and will comply I understand my plans shall be used as public records. with all non-point sou a re i Cupertino Municipal ode, ection 9.18. Licensed Professional Signatu Date 1 ! 01 01 kq GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION go 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 MISC CUPERTINO (408) 777-3228• FAX(408)777-3333• build ingC&-cupertino.orq LUMBING ErMECHANICAL ELECTRICAL/ MISCELLANEOUS PROJECT ADDRESSAPN#"2�( , [ (15 OWNER NAME - E-MAIL �� STREET ADDRESS `I a CITY, T P 1 4j/q FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX OWNER 13OWNER-BUILDER 13OWNER AGENT 13CONTRACTOR 1:1CONTRACTOR AGENT 13ARCHITECT 13ENGINEER 11DEVELOPER ❑TENANT CONTRACTOR NAME 117 LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE 'SE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES, PROJECT IN ❑ IS THE BLDG AN ❑YES lUIIAING: ❑COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE NO EICHLER HOME? ErNO DESCRIPTION OF WORK 1 r �►-/ / �y TOTAL VALUATION: RECEIVED BY: By my signature below,I certify to each of the folio the property owne aOrt ' ed agent to act on the pro owner's behalf. I have read this application and the information I have provided i ct. I h re the ion and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buildi ction tho' sertinoZo enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: Lp/� SUPPLEMENTAL ORMATION REQUIRED OFFICE USE ONLY W OVER-THE-COUNTER ❑ EXPRESS ❑ STANDARD 7U, a ❑ LARGE a ❑ MAJOR MEPMiscApp_201 1.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 11650 wildflower ct. DATE: 09/26/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$1,500 '-PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Du lex PENTAMATION 1 RPGAS USE: p PERMIT TYPE: wORK re lace gas fireplace add new gas line. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Gas <=4 Outlets 1PGASRES 1 # $65 TOTALS: $65.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: ]PPERMIT Other Plumb Insp. 0.0 hrs $44.00 NOTE. This estimate does not include fees due to other Depts(i.e.Public Works,Sanitary Sewer District,School District,etc.). These ees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn'l info, FEE ITEMS (Fee Resolution 11-053 L;jf 7/1/111 FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $65.00 PME Permit Fee: -T-T $44.00 Administrative Fee: ]ADMIN $41.00 Work Without Permit? 0 Yes (D No $0.00 Travel Documentation Fee: 1 TRA VDOC $44.00 Strona Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: ]BCBSC $1.00 SUBTOTALS: $195.50 $0.00 TOTAL FEE-T $195.50 Revised: 09/02/2011 CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36619057. 00 DATE ISSUED. . . . . . . : 09/26/2011 RECEIPT #. . . . . . . . . : BS000014860 REFERENCE ID # . . . : 11090184 SITE ADDRESS . . . . . : 11650 WILDFLOWER CT SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : LECLAIRE RANDY R AND DEBRA ADDRESS . . . . . . . . . . : 11650 WILDFLOWER CT CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : AIRTEK ENVIRONMENTA CONTRACTOR LIC # *OWNER* COMPANY LECLAIRE RANDY R AND DEBRA ADDRESS . . . . . . . . . . : 11650 WILDFLOWER CT 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 1, 500 . 00 1. 00 0. 00 1 .00 0. 00 1BSEISMICR VALUATION 1, 500. 00 0.50 0 . 00 0 .50 0. 00 1PGASRES OUTLETS 1 . 00 65. 00 0 . 00 65 . 00 0 . 00 1PPERMITFE 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 195.50 0 . 00 195.50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 195 .50 #1163 --------------- TOTAL RECEIPT 195.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 506 GAS TEST 507 FINAL PLUMBING OWNER-BUILDER DISCLOSURE FORM is COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333- build ing(d,�cupertino.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 ADDRESS APN BP# /0 G;. / OWNER r OWNER ADDRESS (/ DESCRIPTION OF'At ORK: 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 (DIRECTI :Please read and initial each statement below to signify you understand or verify this information.) understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- uilder" 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 onstruction and are not hiring a licensed Contractor to assume this responsibility. nderstand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that 1-may p tect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name ' stead of my own. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. erstand if I employ or otherwise engage any persons, other than California licensed Contractors, and the 19t—al 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. I understand if I am considered an "employer" under state and federal law, I must register with the state and deral 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 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 perform rider 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. OwnerBuilderForni 2010,doc revised 04/14/10 erstand I may obtain more information regarding my obligations as an "employer"from the Internal Re enue 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 co5t5actors. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I !amparry legally and financially responsible for proposed construction activity at the site address listed above. 1 ree that, as the party legally and financially responsible for this proposed construction activity, I will abide II 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 info mation 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 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: --------------------------------------------------------------------------------------------------------------------------------------------- (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: ( 0/4�050 eny Name of Authorized Agent: Tel No Address of Authorized Agent: I declare under penalty of perjury that I am the property for the address listed above and I personally filled out the above information and certify its accuracy. Note: p he roperty owner's driver's license, form notarization, or other verification acceptable to the city maybe req a pre d hen the permit is issued to veri the property owner's signature. Property Owner's Signat re: Date: r / CkvnelBullderForm 2010.doc revised 04/14110