11020095 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10052 BYRNE AVE CONTRACTOR:REALSMART FUND PERMIT NO: 11020095
OWNER'S NAME: REALSMART FUND 10052 BYRNE AVE DATE ISSUED:02/24/2011
OWNER'S PHONE: 6503632808 CUPERTINO,CA 95014 PHONE NO:
L LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH r— RESIDENTIAL COMMERCIAL F
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:DEMO&DRYROT&TERMITE REPAIRS,WINDOW TRIM
(commencing with Section 7000)of Division 3 of the Business&Professions EXTERIOR SIDING;APPROX 100SQ
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:$1000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION APN Number:35716089.00 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 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 QA DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DA OM 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 r
9.18. Issued by: Date:
Signature Date
OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby 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
the following 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)
I,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 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. I 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
permit is issued. 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
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,I Owner or authori ed agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must ? Date:
forthwith comply with such provisions or this permit shall be deemed revoked. n c,
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
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
cr and expenses which may accrue against said City in consequence of the
z ig of this permit.Additio ally,the applicant understands and will comply ARCHITECT'S DECLARATION
wiu,all non-point sour egu tions per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Signature
Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10052 Byrne DATE: 02/24/2011 REVIEWED BY:
APN: BP#: *VALUATION: j$1,000
xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition
PRIMARY PENTAMATION
USE: SFD or Duplex PERMIT TYPE: t
WORK Remove and replace drotted window trim and replace 100 sq. ft. of siding.
SCOPE
T-T
F
d��il_
LL]
NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS (Fee Resolution 09-051 Elf. 7/1/101 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Select a Misc Bldg/Structure
Suppl. PC Fee: (F) Reg. 0 OT 0.0 hrs $0.00 or Element of a Building
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee Reg. 0 OT 1 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Conwlwciion Tax F]
Acoustical Fee: 0 Yes (F) No $0.00 0
Work Without Permit? 0 Yes E) No $0.00 E)
Planning L;ee: $0.00 Select a Non-Residential
t i tr;c'1 i)cxrrrit�rlrrl%cert 1es: Building or Structure
Strong Motion Fee: IBSEISMICR $0.50 2.0 hrs Inspections
Bldg Stds Commission Fee: IBCBSC $1.00 $252.00 IINSPMIS Standard Inspections
SUBTOTALS: 1 $1.50 $252.00 TOTAL FEE: 1 $253.50
Revised: 01/15/2011
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 35716089. 00
DATE ISSUED. . . . . . . : 02/24/2011
RECEIPT # . . . . . . . . . : BS000012767
REFERENCE ID # . . . : 11020095
SITE ADDRESS . . . . . : 10052 BYRNE AVE
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER REALSMART FUND
ADDRESS 10052 BYRNE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : BRYAN JACOBS
CONTRACTOR LIC # *OWNER*
COMPANY REALSMART FUND
ADDRESS 10052 BYRNE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------ ------ ---------- ---------- ---------- ---------- -
1BCBSC VALUATION 1, 000 .00 1. 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 1, 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1INSPMIS HOURS 2 .00 252 . 00 0 . 00 252 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 253 . 50 0 . 00 253 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 253 . 50 VISA
---------------
TOTAL RECEIPT 253 . 50
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• buildino5cuoertino.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 v� /� APN BP#
OWNER NAME OWNER ADDRESS �C,)
DESCRIPTION OF WORK:
C
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.
t2. I understand building permits are not required to be signed by property owners unless they are responsible for
4the onstruction and are not hiring a licensed Contractor to assume this responsibility.
�. I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
pro
ect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
-L4-.I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
45. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
tot 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.
1,6. 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.
L7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family
dential 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
a financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
O vneYBuildeYForin 2010.doc revised 04/14/10
4nu
I understand I may obtain more information regarding my obligations as an "employer"from the Internal
e 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.
nX10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am t 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
b all applicable laws and requirements that govern Owner-Builders as well as employers.
A12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
nfrmation 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.)
I. 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: 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):
Project Location or Address: is
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 b* equired to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date: -Z
Owne7BuilderFornl 2010.doc revised 04/14/10
CITY OF a
CITY OF CUPERTINO
III GENERAL BUILDING
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
Mailing Address (if different from building address):
�; fl- c �� Cox� L-( ( ,,---) , ,C� C
Are Hazardous Materials being used as part of this project? Yes No'2� 1
HOA: (Exterior work only) Yes ❑ No V� If yes, provide letter from HOA
If Residential,is house an Eichler? Yes ❑ No If yes, needs planning approval.
Owner's Name: Phone #:
/ ' /
/; G. ..1 moi. k
Contractor: p Phone:
L�u 1) Fax:
Contractor License#:
Cupertino Business License #:
Contact: Phone:
It Fax/e-mail:
Residential Commercial
Job Description:
L�1 J
e4
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Typ of Construction(Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B ❑
Valuation: Square Footage:
Project Size: Counter Express ❑ Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green at www.builditareen.org
Revised 12/06/10