10090163 CITY OF CUPER TINO BUILDING PERMIT
BUILDING ADDRESS: 10421 PINEVILLE AVE CONTRACTOR:DOLORES KOSER PERMIT NO: 10090163
OWNER'S NAME: DOLORES KOSER 10421 PINEVILLE AVE DATE ISSUED:09/17/2010
VNER'S PHONE: 4082527508 CUPERTINO,CA 95014-4522 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL
License Class Lic.# PANEL UPGRADE TO 200 AMP
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Profession!
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarati,ins:
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
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
APN Number:36913017.00 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 rely ting WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to entc r
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS ROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgment,
costs,and expenses which may accrue against said City in consequence of the /
granting of this permit. Additionally,the applicant understands and will compl) Issued by:. / G Ci Date:
with all non-point source regulations per the Cupertino Municipal Code,Sectior ;
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.
11,10-" l OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for or a of Signature of Applicant: Date:
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 compensa tion,
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 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. I 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,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Ave—mo Owner or authorized agent: /moi Date:
permit is issued.
I certify that in the performance of the work for which this permit is issued,I sh:.11
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,1 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I r lust 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 revoked. work's for which this permit is issued(Sec.3097,Civ C.)
A � Lender's Name
-VAPPLICANT 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
-mnify and keep harmless the City of Cupertino against liabilities,judgment_', ARCHITECT'S DECLARATION
s,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18. //JJ /J
Signature AQWit,60 U/, C�ZI�� Date / —Ar
CITY OF C'UPERTINO
FEE ESTIMATOR— BUILDING DIVISION
71
ADDRESS: DATE: REVIEWED BY:
APN:
BP#: *VALUATION: $500
RPERMITTYPE: Electrical Permit PLAT(CHECK TYPE: Alteration/Addition / Repair
0 , 'lPENTAMATION 1 REAP2
PRIMARY SFD or Duplex PERMIT TYPE:
USE:
I•'1 t�tJTi:1i�r' ,t:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1ERT<200 100 Amps $42
TOTALS: $42.00
� I ..7, 7,
I Elec.Plan Check 0.0 hrs $0.00
1; Elec.Permit Fee: 1 EPERMIT
I'i rnr;t!
Other Elec.Insp. 0.0 hrs $42.00
: LiCi 1'iI3, I`c'c
t''i rtt�t. I7 r
_ r €'d-
NOTE: These fees are based on the preliminary informatio available and are only an estimate. Contact the De dor addn'l info.
F
7ITEMS (Fee Resolution 09-051 Eff %!1.101 FEI: Q
TY/FEE MISC ITEM
e:
ttj)jL PC'1-,ec
PME Plan Check: $0.00
Pc:nnit
Str/tl,f. I/Iso Fee
PME Unit Fee: $2.2.00
PME Permit Fee: $2.2.00
E-`at,�trx<=tiott Tc�a
Work Without Permit? 0 Yes No 60.00
Ix/tlt7ltlth' /`t't J:
Travel Documentation Fee:
I TRA VDOC $42.00
Strom.Motion Fee;
$0.50 Select an Administrative Item
Bldg S tcls Commission Fee_ IBCBSC $1.00
SUBTOTALS: $127.50 $0.001TOTAL FEE: $127.50
Revised: 9/14/2010
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228-FAX(408)777-3333- buildin4(CDCUDertino.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 ,�. I APN BP#
�'. q'. ,-
OWNER NAME,7) / OWNER ADDRESS
DESCRIPTION OF WORK: IAp C 1.2ewMo
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 indicat3d. An agent of the owner cannot execute this notice unless
you,the property owner, obtain the prior approval of the p armitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement be,ow to signify you understand or verify this information.)
.,Z-1. I 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 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.
�2. I 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.
&3. 1 understand as an"Owner-Builder" I am the rE!sponsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a I censed Contractor and having the permit filed in his or her
name instead of my own.
�4. I understand Contractors are required by law ti be licensed and bonded in California and to list their license
numbers on permits and contracts.
45. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
tota 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" ender state and federal law, I must register with the state and
fed ral 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.
1"_7. 1 understand under California Contractors'Staie License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with tho intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures Joes not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general bL ilding Contractor.
I
&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 2010.doc revised 04/14/10
my
as an"employer"from the Internal
9. I understand I may obtain more information regarministration,
d�ist at on,lthe obligations
ornia Department of Benefit Payments,
Revenue Service,the United States Small Business Ac I may con
the California Contractors' State
and the California Division of Industrial Accidents. I also understand Y
License Board(CSLB)at 1-800-321-CSLB (2752)or www.csib.ca.gov for more information about licensed
contractors.
10. 1 am aware of and consent to an Owner-Build ar building permit applied for in my naKme, and understand that I
m the a legally and financially responsible for pro posed construction activity at the site address listed above.
a t party
11. 1 agree that,as the party legally and financial'y responsible or this pro
well as employerposed sstruction activity, I will abide
all a liLcable laws and requirements that govern Owner
uilders
. hanges to any of the
by pp
a12. 1 agree to notify the issuer of this form im aitaclo os are regulated additions, deletionslaws des r ced o protect the public. If
information I have provided on this form. Licensed
against unlicensed
you contract with someone who does not have ain as �result of atcomplaintt Your ate f onlyeemedy Board may
y be unable o
assist you with any financial loss you may sus
tractor or
Contractors may be in civil court. It is also important f�r you to understand t you may be held liable nfor damages. If
employee of that individual or firm is injured while working on your prow will be responsible for verifying whether or not
you obtain a permit as Owner-Builder and wish s atL Contractors,y
P
those Contractors are properly licensed and the stats s of their workers'compensation insurance coverage.
CONSTRUCTION LENDING AGENCY information.)
(DIRECTIONS:Please complete the following construction lending agency
I hereby
affirm that there is a construction lending agen:y for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Ler der Address:
Lender Name:
owner and
r7=sponsibleg permit can be issued,this form mrist be completed and signed by the property
agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
, or other verification acceptable to the city may be required to I)e presented when the permit is issued
ert owner's si nature. Date: I
Property Owner's Signature:
----
- - - - - - -- ------ ------------------ -----------------------owneronl when designating an
be
ed by the
(NOTE: The following Auth riapply trofora is reconsquctionc�ermit for pthe Owner-Builder). y
uire
agent of the property owner
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
I forsign,and file the documents necessary to obtain an
authorize the following person(s)to act as my agent(s)to appy , 9
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work;:
Project Location or Address:
Tel No
Name of Authorized Agent:
Address of Authorized Agent:
and declare under penalty of perjury that I am the property owner for t the
address
listed
vabove
's license,)orrm notarization, ored out tother
of thpropertyowner's
above information and certify its accuracy:Note:A cc py ermit is issued to verify the property
verification acceptable to the city may be required to,)e presented when the p
signature.
Date:
Property Owner's Signature:
OwnerBuilderFornn_2010.doc revised 04/14/10
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
CUPERTINO
CONTRACTOR/ SL BCONTRACTOR LIS
PERMIT# _
JOB ADDRESS: �� PHONE#
OWNER'S NAME: C' BUSINESS LICENSE#
GENERAL CONTRACTOR: C CITY/ZIPCODE:
ADDRESS: ��
of Cupertino business license.
THE
* T ON(S) WILL BE SCHEDULED UNTIL
*Our municipal code requires all businesses working iu the cityCto have a City E
NO BUILDING FINAL OR FINAL OCCUPANCY INSP
AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY C
RAL CONTRACTOR A
GENE
BUSINESS LICENSE. � Date
Gtr„ ., i
I am not using any subcontractors: c,ignature
applicable subcontractors and complete the following information
Please heck app BUSINESS LICENS
� S CONTRACTOR
BUSINESS NAME
Cabi is & Millwork
Cement inishing
Electrical
Excavation
Fencing
Flooring/ Carpeting
Linoleum/Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Ta
Sheet etal
S et Rock
Tile
Date
6?1'-16-
Owner/Contractor Signature
V=
CM of CITY OF C UPERTINO
CUPEKTINO GENERAL BUILDING
PERMT APPLICATION FORM
APN lCoq(1IG13
--�� Date:
Building Address:
e Sfd
Mailing Address (if di erent from building address):
Are Hazardous Materials being used as part of this Iroject? Yes Lj No
HOA: xterior work only) Yes
❑ No If a s, rovide letter from HOA
Owners Name- Phone#
v o e3 �Se
Contractor: Phone:
Fax:
Contractor License#:
Cu ertino Business License#:
Contact:
Phone:
Residential Commercial ❑ Fax:
Job Description:
Building PeLo:n
Bldg ❑ lect Plur.ib ❑ Mech ❑
Type of Coe C s): Occupancy T e:
1-A, 1-B ❑ II/III B, IV-HT, V-B Valuation: D Square Footage:
Project Size: Ex esS E�' Standard ❑ Large ❑ Major ❑
Fdr�eenBui- ldinc;: Please complete relevant portion of the Green Building/LEED Checklist& attach it
Points Achieved:
to the application or if applicable, include in plan set& the sheet index.
_
For help, contact Build it Green at www builditgreen or
Revised 07/14/09
3