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11030057 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18771 TILSON AVE CONTRACTOR:LOISA KILPATRICH PERMIT NO: 11030057 OWNER'S NAME: LOISA KILPATRICH 18771 TILSON AVE DATE ISSUED:03/11/2011 Oyu=PER'S PHONE: 5412803532 CUPERTINO,CA 95014 PHONE NO: G LICENSED CONTRACTOR'S DECLARATION [_ F r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH F RESIDENTIAL r— COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMODEL:KITCHEN 120 SF,REPLACE CABINETS, (commencing with Section 7000)of Division 3 of the Business&Professions COUNTERTOPS,AND SINK, HALL BATH,40 SF,REPLACE Code and that my license is in full force and effect. WALL TILES&SINK. MASTER BATH,35SF,REPLACE 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 Sq.Ft Floor Area: Valuation:$22000 permit is issued. APPLICANT CERTIFICATION APN Number:37517033.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. / Issued by Date: Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: 1,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: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. CaliforniaHealth&Saf 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 Cu ertino 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 25132(a)should I store or handle hazardous material. Additionally,should I u e equipment or devices which emit hazardous air permit is issued. conte nants as deli by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with'-e ththe Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&S fety Cod , ections 25505,25533,and 25534. 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 Owner or an horized ent: / forthwith comply with such provisions or this permit shall be deemed revoked. Date: rONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereb authorize representatives of this city to enter Lender's Name upon the above mentioned pr( for inspection purposes.(We)agree to save indemnify keep harmless the ity of Cupertino against liabilities,judgments, Lender's Address r' and ex enses which may,a rue against said City in consequence of the Ig of s emit.Additi n ly,the applicant understands and will comply ARCHITECT'S DECLARATION witn all non- oint ource reg at ns per the Cupertino Municipal Code,Section 9.18. / I understand my plans shall be used as public records. Signature Date ��C— Licensed Professional V CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 37517033 . 00 DATE ISSUED. . . . . . . : 03/11/2011 RECEIPT #. . . . . . . . . BS000012882 REFERENCE ID # 11030057 SITE ADDRESS . . . . . : 18771 TILSON AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : LOISA KILPATRICH ADDRESS . 18771 TILSON AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : BRANDON SCHAEFFER CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : LOISA KILPATRICH ADDRESS . . . . . . . . . . : 18771 TILSON AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 0 . 00 1. 00 0 . 00 1 . 00 0. 00 1BSEISMICR VALUATION 0 . 00 0 . 50 0 . 00 0 . 50 0. 00 1REMRESBAT SQ FEET 75 . 00 570 . 00 0 . 00 570 . 00 0. 00 1REMRESKIT SQ FEET 120 . 00 570 . 00 0 . 00 570 . 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 1141 .50 0 .00 1141 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 1, 141. 50 MC --------------- TOTAL RECEIPT 1, 141. 50 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 18771 Tilson Ave. DATE: 03/11/2011 REVIEWED BY: jsg APN: 375-17-033 BP#: '"VALUATION: 1$22,000 -� Y PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY SFD or Duplex PENTAMATION 1 R3SFDREM USE: I PERMIT TYPE: WORK Kitchen: Replace cabinets countertop, sink. Hall bath replace wall tiles and sink. Master bath replace SCOPE wall tiles and sink Li L NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn 7 info, FEE ITEMS (1'ee Resolution 09-05I Etf. 7/1,10 FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = s.f Remodel,Kitchen(<=300 sf) Suppl.PC Fee: 0 Reg. 0 OT 0.0 1 hrs $0.00 $570.00 1REMRESKIT PME Plan Check: $0.00 = s.f. Remodel,Bath(<=300 sf) Permit Fee: $0.00 $570.00 1REMRESBAT Suppl.Insp. Fee-E) Reg. 0 OT 0.0 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 E) Planning Fee: $0.00 Select a Non-Residential Building or Structure 0 i Strom Motion Fee: 1BSEISMICR $2.20 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC 1 $1.00 SUBTOTALS: $3.201$1,140.00F TOTAL FEE: I $1,143 Revised: 01 /2011 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333•building(cDcupertino.org ❑ NEW CONSTRUCTION ❑ADDITION/ALTERATION ❑ REVISION/DEFERRED SUBMITTAL PROJECT ADDRESS ,x` 7APN# C7 — n� 3`5 ( f MAIL l C125± STRE RESSus jL/1� , 11�U CA c1`5 Q( FAx *0 STREET AlnESSIfY,STATE IP FAx CIA: c�S' '�j� ❑OWNER ❑ OWNER-BUILDER 9OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CON r ��6 LICENSE NUMBEN674R 6L I�NSEyTY� BUS.LIC# C M t+tq4Y A l `C7� EG.�n v�� F C{ _ _ �I J S ADD SS Cr ATE,ZIP P O – a�c^ p TO �k3ca ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAx STREET ADDRESS CITY,STATE,ZIP PHONE DES" ON Q RIKR t•. N .._ ' . tks EXIST G USE2 PROPOSED USE CONSTR.TYPE #STORIES OFFICE USE ONLY" r lTYPE SO.F r. VALUATION EXISTG NEW FLOOR DEMO TOTAL p AREA AREA AREA NETAREA BATHROOM04 KITCHEN OTTII�p�'" REMODEL AREA REMODEL AREA ZU REMODEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: ❑ DETACH s ...,. - . ❑ ATTACH q DWELLING UNITS: IS A SECOND UNIT ❑YES SEC D STORY ❑YES BEING ADDED? ❑NO AD TION? ❑NO r ';. PRE-APPLICATION ❑ YES IF YES,PROVIDE . CO OF PLANNE S NAME: RECEP✓ED B [TOTAL V, UATION: PLANNING APPLN ❑ NO PLANNING APPROV LLE ER By my signature below,I certify to each of he fo]owing: I athe property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have prov ded i correct. I e read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buildi g con ruction. a thorize representatives of Cupertino to enter the above-identified property fo inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION D xo � _New SFD or Multifamily dwellings: Apply for demo Ition permit forHECIf'[YPE ,.. 1�u�zrlGSLtr existing building(s). Demolition permit is required prior to issuance of building k permit for new building. ovEx-z> COUNrEIz st�Il,DdvGPtWxE_M. _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure Q ExrRr ss LeSPTnritlkrSGPLNrE ^,_ form if any Hazardous Materials are being used as part of this project. C1e_sTNnAxD Q;PusilGwo>z ;. _Copy of Planning Approval Letter or Meeting with Planning prior to Q',LAiICE ❑ F'IR'E DEPT submittal of Building Permit application. ❑ 'MAJOR Q``ENV MONMENTAL HEALTH ,A—J _ BldgApp_201 1.doc revised 03/03/11 CTl qN �� c�GC- March 9, 2011 Community Development Department Building Division 10300 Torre Avenue Cupertino, CA 95014 Dear Sirs — We authorize Brandon Schaeffer to act on our behalf in regards to obtaining permits with the City of Cupertino, for the improvement of deferred maintenance at 18771Tilson Avenue in the City of Cupertino. Sincerely, Don Giallanza Lois Kilpatrick PROJECT DATA - RESIDENTIAL COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228 • FAX(408)777-3333•buildinp(acupertino.org PROJECT` RES ( APN# �7_ 9�� ER NAME, t PHONE E-MAIL STREET DRESSCTfY STA Z F VZ I APPLICANT N ME PHONE, E-MAIL f'�rn cl�ce '� rd. 44)6- '/'?-7 '? STREET ADDRESS 2 CITY, TATE, IP /;,5 / FAX G� o� `z ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT A ION OF"VW ilk EXISTING USE(S): � PROPOSED USE(S): S �� OCCUPANCY(S): p, TYPE OF C PARCEL �=r7 I CONSTRUCTION: AREA: FIRE Y N 71 AREA: Y N FLOOD AREA: Y N SIESMIC AREA: Y N SPRINKLERS: Existini; Proposed - Floor Area: First Floor: s.f. s.f -- Second Floor: s.f. s.f. r= Garage S.f. TOTAL: s.f. s.f. t Are there at least two 10 feet by 20 feet clear spaces inside the garage? Is privacy protection planting required for the project? Yom` 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 Uniform Plumbing Code) 2010 California Mechanical Code(based on the 2009 Uniform Mechanical Code) 2010 California Electrical Code(based on the 2009 International Electrical Code) 2010 California Energy Code 2010 California Green Building Standards Code Cupertino Municipal Code ProjectData-Residential.doc revised 0310 h r•� A 1 1 r • • 6r Pf RTINO hi. Pi of nl,� `'—if1 i. ns and sr- MU r.^ CS T to ker+ .^the fob at a,.limes A is ,nlawfim any ctiange3 y eratic ns per—mission from "-�e Ruiltlrnq f? tno+ A City of Cupertint>. ^� Tt,, ata . of this l _.-r anc�<;faectf►caMns oruvisrons � ti FL t �+. .j'.':�t dw 'Si. ry? F �� .'R. "�.t•.,��{I.'' r' i5:•ki�'�. _ -'SH" �: ' j r pp - f f wiw �p � � �C `��CK 71 lO �, �--�--�, n � r D F,, OWNER-BUILDER DISCLOSURE FORM is COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228- FAX(408)777-3333- building(dcupertino.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 ADBRES APN375 'l •_ p � BP# WNE N 4E--,, OWNE ADDRESS may, C� �, 1 22 1 `-- " 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.) l1. 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. t� understand building permits are not required to be signed by property owners unless they are responsible for nstruction 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 ' 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. -6�24. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license riufnbers 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. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and erderal 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. V7. 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 y financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. OwneYBuilderForrn 2010.doc revised 04114/10 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: ' 1��, � PERMIT# l� S-? OWNER'S NAME: 1 t CkZ PHONE # Z- GENERAL CONTRACTOR: C"aV-r, '725LXL _ BUSINESS LICENSE# ADDRESS: k p CITY/ZIPCOD *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: �:� ' t ' 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 Owner/Contractor Signature Date