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10120045 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10460 MADERA DR CONTRACTOR:RICHARD HAYES& PERMIT NO: 10120045 LESLIE SULLIVAN OWNER'S NAME: RICHARD HAYES&LESLIE SULLIVAN 10460 MADERA DR DATE ISSUED: 12/08/2010 ER'S PHONE: 4082458505 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F ELECT F PLUMB F License Class Lie.# MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE HEATING&AIR CONDITIONING(SAME (commencing with Section 7000)of Division 3 of the Business&Professions LOCATION)&REPLACE DUCTWORK 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 Sq.Ft Floor Area: Valuation:$12700 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:32635048.00 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 to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DA ROM LAST CALLED INSPECTION. 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. Issued by: C/1 Date: Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is erolby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for wing two reasons: inspection. 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, Signature of Applicant: Date: Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to A"Jaralonct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER yrm under penalty of perjury one of the following threeHAZARDOUS MATERIALS DISCLOSURE tions: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air 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 I 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 Compensation laws of California. If,after making this certificate of exemption,IO er author Y gent: become subject to the Worker's Compensation provisions of the Labor Code,I must Date: GG'' forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address -mify 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 granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations pu the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. � G/ Licensed Professional Signature Date ` tS CITY OF CUPERTINO 7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 32635048 .00 DATE ISSUED. . . . . . . : 12/08/2010 RECEIPT #. . . . . . . . . BS000012176 REFERENCE ID # . . • 10120045 SITE ADDRESS . . . . . : 10460 MADERA DR SUBDIVISION . . . . . . : CITY . . . . . . . . . * : CUPERTINO IMPACT AREA . . . . . . : OWNER RICHARD HAYES & LESLIE SULLIVA ADDRESS 10460 MADERA DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM RICHARD A HAYES CONTRACTOR LIC # *OWNER* COMPANY . . . . . . . . . . : RICHARD HAYES & LESLIE SULLIVA ADDRESS . . . . . . . . . . : 10460 MADERA DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ------ 1BCBSC VALUATION 12, 700 . 00 1 .00 0 . 00 1.00 0 . 00 1BREMAIRHA NO.UNITS 1. 00 63 . 00 0. 00 63 . 00 0 .00 1BREMVENSY NO UNITS 1. 00 95 .00 0 .00 95. 00 0 . 00 1BSEISMICR VALUATION 12, 700 . 00 1 .27 0. 00 1.27 0 .00 1MFR=<100 UNITS 1 . 00 126 . 00 0 .00 126 . 00 0 . 00 1MPERMITFE FLAT RATE 1. 00 42 .00 0. 00 42 . 00 0 .00 1TRAVDOC FLAT RATE 1. 00 42 . 00 0 .00 42 . 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 370 .27 0 .00 370.27 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 370 .27 VISA --------------- TOTAL RECEIPT 370 .27 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- --------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10460 Madera Dr. DATE: 12/08/2010 REVIEWED BY: gs APN: BP#: "VALUATION: 1$12,700 xPERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY PENTAMATION FURN/AC USE: SFD or Duplex i1 C � � � , � PERMIT TYPE: i WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES A/C Units (<=10K cfm) 1BREMAiR 1 # $63 Furnace, Forced-Air 1MFR=<100 1 # $126 Ventilation System 1 BREMVENS 1 # $95 T_ --- I TOTALS. $284.00 Mech.Plan Check0.0 hrs $0.00 - 1'i<r' Mech.Permit Fee: I MPERMIT Other Mech.Insp. 0.0 hrs NOTE. Theset or addn'l in-fees are based on the relimina in ormation available and are onlyan estimate. Contact the De o. FEE ITEMS (Fee Resolutiofi 09-051 Eff T'1:70) FEE QTY/FEE MISC ITEMS /'/ail Clf(c:k PME Plan Check: $0.00 Pc'f Init F cc>: SrfpIV, his!) l-'ce PME Unit Fee: $284.00 PME Permit Fee: $42.00 C`oasowcfion 1 f n 14OUS/Il:0lii'Ple'it Work Without Permit? 0 Yes E) No $0.00 �'jCd17t"f1F1jY l`E`c'S: Travel Documentation Fee: ITRAVDOC $42.00 A Strong Motion Fee: IBSEISMICR $1.27 Select an Administrative Item Bldp-Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $370.27 $0.00 TOTAL FEE: $370.27 Revised: 12/07/2010 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RTI N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: (Q (, O Il le l rr Cv lr ho PERMIT# t� OWNER'S NAME: ard( Z{ art H PHONE# el u �'- Z `1 S — GENERAL CONTRACTOR: C BUSINESS LICENSE# . ADDRESS:22 ks=-L -Or((/ht vt 3 CITY/ZIPCODE: *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: Signature Date Please check applicable subcontractors and complete the following information: 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 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__)cupertino.org CUPERTINO 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 DDRES 1 r APN BP# v �j v � 1 a Gt>'vbc - U t v lvw OWNER ADDRESS C P ` c / t S�((�✓G� Stivne__ 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.) �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. 3. I 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. &14. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license nu mbers on permits and contracts. �5. Iunderstand if I employ or otherwise engage any persons, other than California licensed Contractors, and the l 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. L". 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. tnom. I 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. understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for Onyl'!financial 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 04114110 CITY OF CUPERTINO ��` �� 4 FURNACE/AC CUPE(�TINO PERMIT APPLICATION FORM APN # � � � Date:DeG Building Address:10 '160 0 '160 / O ner's Name: G t Ir�/rPl hrione#:XC-buVC4 S� �( L( 000 �f S- -S -S Contractor:/1 C-C"111c"'J /� Phone#: Yb Lt 3 2-9-213 -11 Fax#: Contractor License#: Cupertino Business License#: -3 5-� 1/6 Contact: Phone#: � 32 --- g Z 9 Z S 6 o-ffL Fax #: L/ 09 Building Permit Info: Elect 19 Plumb Mech 125 Residential X Commercial ❑ Job Description: ffe4l' / w� c� � �lr1O� tY Co i v"� t� Gk re Ictee- Ood lu,-,"' k For Residential Installations: Attic ❑ 1St floor 2nd floor ❑ Adhere to minimum setback requirement For Commercial Installations: Replacement same weight ❑ Additional weight (structural calcs) ❑ Structural Calculations required for new installation ❑ New installation Planning Approval Required ❑ Cost of Project: Type of Construction (Usage Class): Strapped ❑ On Platform Bonded ❑ New Location ❑ Replacement Project Size: Express ❑ Standard�j Large ❑ Major ❑ Valuation: /Z Z VC- Green Build' g: Please complete relevant portion of the Green Building Checklist& attach it to the application or if applicable, include in plan set & the sheet index. Revised 01/07/09