11070107 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22821 MEDINA LN CONTRACTOR:PONCE ROBERT A AND PERMIT NO: 11070107
SCOTT-PONCE
OWNER'S NAME: PONCE ROBERT A AND SCOTT-PONCE 22821 MEDINA LN DATE ISSUED:07/18/2011
< ER'S PHONE: 4089962046 CUPERTINO,CA 95014-2617 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r— PLUMB F
License Class Lic.#
MECH RESIDENTIAL F COMMERCIAL r
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:APT A-DRY ROT REPAIR IN BATHROOM(72SQFT)
(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
1 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:34230011.00 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 D S 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 Issue W� ' 1 ( Date:
9.18.
Signature Date
RE-ROOFS:
L 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 oe of inspection.
the following two reasons:
I,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)
I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.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
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
[certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's Own r or Thor'
Compensation laws of California. If,after making this certificate of exemption,I te: 7 ! 6/
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 cork'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
ir'--nnify and keep harmless the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
g,.:...ung of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Q Licensed Professional
Signature6n�l �� ate /V
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 34230011. 00
DATE ISSUED. . . . . . . : 07/18/2011
RECEIPT #. . . . . . . . . : BS000014072
REFERENCE ID # . . . 11070107
SITE ADDRESS . . . . . : 22821 MEDINA LN
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : PONCE ROBERT A AND SCOTT-PONCE
ADDRESS . . . . . . . . . . : 22821 MEDINA LN
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2617
RECEIVED FROM . . . . : LISA SCOTT-PONCE
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : PONCE ROBERT A AND SCOTT-PONCE
ADDRESS . . . . . . . . . . : 22821 MEDINA LN
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2617
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
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
1REMRESBAT SQ FEET 1.00 588 . 00 0. 00 588 . 00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 589.50 0. 00 589.50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 589. 50 VISA
---------------
TOTAL RECEIPT 589.50
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 22821-a medina lane DATE: 07/18/2011 REVIEWED BY: Is
APN: BP#: "VALUATION: 1$1,500
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex 2nd Unit? 0 Yes G No PENTAMATION
USE: I OTC. 0 Yes ONo PERMIT TYPE: 1 R3SFDREM
WORK d rot repair in bathroom
SCOPE
OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID
CONSTR. s.f.
R-3(Custom) II-B,III-B,IV,V-B 0 $0.00 $0.00
TOTALS: 0 $0.00 $0.00
MECH,HOURLY 0 Yes 0 No PLUMB,HOURLY 0 Yes 0 No ELEC,HOURLY 0 Yes 0 No
ELI LL]
NOTE: Theseees are based on the preliminary information available and are only an estimate. Contact the De t or addn7 info.
FEE ITEMS (P" e Resolution I1-053 Eff 1.-"111 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = s.f. Remodel,Bath(<=300 sf)
Suppl.PC Fee: 0 Reg. 0 OT P.0 hrs $0.00 $588.00 IREMRESBAT
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee-E) Reg. 0 OT Fo.o hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Acoustical Fee: 0 Yes 0 No $0.00 0
Work Without Permit? 0 Yes 0 No $0.00 0
Planninm Fee: $0.00 Select a Non-Residential E)
Building or Structure 0
A
Strom Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.50 $588.00 TOTAL FEE: $589.50
Revised: 07/04/2011
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228- FAX(408)777-3333- buildina(a)cuoertino.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 ADDRESS�()&'1 APN BP#
07 ER NAME OWNER ADDRES§ I'
g:Zd
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.)
--e1. I 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.
;��3. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
otect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
nu� understand Contractors are required by law to be licensed and bonded in California and to list their license
bers onP ermits and contracts.
*5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
toavalue 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.
P6. I understand if I am considered an "employer" under state and federal law, I must register with the state and
de
f ral 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.
understand under California Contractors' State License Law, an Owner-Builder who builds single-family
reidential 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.
V8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
ay inancial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderFonn 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.cslb.ca.gov for more information about licensed
kthontractors.
10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
e party legally and financially responsible for proposed construction activity at the site address listed above.
11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
all 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
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:Plea omplete the f o�' construction lending agency inf mation.)
I hereby affirm that t ere is onstru tiong ag for the performa e of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building permiOwin 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 si natur .
Property Owner's Signature: — Date: ,V / /
---------------------------------------------------------------------------------------------------------------------------------------------
(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:
GWvne1BuilderFornz 2010.docrevised04/14/10
D-7
CONSTRUCTION PERMIT APPLICATION
[is COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
'UPERTINO (408)777-3228• FAX(408)777-3333• buildin-gacupertino.ora
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESSAP
N % 0//
2-Y21-A eLr1�Cl
kerE AME yJC�� i-- S�% 2f Cf�C° PHONE /Ic' ZC'L �y E-MAIL
STREET ADDRESS CITY, STATE,ZIP T/ FAX
<' L,qIA1 e-, lu, e-:A f,5v/y
CONTACT NAME PHONE E-MAIL
SC1�12v
STREET ADDRESS CITY,STATE, ZIP FAX
ZOWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER v LICENSE TYPE BUS.LIC#
COMPANY j$LAME -, E-SIL FAX
�i'�
STREET ADDRESS CITY,STATE,ZIP PH N
C/f `f'SZ'L'a' v '3 71-�'�5�
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX ^ �/
STREET ADDRESS CITY,STATE,ZIP PHONE /lv
-"CRIPTION OF WORK
lea�in do f1j ��?Gc�.!cl ;!a ,
4.' <i 1r f 64- 1L e- . L,-• lgey-
EXISTING USE PROPOSED USE CONSTR TYPE I #STORIES
USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
k
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH
❑ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES
BEING ADDED? 'UNO ADDITION? J�rO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YEST7��
By; TOTAL VALUATION:
PLANNING APPL# VINO PLANNING APPROVAL LETTER EICHLER HOME? rLNO
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 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 to building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED PLAN CHEM TYPE ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER ❑ BUHAING PLAN REVIEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ ExPREss ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS
n 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
B1dgApp_2011.doc revised 06/21/11