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11010132CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10775 WILLOWBROOK WAY CONTRACTOR- A 2�I'D Rim61 PERMIT NO: 11010132 t"IlkE. .. -1 rry . I AU G .. . '-"NER'S NAME: HERNANDEZ MATHEW R AND LISA B G WNER'S PHONE: ❑ LICENSED CONTRACTOR'S DECLAMATION License Class C-3 6 Lic. # 4 3` 35-0 Contractor 1. Date i — 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. Yditionally, the applicant understands and will comply with all non -point sour regulations per C o Municipal Code, Section 9.18. 1 � 1 vionature Date ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: I, 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 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. 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 ion the above mentioned property for inspection purposes. (We) agree to save iemnify 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 DATE ISSUED: 01/25/2011 PHONE NO: JOB DESCRIPTION: RESIDENTIAL u COMMERCIAL INSTALL PROPERTY LINE CLEANOUT Ft Flodr Area: I Valuation: $925 APN Number: 36922036.00 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 J 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 Applicant: 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 Ar a Air Quality Management District I will maintain compliance with the Cupe mo Municipal Coapter 9.12 and the Health & Safety Code, Sections 25 5, 25533, an025334• / 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 Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: O ?Z S �, : li v ► �:• �A PERMIT # D OWNER'S NAME: „ N Fi �,• h, A d z PHONE # - n'2 _ v GENERAL CONTRACTOR: AVP0 )-.% 1 A✓! �ti• L . BUSINESS LICENSE # ADDRESS: & �p t-1.c�lr. e b S� z t. QS'1Z(� CITY/ZIPCODE: S a, jv�t J' 12 *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 SUB C TRACTORS HA BTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: L ► 2 F� 1 \ 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 7c Plumbing v vv , �' �,, �/ Z' • r? 3 3 #' D Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner- Contractor Signature Date CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinora)cuoertino.oro Dear Properly 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 IrrPec -c OWNER ADDRESS r 0/4rn� 2-84v 5io��ebrc E etfvnd DESCRIPTION OF WORK: 6 re�s�d y, r �luri� (v� ►71�Sfiw Fat_d►aom 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 verlfy this information.) -U4 � 1. 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. _,0 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. W 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. _JL5. I 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)f -Y, including labor and materials, I rpay be considered an "employer" under state and federal law. V ,Y_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. J7. 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. JC 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 owners) that result from any latent construction defects in the workmanship or materials. Owne7BuilderForni 2010.doc revised 04/14/10 t.�9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal venue 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.csib.ca.gov for more information about licensed contractors. IL10. 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. y') 11. 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. 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 maybe 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 signature. Property Owner's Signature: f A -k .tJ'-tk i- Date: --------------------------------------------------------------------------------------------------------------------------------------------- (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): ProjectLozation 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: OmwerBuilderFornt 2010.doc revised 04114110 CITY OF CUPERTINO 1 F1P. ' QTII M A TnR — RI TII ,DING DIVISION APPLIANCE / EQUIP TYPE ADDRESS: 10775 willowbrook way DATE: 01/25/2011 REVIEWED BY: bobs. UNITS APN: 3 7i�� BP#: 0 10 13J- *VALUATION: $925 *PERMIT TYPE: Plumbing Permit 1 PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Du lex p PENTAMATION 1RPSS PERMIT TYPE: USE: Suppe. hisp ret' PME Unit Fee: WORK install property line clean out $42.00 SCOPE ,Icouslicol Review1'CV. APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check 1 0.0 hrs $0.00 QTY UNITS BP FEES 'A Sewer, Building 1 PRSEWER C rr'r "'iec. hlf ll. 1 # $21 P('rinii Fce: Suppe. hisp ret' PME Unit Fee: $21.00 PME Permit Fee: $42.00 ,Icouslicol Review1'CV. Work Without Permit? 0 Yes E) No $0.00 TOTALS: Travel Documentation Fee: I TRAVDOC $21.00 Strong Motion Fee: IBSEISMICR _.,.— -. — I - , _- _-- _ ""d aro nn/v an o.0imatte. Contact the Dept for addn'l into. N07 E: l nese fees are bused urs thi ie 1-a-ui v s•s v FEE ITEMS (Fee Resolution 09-051 Eff. T`1;'10) ............ .......»... FEE Plumb. Plan Check 1 0.0 hrs $0.00 F'�`��' �'�«�� Ch"Vk 14cch.Plumb. Permit Fee: IPPERMIT 'A Oth'.!r Al" h. Ia,,.>- Other Plumb Insp. 0.0 hrs $42.00 C rr'r "'iec. hlf ll. PME Plan Check: FCC _.,.— -. — I - , _- _-- _ ""d aro nn/v an o.0imatte. Contact the Dept for addn'l into. N07 E: l nese fees are bused urs thi ie 1-a-ui v s•s v FEE ITEMS (Fee Resolution 09-051 Eff. T`1;'10) ............ .......»... FEE ..... �. - --- QTY/FEE ------- MISC ITEMS Platt Checl, Fce: 'A Supp/. PC Fee PME Plan Check: $0.00 P('rinii Fce: Suppe. hisp ret' PME Unit Fee: $21.00 PME Permit Fee: $42.00 ,Icouslicol Review1'CV. Work Without Permit? 0 Yes E) No $0.00 Plrtrztttft�r 1���e,. Travel Documentation Fee: I TRAVDOC $42.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item B1dpStds Commission Fee: IBCBSC $1.00 SUBTOTALS: $106.501 $0.00 TOTALFEE.-7 $106.50 Revised: 01/15/2011 6 ITEMS OF 6 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 36922036.00 DATE ISSUED.......: 01/25/2011 RECEIPT #.........: BS000012563 REFERENCE ID # ...: 11010132 SITE ADDRESS .....: 10775 WILLOWBROOK WAY SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ......: OPERATOR: SylviaM COPY # : 1 OWNER ............: HERNANDEZ MATHEW R AND LISA B ADDRESS ..........: 10775 WILLOWBROOK WY CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM ....: MATT PATRICK CONTRACTOR .......: TBD - TO BE DETERMINED LIC # 00096 COMPANY ..........: TBD - TO BE DETERMINED ADDRESS .......... CITY/STATE/ZIP ...: , TELEPHONE ........ FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---------- 1BCBSC ------------- VALUATION ---------- 925.00 ---------- 1.00 ---------- 0.00 ---------- 1.00 ---------- 0.00 1BSEISMICR VALUATION 925.00 0.50 0.00 0.50 0.00 1BUSLIC FLAT RATE 1.00 115.00 0.00 115.00 0.00 1PPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1PRSEWER UNITS 1.00 21.00 0.00 21.00 0.00 1TRAVDOC FLAT RATE 1.00 42.00 0.00 42.00 0.00 TOTAL PERMIT ---------- 221.50 ---------- 0.00 ---------- 221.50 ---------- 0.00 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT AMOUNT --------------- 221.50 --------------- 221.50 VOICE ID DESCRIPTION -------- ---------------------------- 106 SEWER & WATER 301 ROUGH PLUMBING 507 FINAL PLUMBING REFERENCE NUMBER -------------------- 11065 VOICE ID DESCRIPTION -------- ---------------------------- 202 UNDERFLOOR PLUMBING 400 SEWER/LATERAL RESIDENTIAL PROJECT COVER SHEET - Assessor's Parcel Number: -.3 q el _/ 3_7 Name of owner. Ir 1)') a, Pe r -f Project address. —'229H,6 tz4ct) i S-61 1 4f, Contact person. -Lrn A Phone. c Ir - t- 1 (4 L-1 Fax. Net square footage of lot. Existing Proposed Square footage: First floor: Second floor: Garage: TOTAL: Are there at least two 10 foot by 20 foot clear spaces inside the garage? Y dvacy protection planting required for the project? Build it Green Total Points I On what floor(s) is work being done? Brief description of work. 5 L�)i-rs t&)' W)a StIu' at.ci rz°o n-) Code editions: 2007 CBC (Y - N) 2007 CFC N) 2007 CMC (Y- N) 2007 CPC (Y - N)2007 NEC AP OF& Effective 1/1/08 LAW This set of pur), ,jniawfu,� I irld On Arne without 'j� the BuildingDe arment (,,t,/ 6t C,Upe"It , The stamping of thr,� )J j, ind ;pecifica. ,-,HALL NOT be need permit or to be ­ aPPrOvalofthe violij, )"YPr0VJSI4) Of any City ""Spyy 1 Plan Review Process Work Book Page -8- Revised 06-15-10 liI P C— o 2k V ADD 5- (C- s 5-E —to jtjljSTEe BBIR�oi",l 514c i-4 .3 1 C- 14t R T I TE 6 " C1110 E 0 CA-) A "rr 5 To TA L— C�03E'r . .... ..... LJ/J-3 Cli-i t -E T- L) i vri m C— cz— CITY OF CUPERTINO CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE PERMIT APPLICATION FORM ©t� APN # Date: Building Address: Fee Group 24. wa. Owner's Name: Phone #: p Contractor: Phone #: ✓v o ( - Aw ✓.1 Uti, �+^ G , Fax #: Contact: �� 1Mn it Poi (L )-e PhoneI #: 1 CPRP At .414 '00 AJ,c-aw, 1PGASCOM Fax/e-mail: Contractor License #: y 3 9 3 S o Cupertino Business License #: 1BCBSC Job Description: Residential Commercial ❑ Valuation: # Project Size: Counter [Express ❑ Standard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Green Building Points: Quantity - Fee ID Fee Description Fee Group Permit Type 1PCSEWER Commercial building sewer/sanitary sewer P 1CPSS 1 BPREPIPE Commercial re -pipe per fixture P 1 CPRP 1PGASCOM Commercial Gas Piping System 1-4 Outlets P 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICOM Seismic Commercial P Revised 12/06/10