10110104 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1348 S STELLING RD CONTRACTOR:DAVIS JANICE A PERMIT NO: 10110104
OWNER'S NAME: DAVIS JANICE A 1348 S STELLING RD DATE ISSUED: 11/16/2010
VNER'S PHONE: 4084464410 CUPERTINO CA, 95014-5204 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class Lic.# REPLACE EXISTING WATER HEATER AT SAME
LOCATION IN
Contractor Date GARAGE,BONDED,CUSTOMER AGREES TO PROVIDE
I hereby affirm that I am licensed under the provisions of Chapter 9 FIELD
(commencing with Section 7000)of Division 3 of the Business&Professions INSPECTOR WITH CFIR ALT.
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. Sq.Ft Floor Area: Valuation:$500
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 APN Number:36611100.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
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 Issued b}ca Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date 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.
`I OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 contcactors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,, ctions 25505,25533,and 25534
Section 3700 of the Labor Code,for the performance of the work for which this /
permit is issued. Owner or authorized age Date:
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 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revo ed. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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 ARCHITECT'S DECLARATION
'-demnify and keep harmless the City of Cupertino against liabilities,judgments,
's,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
a.dnting of this permit.Additionally,the applicant understands and will comply
with all n point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature, Date
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
GUPERTINO (408)777-3228-FAX(408)777-3333• buildingecuoertino.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
ERSNAME� OWN R DDRES�'
D SCRIPTION OF WORK: v-C /Q
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.)
t'
,�_1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
GBuilder" 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.
�
F2.2. 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.
`�7 3. 1 understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may
rotect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
� 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
tu—m—bers4z�-_5.
on permits and contracts.
I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
tal 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.
. 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.
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.
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 owner(s)that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderForm 1010.doc revised 04/14/10
i
44�- I understand I may obtain more information regarding my obligations a�an"employer"from the Internal
Revenue
Service the United States Small Business Administration,the California Department of Benefit y State
and the California Division of Industrial Accidents. I also understand I may contact the CaliforniaContractors'
r www.cslb.ca.gov for more information about licensed
License Board(CSLB)at 1-800-321-CSLB (2752)o
contractors.
0. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
/am the a legally and financially responsible for proposed construction activity at the site address listed above.
party
2y1. I agree that,as the party legally and financially responsible for this proposed construction activity, I will abide
a-1-11applicable laws and requirements that govern Owner-Builders as well as employers.
IP2. 1 agree to notify the issuer of this form immediately of any additions, deletions,or changes to any of the
m� formation I have provided on this form. Licensed contractors are regulat Stat by IL cense Board aws designed tmay be unable to protect the olic. If
you contract with someone who does not have a license,the Contractors
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:
owner and
Before a building perrriit can be issued,this form must be completed copyd signed by the the property owner's driver's licen e,
returned to the agency responsible for issuing the permit. Note. py
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to verify the p )perty owner's si ture. Date:
Property Owner's Signature:
--------------------------------------------------------------------------------------------------------------------------
(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
I hereby
Excluding the Notice to Property Owner,the execution of which frs gn,and understand is
he documents pneceslsary to obtain an
authorize the following person(s)to act as my agents)to app y yo ,
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent:
`fel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and er's license, form notarization, ored out ohe
ther
above information and certify its accuracy. Note:A copy of the property owner's dnv owner's
verification acceptable to the city may be required to be presented when the permit is issued to verify the property
signature.
Date:
Property Owner's Signature:
OwnerBuilderForm_2010.doc revised 04/14/10
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: DATE: 11/16/2010 REVIEWED BY:
APN: J (Q 1 1()Q BP#: 10+ *VALUATION: $500
•PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition / Repair
PRIMARY hCt I l f, PENTAMATION
USE: SFD or Duplex � )t>h �hr:;� PERMIT TYPE: PRWHEATR
WORK re lace existing water heater at garage location
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1PRWHEATR 1 # $25
TOTALS: $25.00
bf< r Pian t'i,oc Plumb.Plan Check 0.0 hrs $0.00
Plumb.Permit Fee: IPPERMIT fr Patrr.r t <
F-1
Other Plumb Insp. 0.0 hrs $42.00 �rir��r 1 =t_I,s .
taco
NOTE: Thesefees are based on the preliminaty in ormation available and are only an estimate. Contact the De t or addn 7 info.
FEE ITEMS (Fee Resolution 09-051 Elf. T'1/1 0) FEE QTY/FEE MISC ITEMS
PhIII Chec:f F cc<
Seipp/. PC"Fcc,
PME Plan Check: $0.00
Perini! Fcc:
Srrppi, 111'sp 1-'1 c
PME Unit Fee: $25.00
PME Permit Fee: $42.00
( on,�Irlwfion I,Klk, F-1
Work Without Permit? Yes E) No $0.00
Platinbig Fck'S
Travel Documentation Fee: ITRA VDOC $42.00
Strong;Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldgs Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $110.50 $0.00 TOTAL FEE: $110.50
Revised: 11/08/2010
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM
COPY ## 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 36611100 . 00
DATE ISSUED. . . . . . . : 11/16/2010
RECEIPT #. . . . . . . . - : BS000012020
REFERENCE ID # . . . : 10110104
SITE ADDRESS . . . . . : 1348 S STELLING RD
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER DAVIS JANICE A
ADDRESS . . . . . . . . . . : 1348 S STELLING RD
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5204
RECEIVED FROM . . . . : JANICE DAVIS
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY DAVIS JANICE A
ADDRESS . . . . . . . . . . : 1348 S STELLING RD
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5204
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 500 . 00 1. 00 0 . 00 1. 00 0 . 00
1BSEISMICR VALUATION 500 . 00 0 . 50 0 . 00 0 .50 0. 00
1PPERMITFE FLAT RATE 1 .00 42 . 00 0 .00 42 . 00 0. 00
1PRWHEATR UNITS 1.00 25 . 00 0 .00 25 . 00 0 . 00
1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 110 . 50 0 . 00 110 . 50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 110.50 209752
---------------
TOTAL RECEIPT 110 . 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
M.Indoor Air Quality_abd Finishes
' MIN � -- 1 IAQ/Health pts yges p
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts pye p
3 IAQ/Health pts Y=Ye 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts Ayes 0
5.Use Engineered Sheet Goods with no added Uraa
Formaldehyde B L4Q/Health Pts y=yes p
G.Use Exterior Grade Plywoodfor•Interior Uses 1 IAQMealth pts pyes p
_ 4IAQ/Health pts pyes 0
3.Use FSC Certified Materials for Interior Finish 4 Resource pts Ayes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts Ayes p
10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes p
1 i 1
N.Flooring
1.Select FSC Certified Wood Flooring _ _ B Resource pts Ayes 0
> q-10—101 MOO 4 Resource Pis Yes
D
3.Use Recycled Content Ceramic Ties 4 Resource pts Ayes p
4.Install Natural Linoleum in Place of Vinyl -5 IAQ/Health pts pyes p
5.Use Exposed Concrete as Finished Floor 4 Resource pts Ayes 0
5.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
Total Points Available: -140 . 1301 57
Total Points Project Received:
o o a
G datalpmWgreenbuilcgngodeDneSITBMDdelers1gn:enpointsfinaIZ12D4proteatedAs
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: PERMIT#
OWNER'S NAME: PHONE#
GENERAL CONTR TOR: BUSINESS LICENSE#
ADDRESS: CITY/ZIPCODE: 9,5-VI
*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 CUPPERTINO
BUSINESS LICENSE. %% .—�11��
I am not using any subcontractors: /�
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 ate
CITY OF CUPERTINO
WATER HEATER
CUPS TINO PERMIT APPLICATION FORM
APN# k01 Date:
31Pb- 1 HDD
�'
Building Address:
l34 S . Sfie �Cr ?d, � 9�� y�
Owner's Name: Phone #:
Cow Tactor: , Phone#:
Fax
Cupertino Business License#: Contractor State License#:
Contact: Phone#: ��
Fax#:
Building Permit Info:
Bldg Elect Plumb Mech
Residential [ Commercial ❑
Job Description:
Strapped On Platform nded Ne<v Location Replacement
Valuation(cost of project): __--
Project Size: Express S -Large MajorEl
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 achieved: '
Revised 03/10/10