10090206 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10239 AMELIA CT CONTRACTOR:KELLY GORDON PERMIT NO: 10090206
DEVELOPMENT CORP
"NER'S NAME: KELLY GORDON DEVELOPMENT CORP 12241 SARATOGA SUNNYVALE RD STE C DATE ISSUED:09/21/2010
0WNER'S PHONE: 4088738774 SARATOGA,CA 95070 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT f— PLUMB
License Class Lie.#
MECH r- RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:LOT 2-TEMP POWER POLE FOR SFDWL
(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:$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
permit is issued. APN Number:32617017.10239 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 'Z
Issued by: .=.,��' Date:
9.18.
-ature 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
1 hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
1,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 ontors 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 following three 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. I 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.
1 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'sO er o 'r au etre Q Z�
Compensation laws of California. If,after making this certificate of exemption,I C Date: C
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 r ked CONSTRUCTION LENDING AGENCY
F I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(See.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
the above mentioned property for inspection purposes.(We)agree to save
anify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the
granting 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 t upertino Municipal Code,Section
9.18. r Licensed Professional
Zf� 0
Signature Date 9
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPAR7MENT•BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO. CA 95014-3255
CUPERTINO (408)777-3228-FAX(408)777-3333-t>uilding(aDcuoertino.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 ADDREfS Q jr
t, fo APN Z J 7_ D BP#
OWNER'NAM,
I t OWNER AC DRESS
DESCRIPTION O ORK:
We are providing you with an Owner-Builder AcknowledgrT ent 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 pt:rmitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
/�" l_lunderstand 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.
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 Contract)r to assume this responsibility.
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 li sensed Contractor and having the permit filed in his or her
name instead of my own.
understand Contractors are required by law tc,be licensed and bonded in California and to list their license
numbers on permits and contracts.
5vv__'5. I understand if I employ or otherwise engage airy persons, other than California licensed Contractors, and the
otal 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.
6. I understand if I am considered an"employer"tinder state and federal law, I must register with the state and
ederal government,withhold payroll taxes, provide wcrkers'compensation disability insurance, and contribute to
unemployment compensation for each "employee." I a so understand my failure to abide by these laws may subject
me to serious financial risk.
�/ %"'7. I understand under California Contractors' Stat: 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 perfor under contract with a licensed general building Contractor.
8. 1 understand as an Owner-Builder if I sell the p-operty 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 2010.doc revised 04/14/10
1
I understand I may obtain more information regarding my obligations as an"employer"from the Internal
Revenue Service,the United States Small Business d%d ministration,the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I a so 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.
0. 1 am aware of and consent to an Owner-Builder building permit applied for in my name,and understand that 1
5�1
am the 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
by all apple 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 lice-ise,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 we rking 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 states 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: Ler der Address:
Before a building permit can be issued,this form mt;st be completed and signed by the property owner and
returned to the agency responsible for issuing the parmit. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the :ity may be required to be presented when the permit is issued
to verify the property owner's si natur
Property Owner's Signature: Date: /C
---------------------------------------------------7-----------------------------------------------------------------------------------------
(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 F ermit 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:
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 I personally filled out the
above information and certify its accuracy. Note:A cope 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:
OwnerBuilderFOrn7 2010.doc revised 04/14/10
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Bl{: Lot:
APN :32617017 .10239
DATE ISSUED. . . . . . . : 09/21/2010
RECEIPT #. . . . . . . • • : BS000011527
REFERENCE ID # . . . : 10090206
SITE ADDRESS . . . . . : 1C239 AMELIA CT
SUBDIVISION . . . . . . .
CITY CL PERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : KELLY GORDON DEVELOPMENT CORP
ADDRESS . . . . . . . . . . : 1 :241 SARATOGA SUNNYVALE RD ST
CITY/STATE/ZIP SRRATOGA, CA 95070
RECEIVED FROM SCOTT KELLY
CONTRACTOR . . . . . . . . LIC # *OWNER*
COMPANYK]'LLY GORDON DEVELOPMENT CORP
ADDRESS 1:2241 SARATOGA SUNNYVALE RD ST
CITY/STATE/ZIP SARATOGA, CA 95070
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC --NEW-BAL-
---------- -------------
----------
---------- ----------
-----
1BCBSC VALUATION 500. 00 1.00 0 .00 1. 00 0 . 0
1BSEISMICR VALUATION 500 .00 0 .50 0 .00 0. 50 0 .00
1EPERMITFE FLAT RATE 1.00 42 .00 0 . 00 42.00 0 .00
1ERT<200 UNITS 1. 00 42 .00 0. 00 42 .00 0 .00
1TRAVDOC FLAT RATE 1. 00 42 .00 0 .00 42 . 00 ------ -
TOTAL PERMIT
127 .50 0 .00 127. 50 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- ------------
--
CHECK 127 .5( #1611
---------------
TOTAL RECEIPT 127 .5(1
D DESCRIPTION
VOICE ID DESCRIPTION VOICE I ----------------------------
-------- ----------------------
402 TEMPORARY POWER
l 7 �--
CITY OF CUPERTINO
TEMP POWER
CUPCOF
ETRINO PERMIT APPLICATION FORM
Date:
APN # 2 ,-,_
Building Address: /
Owner's am ' II-� Phone #: -7 1
7 7
Contract
: Phone #:�/ �s-77 ?77c/
i�: ►�, �� rG' Fax #:
Cont fit: Phone_#:
Contractor License #.
Cu ertino Business License #:
Job Description:
r ? !�o
Residential Commercial
al cost of roject): Type of Construction: N/A
_ aFP�
771
Fee Description Fee Group Permit Type
>1K Res. Temp Power>lK E IREAPI4
Amps
<200 Res. Temp Power<200 E
Am s
1 ERT2001 K Res. Temp P ewer 200-1 K E
AmDs :;-
IEPERMITFE Electric Permit Issuance E
1 ELCPLNCK Electric Plan Check E
1BCBSC Cal Bldg Standards B ALL PERMIT _
Commission Fee TYPES
1BSEISMICR Seismic Residential B
ITRAVDOC Travel & Documentation B
Fee
Revised 01/07/09