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11100156 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10370 PRUNE TREE LN CONTRACTOR:JACOBSON IRWIN S AND PERMIT NO: 11100156 LORA F OWNER'S NAME: JACOBSON IRWIN S AND LORA F DATE ISSUED: 10/21/2011 NER'S PHONE: 4082520960 CUPERTINO CA, 95014-2023 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATIONr BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH r RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:SFD,40 SF BATHROOM REMODEL,REPLACE TUB& (commencing with Section 7000)of Division 3 of the Business&Professions SHOWER Code and that my license is in full force and effect. SURROUND,TOILET,VANITY&SHOWER VALVE. NO ELECTRICAL ALTERATIONS 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 permit is issued. Sq.Ft Floor Area: Valuation:$7500 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:31633031.00 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 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. Signature Date Issued by: Date: 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) 1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& 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 forthwith comply with such provisions or this permit shall be deemed revoked. O a :��01 `4 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 work'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 "mnify and keep harmless the City of Cupertino against liabilities,judgments, ,and expenses which may accrue against said City in consequence of the Lender's Address g.-iting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. l iii ^"" I understand my plans shall be used as public records. Signa re Date / Licensed Professional CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: TraciC COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 31633031 .00 DATE ISSUED. . . . . . . : 10/21/2011 RECEIPT #. . . . . . . . . : BS000015111 REFERENCE ID # . . . : 11100156 SITE ADDRESS . . . . . : 10370 PRUNE TREE LN SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : JACOBSON IRWIN S AND LORA F ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2023 RECEIVED FROM . . . . : I .S. JACOBSON CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : JACOBSON IRWIN S AND LORA F ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2023 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 7, 500 . 00 1 . 00 0 .00 1. 00 0 .00 1BSEISMICR VALUATION 7, 500 . 00 0 .75 0 . 00 0 . 75 0 . 00 1REMRESBAT SQ FEET 40. 00 588 . 00 0 . 00 588 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 589 .75 0 . 00 589 . 75 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 589 . 75 1222 --------------- TOTAL RECEIPT 589 .75 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 10370 Prune Tree Lane DATE: 10/21/2011 REVIEWED BY: jsg APN: BP#: WVALUATION: $7,500 r°PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Remodel, Bath (300 s.f. max) ------TPRIMARY PENTAMATION 1 R3SFDREM USE: Residential PERMIT TYPE: WORK Single bathroom remodel replace tub and shower surround toilet vanity, and shower valve. No SCOPE electrical alterations. FEE ID FLR AREA s.f. 1REMRESBAT 40 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 prelininary information available and are only an estimate. Contact the Dept for addn'1 info, FEE ITEMS Lie Resolution 11-053 Eff '/1.-11) FEE Q TY/FEE MISC ITEMS Permit Fee: $588.00 Work Without Permit? 0 Yes No $0.00 i Strom Motion Fee: IBSEISMICR $0.75 Select an Administrative Item Bld&Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $589.75 $0.00 TOTAL FEE: $589.75 Revised: 10/01/2011 CONSTRUCTION PERMIT APPLICATION DEPARTMENT • BUILDING DIVISION COMMUNITY DEVELOPMENT \ 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 �` Cp 191 1 (408) 777-3228• FAX (408) 777-3333 • y `vUPEeRTINO ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS APN# co U tiri.c e if J OWNER NA / ICv �' PHOq6 2 5 a , ! / !, E-MAIL � C TY, STATE, IP FAX STREET ADDRESS j Q`E T A P O /SOf 1� r L CONTACT NAME PHO ZS_ ` l EIL L , h D( v �z ►' hoVao�1S,C6 m STREET ADDRE �� ITY,STATE, ZIP � F 1 JTENANT 3 � 've1�v,�1.o I'C � , 1`jS� 42- .W3❑OWNER ❑ OWNER-BUn DER ❑ OWNER AGENT ONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER CONTRACTOR NAME LIC SE NU .BEIM LICENSE TYPE BUS.LIC#�G� �G�E-MAIL FAX COMPANY NAME 0&t 6 V1 s� -S 6 Lie— Ctme a CITY STATE ZIP (%� P ON�EC_[ARCHITECT/ENGINEER EET ADDRESS L �I j/� �y�J (� 1 7a C LICENSE NUMBER BUS.LIC# NAME MPANY NAME E-MAILFAX EET ADDRESS CITY,STATE,ZIP PHONE 'IESCRIPTION OF WORK 10 s mer aI✓ell i� �e asgL/=�6 EXISTING USE PROPOSED USE TR TYPE #STORIES ��! USE TYPE OCC. SQ.FT. VALUATION($) EXISTG ///��� NEW FLOOR DEMO TOTAL AREA / , AREA AREA NET AREA BATHROOM �J KITCHEN OIETFR REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: E3DTTACH #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: TOTAL VALUATION: PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO ,5�0 By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the properly owner's behalf. I have read this application and the information I have provided 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^o building co traction. authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: f Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for FEI VER-THE-COUNTER BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building El PLANNING PLAN REVIEW permit for new building. xPREss _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS `,)rm 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 ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_201 1.doc revised 06/21/11 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION Is 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333•building cDcupertino.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# �j 376 1�e(V t`K6L OWNER NAME OWNER ADDRESS /Rw) ./ic �'�S 4/'/ .2a A A,Ll 6r DESCRIPTION OF WORK: )5;Q7 1Jr�'L°'L'M 73 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- 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. WL-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. 3. 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. �L4. 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. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the otal 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. L_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. OwnerBuilderForm 2010.doc revised 04/14/10 9. I understand 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 contractors. _L10. 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. IL11. 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. 7 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the in rmation 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 owners drivers 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 owners s' nature. Property Owner's Signature: Date: 0 G I l --------------------------------------------------------------------------------------------------------------------------------------------- (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 owners drivers 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 owners signature. Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revised 04/14/10 1t� . ,7 i i� t^- r �J i � C rt' f rte., �,_�-i��._—.. -. --_- _ v. _ _ - - ....-.•*^,r.:-� ,�' 1 Sj*= 1 � � J t ii r