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11100057 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22897 CRICKET HILL RD CONTRACTOR:WALKER JAMES A PERMIT NO: 11100057 OWNER'S NAME: WALKER JAMES A 22897 CRICKET HILL RD DATE ISSUED: 10/10/2011 OWN'ER'S PHONE: 3103820100 CUPERTINO,CA 95014-2681 PHONE NO: EA LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date JOB DESCRIPTION:ADD 20LF GAS LINE FOR NEW GAS STOVE;USE I hereby affirm that I am licensed under the provisions of Chapter 9 EXISTING (commencing with Section 7000)of Division 3 of the Business&Professions HOOD 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. 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 Valuation:$600 permit is issued. Sq.Ft Floor Area: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:34235055.00 Occupancy Type: 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, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply WITHIN 80 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations per the Cupertino Municipal Code,Section 180 D ROM LAST CALLED INSPECTION. 9.18. Date Issued b lo 1 _ , Date: Signature Y� OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection. Business&Professions Code) Signature of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534. become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or author.5 c gent• forthwith comply with such provisions or this permit shall be deemed revoked. Date: Q I 1 APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of"wrk's to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address ^,)sts,and expenses which may accrue against said City in consequence of the sting of this permit.Additionally,the applicant understands and will comply .:h all non-point source re ulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. k O l � r I understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 34235055 . 00 DATE ISSUED. . . . . . . : 10/10/2011 RECEIPT #. . . . . . . . . BS000014987 REFERENCE ID # 11100057 SITE ADDRESS . . . . . : 22897 CRICKET HILL RD SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : WALKER JAMES A ADDRESS 22897 CRICKET HILL RD CITY/STATE/ZIP CUPERTINO, CA 95014-2681 RECEIVED FROM . . . . : HARISH RAMAMURTHY CONTRACTOR LIC # *OWNER* COMPANY WALKER JAMES A ADDRESS 22897 CRICKET HILL RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2681 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- --------- lADMIN HOURS 1 . 00 41. 00 0 . 00 41 . 00 0 . 00 1BCBSC VALUATION 600 . 00 1. 00 0 . 00 1 .00 0 . 00 1BSEISMICR VALUATION 600 . 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 ----------------- --------------- ------- CREDIT CARD 195 .50 VISA --------------- TOTAL RECEIPT 195.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -- ----------- 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 506 GAS TEST 507 FINAL PLUMBING GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 2 (408)777-3228• FAX(408)TT7-3333• building(a.cupertino.org MISC CUPERTINO PLUMBING ❑NMCHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS 2.Z IM 4 CRICKET H l LL t OAPN# 3 y 2 — 3 5 — C)S S OWNER NAME Np�,��sH �ptr�q ��TKy • PHONE 31O 372o\00 E-MAIL ho,�lSh•YGwww�U>< j@(J Cu`• Conn, STREET ADDRESS 2.2 2 q C k IC K tT N I LL CITY, STATE,ZIP C O P E(ZT 4 Nd FAX U CONTACT NAME V(lNe,1S x ��ryV��µV PHONE E-MAIL STREET ADDRESS r` / CITY,STATE, ZIP FAX T OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHrrscT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STA'L'E,ZIP PHONE ARCHITECT/ENGINEER.NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN YES IS THE BLDG AN 0 YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA �O FLOOD ZONE VINO EICHLER HOME? C7 NO DESCRIPTION OF WORK i�00 A WNS UNC— FOR STOVE 20 TOTAL VALUATI . �, C7(:;, 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 have provided is ect., 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 building cons n I authorize representatives of Cupertino to enter the above-identified property for inspection pu{poses. Signature of Applicant/Agent! Data; O 1 S PLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY ❑ OVER-THE-COUNTER a ❑ EXPRESS Y U T_ ❑ STANDARD V ❑ LARGE ❑ MAJOR MHPMiscApp 2011.doc revised 06121111 CITY OF CUPERTINO F1FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 22897 Cricket Hill DATE: 10/10/2011 REVIEWED BY: gs APN: BP#: "VALUATION: $600 °PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY PENTAMATION 1 RPGAS USE: SFD or Duplex PERMIT TYPE: WORK Add 201f gas line for new gas stove. use existing hood. 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: IPPERMIT Other Plumb Insp. 0.0 hrs $44.00 NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . These fees are based on the prelindina information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS (I ee Resolution 11-053 Lff '%7 j- FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $65.00 PME Permit Fee: $44.00 Administrative Fee: (ADMIN $41.00 Work Without Permit? 0 Yes (E) No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 A Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Btdg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $195.50 $0.00 TOTAL FEE: $195.50 Revised: 10/01/2011 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333- buildinwa cupertino.o l 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 L 2 9 C V iCK ET H�LL (Z(D APN 3Ll 2- ^ Q 3; _ 0` BP# OWNERNAME ��i ,/� ��RMUQ�Ny OWNER ADDRESS 2 2_,9 C P,\C T ►'11LL �01 �UPEm4 DESCRIPTION OF WORK: 1A oo A C-A vAS L- N F E7 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. 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. I 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. I 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. 1---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. '1--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. 771 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. �r_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. OwnerBuilderForm 2010.doc revised 04/14/10 9. I 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.csib.ca.gov for more information about licensed contractors. '+�"tr10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I �__, amthe party legally and financially responsible for proposed construction activity at the site address listed above. 1. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide (b� a y all applicable laws and requirements that govern Owner-Builders as well as employers. t 12. I 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. 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: C)v Date: 10 1, 10 --------------------------------------------------------------------------------------------------------------------------------------------- (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: OH,»erBuilderFonn 2010.doc revised 04/14110 Building Department City Of Cupertino Lo 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: re-1c PERMIT# OWNER'S NAME: PrNj R My 9--k N PHONE# 31 ) O 1 GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: 2 2 '3�4 C LL Q() CITY/ZIPCODE: CUP E R 1 i N O C *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: 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 i o 10111 caner/Contractor Signature ate