11070177 , CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10970 LUCKY OAK CT CONTRACTOR:JOHN&GAIL TRAYLOR PERMIT NO: 11070177
OWNER'S NAME: J014N&GAIL TRAYLOR 10970 LUCKY OAK CT DATE ISSUED:07/25/2011
"WNER'S PHONE: 4153282195 CUPERTINO,CA 95014 PHONE NO:
IJ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL
License Class Lie.# INSTALL NEW GAS LINE IN KITCHEN,REPLACE
EXISTING
Contractor Date SUB-PANEL
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:$700
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:32657008.00 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
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
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
Xinspection.
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
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. [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 de,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Cod4SectZions50 3,an 5 .
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Owner or authorized age Date:
Pi J4 /
1 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 V
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,1 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,
qts,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
tnting of this permit.Additionally,the applicant understands and will comply
with all non-point source regul tions per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signatu Date ,/ Z6
1 T
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 CUDertino.orq
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 AD E S APN�, BP#
1)0 LoOccfk ___0 7
OWNER A E (zOWNER ADDRESS
L`J C
c2 2
DESCRIPTION OF WORK:
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.)
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.
understand building permits are not required to be signed by property owners unless they are responsible for
heconstruction and are not hiring a licensed Contractor to assume this responsibility.
�4ote
-a<understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
ct myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
understand Contractors are required by law to be licensed and bonded in California and to list their license
be
mrs on permits and contracts.
�5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
tal 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.
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
V me to serious financial risk.
C
Piceinsed
understand under California Contractors' State License Law, an Owner-Builder who builds single-family
Irntial structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
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.
tZects'
8'I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
inancial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04114/10
understand I may obtain more information regarding my obligations as an"employer"from the Internal
evenue Service,the United States Small Business Administration, the California Department of Benefit Payments,
a/ nd the California Division of Industrial Accidents. I also understand I may contact the California ContractorsState
License Board (CSLB) at 1-800-321-CSLB (2752)or www.csib.ca.gov for more information about licensed
contractors.
`"T0. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
m the party legally and financially responsible for proposed construction activity at the site address listed above.
Z�t1. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
y all applicable laws and requirements that govern Owner-Builders as well as employers.
agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
nformation 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.)
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 e city may b equired to be presented when the permit is issued
to verify the property owner's atu
Property Owner's Signature: Date: ZJ
i
---------------------------------------------------------------------------------------------------------------------------------------------
(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:
64>>7erBuilderFor7?t_2010.doc revised 04/14/10
CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 32657008 . 00
DATE ISSUED. . . . . . . : 07/25/2011
RECEIPT #. . . . . . . . . BS000014169
REFERENCE ID # . . . : 11070177
SITE ADDRESS 10970 LUCKY OAK CT
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : JOHN & GAIL TRAYLOR
ADDRESS 10970 LUCKY OAK CT
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JOHN TRAYLOR
CONTRACTOR LIC # *OWNER*
COMPANY JOHN & GAIL TRAYLOR
ADDRESS 10970 LUCKY OAK CT
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ----------
---------- --------
1BCBSC VALUATION 700 .00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 700 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1EPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00
1ERT<200 UNITS 1 . 00 44 . 00 0 . 00 44 . 00 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 242 . 50 0 . 00 242 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
-----------------
--------------- --------------------
CHECK 242 . 50 CHK
---------------
TOTAL RECEIPT 242 . 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
_ -------- ----------------------------
-- ---------------
202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING
506 GAS TEST 507 FINAL PLUMBING
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10970 lucky oak st. DATE: 07/25/2011 REVIEWED BY: bob s.
APN: BP#: "VALUATION: $700
rPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY ----rPENTAMATION 1 RPGAS
USE: SFD or Duplex PERMIT TYPE:
WORK install new gas line to new gas stove top, replace existing sub-panel
SCOPE
Plumb.Plan CheckL 0.01 hrs $0.00 Elec.Plan Check 0.0 hrs $0.00
Plumb.Permit Fee: IPPERMIT Elec.Permit Fee: IEPERMIT
Other Plumb Insp. 0.0 hrs $44.00 Other Elec.Insp. 0.0 hrs $44.00
NOTE: These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addh7 info.
FEE ITEMS (P{ e Resolution 11-053 E ff. '-1.-"I1) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Plumbing
Suppl.PC Fee: G Reg. 0 OT 0.0 hrs $0.00 $65.00 1PGASRES Piping,Gas<=4 Outlets
PME Plan Check: $0.00 100 amps Electrical
Permit Fee: $0.00 $44.00 ]ERT<2oo Services
Suppl.Insp.Fee-.E) Reg. 0 OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $88.00
Acoustical Fee: 0 Yes (E) No $0.00 0
Work Without Permit? 0 Yes 0 No $0.00
Planning Fee: $0.00 Select a Non-Residential
Building or Structure
Travel Documentation Fee: ITRA VDOC $44.00 i
Strong Motion Fee_ IBSEISMMCR $0.50 Select an Administrative Item
Bld€zy Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $133.50 $109.00 TOTAL FEE: $242.50
Revised: 07/04/2011
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 MISC
CUPERTINO (408)777-3228 • FAX(408)777-3333• budding(rDcuoertino.org
LUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS O Q APN# 57 U
OWNER NAME NE ✓ E-MAII.
STREET ADDRESSlogO —S+ I r,CITY, STATE,ZIP h I 1 FAX
CONTACT NAME J PHONE E-MAIL
STREETADDRESS CITY,STATE, ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAMELICENSE LICENSE TYPE BUS.LIC#
NI O.�r�lr `"1 c• Z
COMPANY NAME E-MAILFAX
S Q
0. uvw 3 \ e� �M
STREET ADDRESSCITY,STATE,ZIP NE
'L2_3 Uvfa\&"`M (a
'�;CL41 JorR
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
.SE OF &TSFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: `too. O0 ��/r�t�� RECEIVED BY: f
By my signature below,I certify to each of t e f lowing: I e property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provi ed i oaect. a Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to build, co n` u o ' resentatives of Cupertino to enter the above-identified property for inspection pu#poses.
Signature of Applicant/Agent: Date:
SUPPL TION REQUIRED OFF!EE USE ONLY
w OVER-THE-COUNTER
L
❑ EXPRESS
:1
U
w ❑ STANDARD
U
❑ LARGE
❑ MAJOR
MEPMiscApp_2011.doc revised 06/21/11