11070056CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 22420 WALNUT CIR I DORIS CAT TOR: BECCIA ANTHONY RAND I PERMIT NO: 11070056 I
OWNER'S NAME: BECCIA ANTHONY R AND DORIS C T ( 10980 MARIA ROSA WAY
D
DATE ISSUED: 07/11/2011
,R'S PHONE: 4082530428 I CUPERTINO, CA 95014-4720 I PHONE NO: I
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic.#
Contractor
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.
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.
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
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,
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
9.18.
Signature.
Date
EJ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for�of
the following two reasons: ((��
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
construct the project (Sec.7044, Business & Professions Code).
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 Worer'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.
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
Compensation laws of California. If, after making this certificate of exemption, I
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.
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
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
i- nify and keep harmless the City of Cupertino against liabilities, judgments,
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
9.18.
Signature Date
BUILDING PERMIT INFO: BLDG r ELECT r— PLUMB f—
MECH r- RESIDENTIAL F COMMERCIAL
JOB DESCRIPTION: DUPLEX(A & B) A IS WHERE WORK BEING DONE -
INSTALL
5 DEDICATED CIRCUITS IN KITCHEN & 6 OUTLETS,(INC
GFI'S)LIGHT FIXTURES & ELECTRICAL OUTLETS ONLY;
Sq. Ft Floor Area: I Valuation: $600
APN Number: 35703043.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by----
Date-7?
o� l %
RE -ROOFS:
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
inspection.
Signature of Appl
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner 9 iuthori�e ent:
Date: /� �l
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
7 ITEMS OF 7
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 35703043.00
DATE ISSUED.......: 07/11/2011
RECEIPT #.........: BS000014006
REFERENCE ID # ...: 11070056
SITE ADDRESS .....: 22420 WALNUT CIR
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......:
OPERATOR: patg
COPY # : 1
OWNER ............: BECCIA ANTHONY R AND DORIS C T
ADDRESS ..........: 10980 MARIA ROSA WAY
CITY/STATE/ZIP ...: CUPERTINO, CA 95014-4720
RECEIVED FROM ....: DORIS BECCIA
CONTRACTOR .......: LIC # *OWNER*
COMPANY ..........: BECCIA ANTHONY R AND DORIS C T
ADDRESS 10980 MARIA ROSA WAY
CITY/STATE/ZIP ...: CUPERTINO, CA 95014-4720
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
600.00
1.00
0.00
1.00
0.00
1BREMFIXT
NO. FIXTURES
1.00
65.00
0.00
65.00
0.00
1BREMRECEP
NO. OUTLETS
1.00
44.00
0.00
44.00
0.00
1BSEISMICR
VALUATION
600.00
0.50
0.00
0.50
0.00
1EPERMITFE
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
----------
239.50
----------
0.00
----------
239.50
0.00
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT :
AMOUNT
---------------
239.50
---------------
239.50
VOICE ID DESCRIPTION
-------- ----------------------------
304 ROUGH ELECTRICAL
REFERENCE NUMBER
--------------------
VISA
VOICE ID DESCRIPTION
-------- ----------------------------
501 FINAL ELECTRICAL ENERGY
505 FINAL ELECTRICAL 512 FINAL HANDI-CAP
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 • building a(�cuoertino.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#
OWNER NAME
OWNER ADDRESS
DESCRIPTION OF WORK: �V s 7'r¢ t -L- �� / C / �i'i 'T� eltf(T [.,) /7'i IeV
Cl--rL. &_7S / G" ff'i 5
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.)
1Y' 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.
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.
�6 3.1 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.
jM_4. 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
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. I 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.
�1_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.
_k -,t_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.
OwnerBuilderFOrn1 2010.doc revised 04/14/10
V-9. 1 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
contractors.
"&10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that
—the party legally and financially responsible for proposed construction activity at the site address listed above.
y11. 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
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 the city may be required to be presented when the permit is issued
to verify the property owner's si nat e.
Property Owner's Signature: Date: Z // / r
---------------------------------------------------------------------------------------------------------------------------------------------
(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:
Address of Authorized Agent:
Tel No
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:
GxvnerBuilderFornt 2010.doc revised 04114/10
CITY OF CUPERTINO
WN FEE ESTIMATOR - BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 22420A walnut circle
QTY/FEE
DATE: 07/11/2011
REVIEWED BY: bobs.
BP FEES
APN:
BP#:
1BREMFIXT
"VALUATION: $600
*PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
Recep/Switch/Outlets
PENTAMATION 1 REAP11
PERMIT TYPE:
WORK
upgrade kitchen electrical and lighting only
SCOPE
$44
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Fixtures, Lighting
1BREMFIXT
2
#
$65
Recep/Switch/Outlets
1 BREMRECEP
6
#
$44
PME Unit Fee:
$109.00
PME Permit Fee:
$44.00
Work Without Permit? C Yes No
$0.00
TOTALS:
A
Travel Documentation Fee: ITRA VDOC
1 $109.00
Strom Motion Fee: IBSEISAI[CR
NOTE- These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dedt for addh 7 info.
FEE ITEMS (Fee Resolution .1.1-053
FEE
QTY/FEE
MISC ITEMS
PME Plan Check:
$0.00
PME Unit Fee:
$109.00
PME Permit Fee:
$44.00
Work Without Permit? C Yes No
$0.00
A
Travel Documentation Fee: ITRA VDOC
$44.00
Strom Motion Fee: IBSEISAI[CR
$0.50
0.5 hrs Admin./Clerical Fee
$41.00 1ADMIN
Bldg Stds Commission Fee: 1BCBSC
$1.00
SUBTOTALS:
$198.50
$41.00 TOTAL FEE:
$239.50
Revised: 07/04/2011
CUPER"TINO
PROJECT DATA - RESIDENTIAL
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildinq(Qcupertino.org
Existiniz Proposed
Floor Area: First Floor: s.f, s.f.
Second Floor: s.f
Garage s.f s.f
TOTAL: s.f. s.E
Are there at least two 10 feet by 20 feet clear spaces inside the garage? Y N
Is privacy protection planting required for the project? Y N
Governing Codes: 2010 California Building Code (based on the 2009 International Building Code)
2010 California Residential Code (based on the 2009 International Residential Code)
2010 California Plumbing Code (based on the 2009 Un' umbing Code)
2010 California MechatWIRId W orm Mechanical Code)
2010 California Electrical C49RIZ 911X Itgie 2 nternational Electrical Code)
2010 California Energy Code APPROVED
2010 California GreeRing
''n Sta d
Cupertino Munic{OR ani s if fl4�6ns MUST be kept at t �e
I construction. it is unlawful to make any
changes or alterations oding Official. deviate
therefrom, without approval from the Bu
The ;t^mcing of this plan and specifications SHALL WT
1^
f. ;"��Itra to !; :rmit or to be 'in approval of the violatic ', i
any provisions of arnj Ci -Ly
Ordinance or c�tet
�— ProjectData-ResidentiaLdoc revised 03/09/11
- 2 ....
- ° (E ..� —
;74-
zL.
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 misr
CUPERTINO q
❑PLUMBING ❑MECHANICAL ELECTRICAL ❑MISCELLANEOUS
(408) 777-3228 •FAX (408) 777-3333 • building(a�cupertino.or
PROJECT ADDRESS /J �J�j /J
APN# ` 1 �
`/
OWNER NAME -�
PHONE
E-MAIL
STREET ADDRESS ,
�, Ur,C�T.Yv l' `1 '
CITY, STATE, ZIP
FAX
CONTACT NAME IJ� A�
ff
PHO G Ju ,?�7- ire
E-MAIL
STREET ADDRES
C TATE, ZIP , /
FAX
OWNER OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
z4a
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
USE OF SFD or DUPLEX ❑ MULTI -FAMILY
BUILDING: ❑ COMMERCIAL
PROJECT IN WILDLAND ❑ YES
URBAN INTERFACE AREA NO
PROJECT IN ❑ YES
FLOOD ZONE NO
IS THE BLDG AN ❑ YES
EICHLER HOME? �N0
DESCRIPTION OF WORK
TOTAL VALUATION: 00 --
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 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 ilding construc n` I authorize representatives of Cupertino to enter the above -i entified property for inspection puiposes.
Signature of Applicant/Agent: 4 �-� Date:
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE USE ONLY
ER -THE -COUNTER
Y
❑ EXPRESS
U
U
❑ STANDARD
❑ LARCE
❑ AtAJOR
MEPMiscApp_2011.doc revised 06/21/11