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10100171 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10201 AMELIA CT CONTRACTOR:MICHAL DANEK PERMIT NO: 10100171 OWNER'S NAME: MICHAL DANEK 10201 AMELIA CT DATE ISSUED: 10/25/2010 NER'S PHONE: 4083132642 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATIONF BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH F RESIDENTIAL F COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE FURNACE SAME LOCATION (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. Sq.Ft Floor Area: Valuation:$1200 1 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. APN Number:32617019.00 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. 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 Issued b Date: 9.18. Signature Date RE-ROOFS: OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law^for one of inspection. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the followingt�lree HAZARDOUS MATERIALS DISCLOSURE declarations: � I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this 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 Health&Safety Code,Sections 25505,25533,and 25534. 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 Owner or au ed agent: 1012-f`r�J Compensation laws of Califomia. If,after making this certificate of exemption,I Date: 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. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save T::iy 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 as ming of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature "�� Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIP RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Bl ,,: Lot : APN . . . . . . . . : 32517019 . 00 DATE ISSUED. . . . . . . : 10 /25/2010 RECEIPT #. . . . . . . . . : BS )00011827 REFERENCE ID # . . . : 1OL00171 SITE ADDRESS . . . . . : 10.201 AMELIA CT SUBDIVISION . . . . . . CITY CU:?E RT I NO IMPACT AREA . . . . . . OWNER MICHAL DANEK ADDRESS 10:201 AMELIA CT CITY/STATE/ZIP . . . : CU:?ERTINO, CA 95014 RECEIVED FROM . . . . : MICHAEL DANEK CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY MICHAL DANEK ADDRESS 10:?01 AMELIA CT CITY/STATE/ZIP . . . : CU]?ERTINO, CA 95014 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ----------- ---------- ---------- ---------- 1BCBSC VALUATION 1, 200. 00 1 . 00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 1, 200 . 00 0 . 50 0 . 00 0 . 50 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 211 .50 0 .00 211. 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 211 .50 VISA --------------- TOTAL RECEIPT 211 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL M.Indow AirQuality a�nFinishesh .. - . 1 IAQ/Health pts Ayes p 2.Use Low VOC,Water-Based'Wood Finishes 2 IAQ/Health pts pye D S.A- - . _ I V_. . 3IAQ/Health pts y=yes D 4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes D 5.Use Engineered Sheet Goods with no added Urea Formaldehyde B 1AQ/Health pts y=yes D B.Use ExteriDr Grade Plywood lx Inferior Uses 1 IAQ/Health pts y--yes p 4IAQ/Health pts y=yes 0 8.Use FSC Certified Materials for Interior Finish 4 Resource pts Ayes D 9.Use Fnger-Jointed or Recycled-Content Trim 1 Resource pts Ayes D 10.install Whole House Vacuum System 31AQ/Health pts y=yes D N.Flooring _ 1.Select FSC Certified Wood Flooring - e Resource pts y=yes D • 4 Resource pts y=yes D 3.Use Recycled Content Ceramic Tiles 4 Resource pts Ayes D 4.Install Natural Linoleum in Place of Vinyl •5 IAQ/Health pts y=yes D 5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes D 6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y--yes D Total Points Available: 140 130 57 Total Points Project Recelved: r 0 0 0 r r.-A"Pmwgn enbWdngpidelines(remodelaWgreenpointsfina1272D4proteatedxis OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 (408)777-3228- FAX(408)777-3333-Cuilding,5cuoertino.org CUPERTIN0 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: APN BP# SITE ADDRESS j0 7 Q OWNER NAME (�L�G- OWNER AC DRESS �Q / �"��Vic 5)47LtO DESCRIPTION OF WORK: /,�.t�'f �. 7C�y n Form to make you aware We are providing you with an Owner-Builder Acknowledgment having this permit issued in your oname as the Owner-Builder. We your responsibilities and possible risk you y Y 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 indicati:d. An agent of the owner cannot execute this notice unless you,the property owner, obtain the prior approval of the p:rmitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION 13F INFORMATION (DIRECTIONS:Please read and initial each statement be'ow to signify you understand or verify this information.) l )P!-H 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 IiablE and subject to serious fin M cial risk homeof or an insurance may noinjuries sustainedt y an unlicensed person and his or her employees while working on my property. Y provide coverage for those injuries. I am willfully astir g as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. /�` El I understand building permits are not requires to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contra;tor to assume this responsibility. Ce. I understand as an"Owner-Builder' I am the -esponsible party of record on t the pe he it.I undersfiled nth sd that I may protect myself from potential financial risk by hiring a licensed Contra ctor and r her name instead of my own. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. I understand if I employ or otherwise ve hundreet dollars r($500),ther than including Clabo�rnia andlmateeals, I may bes, and the total value of my constructor is at leas considered an"employer' under state and federal law. �n/'-6. I understand if I am considered an"employe" 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' Etate License Law, an Owner-Builder who builds single-family residential structures cannot legally build eof structith ur is does note seed four within any he intent to offer them for sale, less all work calendar yeah, or all of the performed licened subcontractors and the numb work is performed under contract with a licensed general building Contractor. 8. 1 understand as an Owner-Builder if I sell th a 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. OwnerBuilderFornn_2010.doc revised 04/14/10 CITY OF CUPERTINO 71 -:� FUIO'ACE/AC CUPEI�TINO PERMIT APPLICATION FORM APN # �� Date: Building Address: C,7-- Owner's Name: Phone#: Contractor: Phone#: S4�f Fax#: Contractor License#: Cupertino Business License#: Contact: Phone#: Fax#: Building Permit Info: Elect ❑ Plumb ❑ Mech Residential Commercial ❑ Job Description: For Residential Installations: Attic F11"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 C)nstruction(Usage Class): Strapped H On Platform-R Bondi.d R New Location Replacement Project Size: Express ❑ Standard ❑ Large [] Major❑ Valuation: 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. Revised 01/07/09