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10090061 CITY OF CUPERTI NO BUILDING PERMIT BUILDING ADDRESS: 21337 METEOR DR CONTRACTOR:KATHLEEN CROWLEY PERMIT NO: 10090061 OWNER'S NAME: KATHLEEN CROWLEY 21337 METEOR DR DATE ISSUED:09/09/2010 4ER'S PHONE: 4086550485 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F ELECT r PLUMB License Class Lic.# MECH r— RESIDENTIAL r COMMERCIAL r Contractor Date JOB DESCRIPTION: 10'GAS LINE TO FIREPLACE WITH LOG LIGHTER I hereby affirm that I am licensed under the provisions of Chapter 9 (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 APN Number:32643005.00 Occupancy Type: permit is issued. 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 relatir g PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We)agree to save 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,Y.y" Date: 9.18. Signature Date RE-ROOFS: 10installed 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 stricture 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 constrict the project(Sec.7044,Business&Professions Code). l4�9 &- 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 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. I certify that in the performance of the work for which this permit is issued,I shal I not employ any person in any manner so as to become subject to the Worker's Owne or author' d agent: �v O Compensation laws of California. If,after making this certificate of exemption,1 �/ Date: 9 S become subject to the Worker's Compensation provisions of the Labor Code,I rr ust 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 relal ing 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 -►nify and keep harmless the City of Cupertino against liabilities,judgments ARCHITECT'S DECLARATION 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 the Cupertino Municipal Code,Section 9LS 18. Licensed Professional gnatur Date (y�ty '/O CITY OFCUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: I DATE: REVIEWED BY: 101APN: BP#: "VALUATION: $500 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PENTAMATION PRIMARY SFD or Duplex f t 1I��/ 1 RPGAS USE: p t 1 OC)11 t. t PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Piping, Gas <=4 Outlets 1 PGASRES 1 # $63 TOTALS: $63.00 Plumb.Plan Check 0.0 hrs $0.00 P umb.Permit Fee: IPPERMIT Other Plumb Irsp. 0.0 hrs $42.00 NOTE: These fees are based on the preliminaryin ormatic n available and are onlyan estimate. Contact the De t or addn'l info, FEEMS (Fee Resolution 09-051 Eff. 7/1%10) FEE Q TY/FEE MISC ITEMS A I=c":Check: $0.00 c': suppl. Il)S/)Fee PME Unit Fee: 663.00 PME Permit Fee: $42.00 C.`c�rz.,�rrrczr��f7 Fc�.� Work Without Permit? 0 Yes E) No $0.00 I'lc.ttritltr,�r f'cj<'3: Travel Documentation Fee: ITRAVDOC $42.00 Strong Motion Fee: $0.50 Select an Administrative Item Bldu Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $148.50 $0.00 TOTAL FEE: $148.50 Revised: 9/01/2010 CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32543005. 00 DATE ISSUED. . . . . . . : 09/09/2010 RECEIPT ##. . . . . . . . . : BS )00011419 REFERENCE ID # . . . : 10)90061 SITE ADDRESS 21337 METEOR DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER KATHLEEN CROWLEY ADDRESS 21-37 METEOR DR CITY/STATE/ZIP . . . : CUFERTINO, CA 95014 RECEIVED FROM MICHAEL P CROWLEY CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY KATHLEEN CROWLEY ADDRESS . . . . . . . . . . : 21337 METEOR DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . . FEE ID UNIT----- QUANTITY AKOUNT PD-TO-DT THIS REC NEW BAL - ---------- _____ _____ ---------- ---------- _ 1BCBSC VALUATION ---00 500. 00 1 .00 0.00 1. 00 0. 00 1BSEISMICR VALUATION 500. 00 0.50 0. 00 0.50 1PGASRES OUTLETS 1. 00 63 .00 0. 00 63 . 00 0 . 00 0 .00 1PPERMITFE FLAT RATE 1. 00 42 . 00 0. 00 42. 00 1TRAVDOC FLAT RATE 0 .00 1. 00 42 . 00 0. 00 42 . 00 0 . 00 -- ------ TOTAL PERMIT : ---------- ---------- 148 .50 0 .00 148 .50 0. 00 METHOD-OF-PAYMENT AMOUNT REFERENCE NUMBER --------------- -------------------- CHECK 148.50 #2961 --------------- TOTAL RECEIPT 148 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION ---- ---------------------------- 2 ---------------------------- 02 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 506 GAS TEST 507 FINAL PLUMBING OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPAF:TMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• building(o1cupertino.orq 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 ADD SS TBP# 3 5 /y,(,/e, /biz OWNE AME ,t OW R ADDRsS DESCRIPTION OF WORK: 1 �� ,��1 L9 1�1 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 hiving 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 DF INFORMATION (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) )zv I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Builder' building permit that erroneously implies that tie 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 pror erty. IR 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. A��'3. 1 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. �L4. I understand Contractors are required by law 10 be licensed and bonded in California and to list their license numbers on permits and contracts. O3L'15. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total 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. ?L/. 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. VV& 7. 1 understand under California Contractors' Stete License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with tt a intent to offer them for sale, unless all work is performed by licensed subcontractors and thenumber of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general bjilding Contractor. 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 su)Sequent owner(s)that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 El_/9. I understand I may obtain more information regarding my obligations as an "employer"from the Interna Revenue Service, the United States Small Business Administration,the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also inderstand I may contact the California Contractors' State License Board(CSLB)at 1-800-321-CSLB (2752)or wwN.cslb.ca.gov for more information about licensed contractors. K10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for propcsed construction activity at the site address listed above. 11. 1 agree that, as the party legally and financially -esponsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. aG 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 contr actors 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 Vou 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 'ending agency information.) I hereby affirm that there is a construction lending agency 'or the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lende•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. Date: C ,C)iU 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 pen nit for the Owner-Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTYOWNER'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 z pply 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: .a- Name of Authorized Agent: Tel No Address of Authorized Agent: 1 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 o`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: OwnerBuilderForni_1010.doc revised 04/14/10 CITY OF CUPERTINO I CUPEkINO GENERAL BUILDING PERMIT APPIACATION FORM APN# ` Date: '��b_ Building Address: 2� ,__I_ �O (�. q Mailing Address (if different from building address). Are Hazardous Materials being used as part of this project? Yes No HOA: xterior work oRW Yes No I.' es,provide letter from HOA Owner's Name: ,I A 4\ W1 Phone#: F- 01 yob, GIT.04t' ' Contractor: ���� Phone: ' Fax: Contractor License#: Cupertino Business License#: Contact: :L7 Phone: Fax: Residential Commercial Job Description: Building Permit Info: Bldg ❑ Elect ❑ Plumb Mech ❑ Type of Construction(Usage Class): Occupancy Type: V,,- -3 1-A, 1-B IUIII/V-A IMM B, IV-HT,V-B f-eid �� I••S t - �r da► Valuation: Square Footage: Project Size: Express Standard Laze Major Green Building: Please complete relevant portion of the Green B ' ding/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.buttidit -een.or Revised 07/14/09 i