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10090195CITY OF CUPERTIN O BUILDING PERMIT BUILDING ADDRESS: 1151 S STELLING RD OWNER'S NAME: JOANNE PARK VIVNER'S PHONE: 4088737019 Li LICENSED CONTRACTOR'S DECLARATION License Class Lic. # 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 & 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 Section 3700 of the Labor Code, for the performance of the work for which this 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 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, 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 9.18. Signature Date. OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1, 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, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed -Tractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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 Compensation laws of California. If, after making this certificate of exemption, I 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 rev ed. 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 upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, r and expenses which may accrue against said City in consequence of the ng of this permit. Additionally, the applicant understands and will comply wrtn all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature �� Date L9 L)_a CONTRACTOR: JOANNE PARK PERMIT NO: 10090195 1151 S STELLING RD DATE ISSUED: 09/20/2010 CUPERTINO, CA 95014 PHONE NO: BUILDING PERMIT INFO: BLDG r ELECT r— PLUMB F MECH r— RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: RELOCATE EXISTING GAS METER Sq. Ft Floor Area: Valuation: $3600 APN Number: 36222016.00 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued Date: 5� 171,) _'L RE -ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of 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 & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air 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 Health & Safety Code, Sections 25505, 25533, and 25534. Owner orhor�' d agent: ( „Z/,, Date: tZ 4( O CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO 1 ' I FF.F. FCTIMATOR -- RITTI.DTNG DIVISION 9 ADDRESS: DATE: REVIEWED BY: UNITS APN: BP#: "VALUATION: $3,600 *PERMIT TYPE: Plumbing Permit PLA N CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex 7<)Y;tL PENTAMATION 1 RPGAS USE: 11001 A/ kc I" PERMIT TYPE: . upj)l. 1%l y WORK PME Unit Fee: SCOPE PME Permit Fee: APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check 0.0 1 hrs $0.00 QTY UNITS BP FEES Piping, Gas <=4 Outlets 1 PGASRES 0/hc°r 1,/1'(, h1,, p 1 # $63 PerlmII I cc : . upj)l. 1%l y PME Unit Fee: $63.00 PME Permit Fee: $42.00 C�c�fztitruc`zir�n 1�tr:e� "iC(ti/.5J7Ct!/ lic'Yte'lti` �'Pe': Work Without Permit? 0 Yes E) No $0.00 TOTALS: 14 Travel Documentation Fee: I TRAVDOC $63.00 Strong Motion Fee: _ Contact the Dent for addn'1 info. [vu,fc: Ine3e Ces are DaJea urs uoc P,cuuuu , ... ..,, FEE ITEMS (Fee Resolution 09-05].Elf ;7%1/10j Vfc, h. 1 t., r ('h, i; Plumb. Plan Check 0.0 1 hrs $0.00 , r , . t 1,; Cbc,; P/an Chcc k Fcc: Plumb. Permit Fee: IPPERMIT Suhp/. PC /`'e Other Plumb Insl$42.00 0/hc°r 1,/1'(, h1,, p 1,fjw1713- 11 17, 1"<'c': I'lo _ fnvS . 1`cc, _ Contact the Dent for addn'1 info. [vu,fc: Ine3e Ces are DaJea urs uoc P,cuuuu , ... ..,, FEE ITEMS (Fee Resolution 09-05].Elf ;7%1/10j --- FEE .-.-._ _-- _--- QTY/FEE ---- ----- - MISC ITEMS P/an Chcc k Fcc: Suhp/. PC /`'e PME Plan Check: $ 0.00 PerlmII I cc : . upj)l. 1%l y PME Unit Fee: $63.00 PME Permit Fee: $42.00 C�c�fztitruc`zir�n 1�tr:e� "iC(ti/.5J7Ct!/ lic'Yte'lti` �'Pe': Work Without Permit? 0 Yes E) No $0.00 PlCttll?tft<,r l`E'C:'.ti: 14 Travel Documentation Fee: I TRAVDOC $a 2.00 Strong Motion Fee: 10.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $148.50 $0.00 TOTAL FEE: $148.50 Revised: 9/14/2010 5 ITEMS OF 5 CITY OF CUPERTINO PERMIT' RECEIPT Sec: Twp: Rng: Sub: B1}:: Lot: APN 36222016.00 DATE ISSUED.......: 09,'20/2010 RECEIPT #......... BS000011513 REFERENCE ID # ...: 10090195 SITE ADDRESS ...... SUBDIVISION ....... CITY .............. IMPACT AREA ....... 1151 S STELLING RD CU ?ERT I NO OWNER JOANNE PARK ADDRESS ..........: 1151 S STELLING RD CITY/STATE/ZIP ...: CUPERTINO, CA 95014 RECEIVED FROM CHkEWN PARK CONTRACTOR .......: LIC # *OWNER* COMPANY JOkNNE PARK ADDRESS 1151 S STELLING RD CITY/STATE/ZIP ...: CUPERTINO, CA 95014 TELEPHONE ........ OPERATOR: patg COPY # : 1 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC ----- NEW BAL ---------- 1BCBSC ------------- VALUATION ---------- 3,600.00 ---------- 1.00 ---------- 0.00 1.00 0.00 1BSEISMICR VALUATION 3,600.00 0.50 0.00 0.50 0.00 1PGASRES OUTLETS 1.00 63.00 0.00 63.00 0.00 1PPERMITFE 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 ---------- 148.50 ---------- 0.00 148.50 0.00 METHOD OF PAYMENT ----------------- CREDIT CARD TOTAL RECEIPT : AMOUNT --------------- 148.50 --------------- 148.50 VOICE ID DESCRIPTION -------- ---------------------------- 202 UNDERFLOOR PLUMBING REFERENCE NUMBER -------------------- MC VOICE ID DESCRIPTION -------- ---------------------------- 301 ROUGH PLUMBING 506 GAS TEST 507 FINAL PLUMBING CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - tuildin4(cDcupertino.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 1 Ii.(a j^ti APN BP#+ OWNER NAME OWNER ADDRESS 0 V` J c; a 0 VAJC PC, DESCRIPTION OF WORK: f iG (Ai -e t'7f i 3ti k"� JL a We are providing you with an Owner -Builder Acknowledgrrent 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 pe 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.) A21-1. 1 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 actinc as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. A2. 1 understand building permits are not required lo be signed by property owners unless they are responsible for e—construction and are not hiring a licensed Contractor to assume this responsibility. _3. 1 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 licensed Contractor and having the permit filed in his or 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. 5. 1 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 l6. I understand if I am considered an "employer' under state and federal law, I must register with the state and fe eral government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I E Iso understand my failure to abide by these laws may subject me to serious financial risk. lid 7. 1 understand under California Contractors' Sta:e License Law, an Owner -Builder who builds single-family ential structures cannot legally build them with tha 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 building Contractor. 8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for a , financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OivnerBuilderForrn 2010.doc revised 04114110 ve19. 1 understand I may obtain more information regarding my obligations, as an "employer" from the Internal R nue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I al;;o understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or viww.cslb.ca.gov for more information about licensed contractors. a0 I am aware of and consent to an Owner-Builcer building permit applied for in my name, and understand that I thlep-arty legally and financially responsible for proposed construction activity at the site address listed above. bf11. 1 agree that, as the party legally and financial y responsible for this proposed construction activity, I will abide -all applicable laws and requirements that govern Odvner-Builders as well as employers. k-12. 1 agree to notify the issuer of this form immeciately 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 licen se, 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 wordng 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 constructio.i lending agency information.) hereby affirm that there is a construction lending agenc,r 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 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 ci `y may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: ixt,Date: O to --------------------------------------------------------------------------------------------------------------------------------------------- (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 pe mit 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: Address of Authorized Agent: Tel No 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 copy c f the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be p -esented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderForn: 2010. doe revised 04/14/10 S - CM OF CUPS TING CITY OF 4"'UPERTINO GENERAl-j BUILDING PERNUT APPLICATION FORM 609 v 1 APN # Date: Building Address: 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 yes, provide letter from HOA Owner's Name: Phone #: Contractor: Phone: Fax: Contractor License #: Cupertino Business License #: Contact: Phone: Fax: Residential Commercial Job Description: tx S MV Building Permit Info: Bldg ❑ Elect ❑ :?lumb D-- Mech ❑ Type of Construction (Usage Class): Occupancy Type: _ 1-A, 1-B ❑ M= -A ❑ II/III B, IV -HT, V -F • Valuation: Square Footage: Project Size: Express [----Standard ❑ Large [] Major ❑ Green Building: Please complete relevant portion cf the Green Building/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.builditgre+�n.or Revised 07/14/09 2