10090270 CITY OF CUPERTIN O BUILDING PERMIT
BUILDING ADDRESS: 21870 EATON PL CONTRACTOR:PAMELA JACOB&WAIFU PERMIT NO: 10090270
KAN
MR'S NAME: PAMELA JACOB&WAIFU KAN 21870 EATON PL DATE ISSUED:09/29/2010
OWNER'S PHONE: 6505925622 CUPERTINO,CA 95014 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F ELECT r PLUMB
License Class Lic.# MECH I- RESIDENTIAL r COMMERCIAL r
Contractor Date
JOB DESCRIPTION:WINDOW INSTALLMENT TOTAL 25 WINDOWS;
I hereby affirm that I am licensed under the provisions of Chapter 9 NON-STRUCTURAL
(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.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq,Ft Floor Area: Valuation:$5000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. APN Number:32619132.00 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 DAYS FROM 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 T Z f
9.18. Issued by / Date:
ature 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code). ff
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
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
compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued.
by Safety Code,Section q should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for I use e
Additionally,should 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
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 au o a ent:
C/ Date: 02
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 V
ed. 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 relatin; Lender's Name
building construction,and hereby authorize representatives of this city to enter
n the above mentioned property for inspection purposes.(We)agree to save Lender's Address
...demnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,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 per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18. ��
(\`%UG� ,�G� �'D Licensed Professional
Signature Date
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTIAENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•btiilding(cDIscupertino.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:
4PN BP#
SITE ADDRESS <1 l O IV C a L_„ �L r,�
OWNER NAME o� o C T�7, OWNER AD')RESS Q 'Ca"r1 I'`a Ce �I r�-��
`(�a m cla t,�
DESCRIPTION OF WORK: 1 S `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 hawing this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, inil ialed 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 PE rmitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION CIF INFORMATION
(DIRECTIONS:Please read and initial each statement bet)w to signify you understand or verify this information.)
1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner-
Ider"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 fin M cihomeowneral risk for an insurance may noty injuries sustained
an unlicensed person and his or her employees while working on my property. y
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.
4-2. 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.
1( 3. I understand as an"Owner-Builder' I am the r:sponsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a icensed Contractor and having the permit filed in his or her
name instead of my own.
4. 1 understand Contractors are required by law :o be licensed and bonded in California and to list their license
numbers on permits and contracts.
rnia
�5. I understand if I employ
or at least otherwise
hundred dollars age any r($500),ther than including Clabo�and materials,Contractors,may beand the
total value of my construction
considered an"employer'under state and federal law.
S�L6. 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.
U7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family
ntial structures cannot legally build them with 1 he 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 ouilding Contractor.
8. I 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_2010.doc revised 04114/10
Lev
9an"employer"from the Internal
nue Service,the United States Small Business Ac ministration,
the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors'State
wnrw.cslb.ca.gov for more information about licensed
License Board (CSLB)at 1-800-321-CSLB (2752)or
contractors.
V� 10. 1 am aware of and consent to an Owner-Buildor building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
-�1111. 1 agree that,as the party legally and financiall/responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
�12. 1 agree to notify the issuer of this form immed ately of any additions,deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated Eby laws designed to protect the public. If
you contract with someone who does not have a licen 3e,the Contractors' Stpte 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 fc,r you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while worcing 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 mu::t be completed and Signed by the property owner and
returned to the agency responsible for issuing the pe rmit. 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 propert owner's si nature. Date: L71`1 10
Property Owner's Signature:
(NOTE: The following caner to apply t'oForm is required to
construction p 5e completed b the property owner only when designating an
agent of the property o Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Proonr(s owactrashe execution cf which I unmy agent(s)to apply for, sign, and erstand is
he documents responsibility,
to obtain an
authorize the following pens )
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Tel No
Address of Authorized Agent:
ed
I declare under penalty of perjury that I am the property owner for the
address
downer's driver's above
's license,I form y filnotapersonall rizal tion, t the
above information and certify its accuracy. Note:A cop, of the property
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:
OwnerBuilderFonn-2010.doc revised 04/14/10
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CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT' RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 32619132 .00
DATE ISSUED. . . . . . . : 09 /29/2010
RECEIPT #. . . . . . . . . BS)00011599
REFERENCE ID # . . . : 10 )90270
SITE ADDRESS . . . . . : 21370 EATON PL
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER PAMELA JACOB & WAIFU KAN
ADDRESS 21870 EATON PL
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : PAMELA JACOB
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : PAMELA JACOB & WAIFU KAN
ADDRESS . . . . . . . . . . : 21870 EATON PL
CITY/STATE/ZIP . . . : CL:PERTINO, CA 95014
TELEPHONE . . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- -------------
---------- - --------- ----------
1BCBSC VALUATION 5, 000 . 00 1. 00 0. 00 1. 00 0 .00
1BSEISMICR VALUATION 5, 000. 00 0 .50 0 . 00 0 . 50 0 .00
1WINREP EACH 8 25. 00 758 .00 0 .00 ----758_00 ------0_00
- --------- ----------
TOTAL PERMIT 759.50 0. 00 759.50 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- ---------
CREDIT CARD 759 .50 VISA
---------------
TOTAL RECEIPT 759.50
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: "VALUATION: $5,000
xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition
PENTAMATION
PRIMARY SFD or Duplex 1GENRES
USE: P £ t Ott£ [! t::z: PERMIT TYPE:
WORK
SCOPE
l-,tch. Iia, t Frc.c_�
70Lilif't'It, Ir"p,
r t�r, i'ae
_2��j
NOTE. These fees are based on the preliminary in ormation available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 09-05I Ejf. 7%1.40) FE E QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 25 # Window/Sliding Glass Door
Suppl.PC Fee: E) Reg. 0 OT 0.0 hrs $0.00 $758.00 1 WINREP Replacement
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee4E) Reg. 0 OT ro.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
C'oristl•uc°tion lcr1
Acoustical Fee: 0 Yes (F) No 50.00
Work Without Permit? 0 Yes (F) No 50.00
Planning Fee: 50.00 Select a Non-Residential
Building or Structure 0
71-co el 0oc ifflicni atiovi
Strong, Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 0.50 $758.00 TOTAL FEE: 1 $759.50
Revised: 9/29/2010
.Indoor A r Quality an Finishes
1-U se LDWINo-VbC Paint
2.Use Low Voc,Water-Based Wood Finishes 1 IAQ/Health pts y=yes
Y--yes
0
3.Use Low/!�o VOC Adhesives 21AQ/Health pts y=y p
4.Use Salvaged Materials for Interior Finishes 3 IAD/Health pts y--yes p
5.Use Engineered Sheet Goods with no added Urea 3 Resource pts y=yes p
Formaldehyde
B.Use Exterior Grade Plywood for Interior Uses 6 IAQ/Health pts y=yes AD 7Seal-11F�osed Paa ❑)eboard;3r MDF 1 IAQ/Health pts y--yesB.Use FSC Certified Materials for Interior Finish 4 IA(JHealth� is - es
9.Use Finger-Jointed or Recycled-Content Trim 4 Resource pts y=yes 0
10.Install Whole House Vacuum System 1 Resource pts y=yes p
3!AQ/Health pts y--yes0
N.Flooring 1 1 p
1.Select FSC Certified Wood Flooring
2.Use f3apidiy AeneWabie Flooring Materials B Resource pts y--yes 0
4 Resource pts Y--yes3.Use Recycled Content Ceramic Tiles 0
4.Install Natural Linoleum in Place of Vinyl -- 4 Resource pts y--yes p
S.Use Exposed Concrete as Finished Floor 5 IAQ/Health pts y=Yes
1 Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs p
t Resource pts y=yes 0
Total Points Available:
140 130 5-1-11
Total Points Project Received: � 0 0
0
Mdata/progslgreent uilconoguidelines/remodelers/greenpointsfina1212D4proteeted.xls
- CITY OF C'UPERTINO
�1
CUPEKTINO GENERAI. BUILDING
PERWT APPLICATION FORM
APN # Date:
�3 9 � 10
Building Address:
0 E C-0 � 5o I
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of thi: project? Yes No
HOA: (Exterior work only) Yes ❑ No If es,provide letter from HOA
Owner's Name: � _ Phone#:
am eta a Cts (dal �-Qr1 6 tDD 5q 2 1362 2'
Contractor: •/ Phone:
Fax: (0 5th 1 U 1
Contractor License#:
Cupertino Business License#:
Contact: Phone:
Fax:
Residential Commercial
Job Description: (�,rnQ�ti� (G,}-o,L 2 -!�i w i r'
NCO - r v fiv I-rk l_
Building P. t Info:
Bld Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type: (Z,�
1-B ❑ II/IIUV-A ❑ II/VI B, N-HT,V B '
Valuation: ; �60 o Square Footage:
Project Size: Ex ess E3""Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portior of the Green BuRding/LEED Checklist & attach it
to the application or if applicab le, include in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green at www.buIldItw-een.orIZ
Revised 07/14/09
3