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10080092 � CITY OF CUPERTINO BUII,DING PERMIT JILDING ADDRESS: 10387 MARY AVE CONTRACTOR:DAVID HOLLISTER PERMIT NO: 10080092 WNER'S NAME: DAVID HOLLISTER 320 DEL MEDIO AVE DATE ISSUED:08/13/2010 JER'S PHONE: 6504657972 MOUNTAIN VIEW,CA 94040 PHONE NO: LICENSED CONTRACTOR'S DECLARATION gpILDIN G PERMIT INFO: BLDG� ELECT� PLUMB r �ense Class Lic.# MECH r RESIDENTIAL� COMMERCIAL �nttactor Date �ereby aftirm that I am licensed under the provisions of Chapter 9 .iOB DES��RIPTION:REMOVE EXISTING FIREPLACE INSERT&REPLACE �mmencing with Section 7000)of Division 3 of the Business&Professions SURROLJrII�.REMOVE EXISTING TILE TUB SURROLIND. �de and that my license is in full force and effect. REPLACE F ER CBC2007 �ereby affirm under penalty of perjury one of the following hvo declarations: iave and will maintain a certificate of consent to self-insure for Worker's �mpensation,as provided for by Section 3700 of the Labor Code,for the rforn►ance of the work for which this permit is issued. �ave and will maintain Worker's Compensation Insurance,as provided for by xtion 3700 of the Labor Code,for the performance of the work for which this Sq.Ft F7oo r Area: Valuation:$1000 xmit is issued. APPLICANT CERTIFICATION APN Numl�er:32652999.10387 Occupancy Type: :ertify that I have read this application and state that the above information is �rrect.I agree to comply with all city and county ordinances and state laws relating building construction,and hereby authorize representatives of this city to enter �on the above mentioned property for inspection pu�poses. (We)agree to save pER MIT EXPIRES IF WORK IS NOT STARTED demnify and keep harmless the City of Cupertino against liabilities,judgments, �sts,and expenses which may accme against said City in consequence of the wl7'HIN 180 DAYS OF PERMIT ISSUANCE OR anting of this permit. Additionally,the applicant understands and will comply 180 ])AYS FROM LAST CALLED INSPECTION. ith all non-point source regulations per the Cupertino Municipal Code,Section 18. Issued by: Date: gnature Date „ OWNER-BUILDER DECLARATION RE-ROOFS: hereby affirm that I am exempt from the Contractor's License Law for one of All roofs st all be inspected prior to any roofing material being installed.If a roof is ie following two reasons: installed wi thout first obtaining an inspection,I agree to remove all new materials for as owner of the property,or my employees with wages as their sole compensation, ��p�tion. ill do the work,and the stntcture is not intended or offered for sale(Sec.7044, usiness&Professions Code) Signature c f Applicant: Date: as owner of the pmperty,am exclusively contracting with licensed contractors to �nstruct the project(Sec.7044,Business&Professions Code). � ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER � hereby affirm under penalty of perjury one of the following three eclarations: HAZARDOUS MATERIALS DISCLOSURE have and will maintain a Certificate of Consent to self-insure for Worker's ompensation,as provided for by Section 3700 of the Labor Code,for the I have rea�1 the hazardous materials requirements under Chapter 6.95 of the erformance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain have and will maintain Worker's Compensation Insurance,as pmvided for by complianc:with the CuperHno Municipal Code,Chapter 9.12 and the Health& ection 3700 of the Labor Code,for the performance of the work for which this Safety Co�le,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air ermit is issued. contaminants as defined by the Bay Area Air Quality Management District I will certify that in the performance of the work for which this permit is issued,I shall maintain c ompliance with the Cupertino Municipal Code,Chapter 9.12 and the ot employ any person in any manner so as to become subject to the Worker's Health&t�afety Code,Sections 25505,25533,and 25534. 'ompensation laws of Califomia. If,after making this certificate of exemption,I ecome subject to the Worker's Compensation provisions of the Labor Code,I must Own�or aut o iz �t: ��thwith comply with such pmvisions or this permit shall be deemed revoked. �d� Date: � �� CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION certify that[have read this application and state that the above information is I hereby af_irm that there is a construction lending agency for the performance of work's orrect[agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) �building constnxction,and hereby authorize representatives of this city to enter Lender's r�ame pon the above mentioned property for inspection pucposes.(We)agree to save �'�-nnify and keep hannless the City of Cupertino against liabilities,judgments, Lender's�►ddress and expenses which may accnie against said City in consequence of the ,,....ing of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION rith all non-point source regulations per the Cupertino Municipal Code,Section .1 g. I understar d my plans shall be used as public records. ignature Date 3 Licensed 1'rofessional CITY OF CUPER�.'INO 3 ITEMS OF 3 PERMIT RECE:=PT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 32652999 .10387 DATE ISSUED. . . . . . . : 08/13/20L0 RECEIPT #. . . • • • • • • : BS000011179 REFERENCE ID # . • • : 10080092 SITE ADDRESS . . . . . : 10387 MA�Y AVE SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTIN� IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : DAVID HOLLISTER ADDRESS . . . . . . . . . . : 320 DEL �lEDIO AVE CITY/STATE/ZIP . . . : MOUNTAIN VIEW, CA 94040 RECEIVED FROM . . . . : DAVID L HOLLISTER CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : DAVID HOLLISTER ADDRESS . . . . . . . . . . : 320 DEL MEDIO AVE CITY/STATE/ZIP . . . : MOUNTAIN VIEW, CA 94040 TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY AMOUN'I PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- --------- 1BCBSC VALUATION 1, 000 . 00 1 .00 0. 00 1. 00 0 .00 1BSEISMICR VALUATION 1, 000. 00 C .50 0 .00 0. 50 0 .00 lOTPLNCK HOURS 2 . 00 37� .00 0. 00 378. 00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT : 37� .50 0.00 379.50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- ---- ---------------- CHECK 379 .50 #13E7 --------------- TOTAL RECEIPT : 379.50 C \._-'`.J � � �� G J-- � ��-��`` CITY OF CUPEIZTINO CUPE�TINO GENERAL BUII�DING pERMIT APPLICAT ION FORM APN # - Date: �� .�� 8 r� t� Building Address: 1 c"�'�R-7 (W�� i°�.�/L�' - Mailing Address (if different from building address): �Q� 32� D� �►6�i o A�' r�n ov,.rc`�w vtE�! c� Are Hazardous Materials being used as part of this project'' Yes No 1 Yes No If es, ro�ide letter from HOA HOA: xterior work on ❑ Owner's Name: Phone#: . �v� Ho�.L� � 5 O � Ll6 5- �? Contractor: Phone: � �w N �v 1 r�� Fax: �SO--�i�!9-l3'� Contractor Licen #: Cu ertino Business License#: Contact: Phone: t'�t�Y�.a� Fax: Residential Commercial ❑ _ JobDescription:i�fZ��J� ��1ST�ti1C-7- �tRt�l�4cL iti1SERT'fiNd �RE1�1.� SvR Ro�No, �� R�i�a� �ct s?�N� TI�F' "r'c�l3 S�2Ro�N iD. R�°L�G� PC--l� c6c 200"7 � Building Permit Info: ' Bldg C-I--- Elect ❑ Plumb ] Mech ❑ Type of Construction (Usage Class): Occupancy Type: � �_� 1-A, 1-B ❑ IUIII/V-A ❑ IUIII B, IV-HT, V-B �� u-= � - Valuation: Square Footage: C-G �� IOvU Project Size: Express�tandaz'd ❑ Large ❑ N�ajor ❑ Green Building: Please complete relevant portion of the C:reen Bu' ding/LEED Checklist& attach it to the application or if applicable, inclucle in plan set & the sheet index. ''oints Achieved: ��,.__._ � r,or help, contact Build it Green at www.buildit�reen.or� Revised 07/14/09 s CITY OF CUPEP.TINO FEE ESTIMATOR—BUILI)ING DIVISION ADDRESS: DATE: REVIEWED BY: APN: BP#: , `VALUATION: $1,000 rPERMIT TYPE: Building Permit PLAN CHECI�:TYPE: Alteration/Addition/ Repair PRIMARY OVER THE APPLICATION USE: SFD or Duplex COUNTER? �'les O No' TYPE: Nl2 WORK SCOPE OCCUPANCY TYPE: TYPE OF FLR AREA pC FEES PC FEE ID BP FEES BP FEE ID CONSTR. s.f. R-3(Custom) II-B,III-B,Iv,V-B 0 $0.00 $0.00 .K 4 r� Y ,� ��- ��: TOTALS: 0 $ ` { �" $0.00 �. � �* 0 00 ��`�'��.' f .�� ✓V ..�ey W'��N�.++�(a��,} , �� C,r x x� �.� �a ,�. �� , ��(► .� ... �ry� .h,A�� p�P��''��F' ik�9` ��F��ill�sw+ F �� ! !�.�t�A��• �..slt y � •.rn.� fi �f^;:�'� .+��'a��t.'+��Xs.�•��. ��ViiAL1J.�� ,�� G��. �AI< � �� .r�� :M. ..X�. �� .:br� F, v� ?eX ,'�. � _�-.ir� ��c� 4'�Z� 3 � .�� U � ,� 1:��.� !�'lrr�l�h P(r�it('h,��% 17c��. P!'�tri C'hcri�k �1�1�>r l; ;'z��r��i:F��r_ E'lz�rrth 7'L��ni;!I �u�- � 1i1��r�. �'<+rn�i�!'e�c': � l .. ir;�i, r i ur;'i�ucr�b I�:��;�, C)ll�er'l�iii�r. l��s/� ,r r��:�� 1";r��r?�. ln;�;. 1��;�_ I l�lrr Ins�+ 1'��'o" NOTE: These ees are based on the reliminar in ormation available c nd are onl an estimate. Contact the De t or addn'1 in o. FEE ITEMS(Fee Resolution 0�-OSl E f� FEE Q7'Y/FEE ' MISC ITEMS Plan Check Fee: � $0.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: � Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee{'� Reg. � OT 0.0 hrs $0.00 PME Unit Fee: $0.00 � � PME Permit Fee: $0.00 t�'rnrr;r,�r�rrrur�r 7��;.;� �� Acoustical Fee: � Yes � No $0.00 � Work Without Permit? � Yes � No $0.00 ' � Planning I�ee: $0.00 ' Select a No esidential � Building or Structure 0 �l��ur��' '!r��rnr��'y;�tcr�iori 1��,�,� � � Stron�Motion Eee: IBSEISMICR $0.50 2•0 hrs • Inspections Bld�Stds Commission Fee: IBCBSC $1.00 $379.00 B TIME Outside Work Hours �t�Tk �„��, �� ' $U$'�'OTALS:' $1.50 $379.00 ;t M ' �Q'��;��.e $380.50 �_ _ . .. � '� Revised: 8/12/2010 � �. �t� OWNER-BUILDER DISCLOSUF:E FORM COMMUNITY DEVELOPMENT DEPARTMENT•E�UILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 9501��-3255 (408)777-3228• FAX(408)777-3333• buildin c:uoertino.ora CUPERTINO Dear Property Owner(s): An application for a building permit has been submitted in your nam:listing yourself as the builder of the property improvements specified at: SITE ADDRESS APN BP# �3 M� �1�' OWNER NAME OWNER ADDRESS �G� Ho�.t.. s 3�o OE1_ M,��o A�C DESCRIPTION OF WORK:1 R,�10✓E� �tR 2�'P G —'ILE —T V SU l7V � 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 ��ermit 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 acient of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting �wthority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFOF;MATION. (DIRECTIONS:Please read and initial each statement below to sig�iify you understand or verify this information.) �-N 1. I understand a frequent practice of unlicensed persons i�to have the property owner obtain an "Owner- Builde�"building permit that erroneously implies that the propery owner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable and subjE:ct to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working c n my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an O�vner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. �..rl 2. I understand building permits are not required to be sigr ed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to ass��me this responsibility. 1�1�H 3. I 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 C:ontractor and having the permit filed in his or her name instead of my own. �u�4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. 'D�5. I understand if I employ or otherwise engage any persoiis, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars($��00), including labor and materials, I may be considered an"employer" under state and federal law. _ _ _.,, �6. 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 undeistand my failure to abide by these laws may subject me to serious financial risk. Qi.�.t-i7. I understand under California Contractors' State Licens�; Law, an Owner-Builder who builds single-family residential structures cannot legally build them with the intent tc�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 Ccntractor. aL.H 8. I understand as an Owner-Builder if I sell the property fc�r which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent �wner(s)that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 'Du�_9. I unde�stand I may obtain more information regarding my oCligations asl,an "employer"from the Intemal Revenue Service,the United States Small Business Administration, the California Department of Benefit Payments, and the Califomia Division of Industrial Accidents. I also understanc I may cont'act the California Contractors' State License Board (CSLB)at 1-800-321-CSLB (2752)or www.cslb.ca.gov for more',information about licensed contractors. f,�r�i 10. I am aware of and consent to an Owner-Builder building pE�rmit appliec�for in my name, and understand that I am the party legally and financially responsible for proposed constr��ction activity at the site address listed above. 'D�N 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builder��as well as employers. 0�12. I agree to notify the issuer of this form immediately of any;�dditions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by',laws designed to protect the pubiic. If you contract with someone who does not have a license, the Contr�ctors'State,License Board may be unable to assist you with any financial loss you may sustain as a result of a c��mplaint.Your only remedy against unlicensed Contractors may be in civit court. It is also important for you to undE�rstand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your��roperty, you may be held liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractors, you will be r.esponsible for verifying whether or not those Contractors are properly licensed and the status of their wor.kers'compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS:Please complete the following construction lending agency informaCion.) I hereby affirm that there is a construction lending agency for the perfc>rmance 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 city may be rec uired to be presented when the permit is issued to veri the ro e owners si nature. Property Owner's Signature: Date: -----------------•-------------------------------------------------------------------- ------------------------------------------------------ (NOTE: The following Authorization Form is required to be completed 5y the property owner only when designating an agent of the property owner to apply for a construction permit for the O Nner-Builder�. AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Properry Owner, the execution of which I undeistand is my personal responsibility, I hereby authorize the following person(s)to act as my agent(s)to apply for, sig i, 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: Tel No Address of Authorized Agent: I declare under penalty of perjury that I am the property owner for the�.ddress listed''above and I personally filled out the above information and certify its accuracy. Note:A copy of the properh�owner's driver's license, form notarization, or other veri�cation acceptab/e to fhe city may be required to be presented whE n the permit is issued to verify the property owner's signature. , Property Owner's Signature: Date:: ChvnerBuilderForn: 2010.doc revised 04/14/]0 � � ��, �� 1 r��"? ��''�.�,y�� ' ��r��1�' �'��,��` f L...lV a.A.1� !�� "�`��'�`�'�"` ,p�AJ G '��'��,,,, t--��,��;"�"'�..�n• f'�;�d+� ��-� d4'�'It�,VEU IN A�.� :)Nt�Ar� f :^:iTf� iNE CITYOF a� Q�,�. _.,_.��.�..�.�� CUPE f��iN�J G��Uk ' AN(�ORDINANCE`.� ; DATE__� 13 � ��_ _. � �v' U R RU lJ 1V� pE� � n SIGN�D�„' C I.�G�..Od� . fhi o� ��e�cat�ons MU�� U� '�IQ C �—�,HR��1�/� kept on the�oh at all times and it is ��.� ` �r �nl wf��to make any�.hanges or alteratio�� o same without written perm�ssion fro� �" � ... , th H��ildin Depariment,City of Cupertir� :�'��,.��.;,.�."�*J�„+'19;�''.`��' ,� Th stamping of th�s E�tan and specificatio�s �` g ,9�,,.�r ,. 4 a 5., F".. -rw S' Al l NOT br�held to permit or to be a� �+�q,y�,'� t ia;.�; �""'�M,. ';- �,� � �`"M,, a prova�ot the wol�tion of any provisior� � , . ��t.lr�y C:Ity�.irClin:i�'�:;P Ul `j131B l dW "`�.� '��:r=�.° a.�.»,6�a��e '�,�ra 8�,.,�•a=R a .. _. �`✓1 t'�;�l�'_r-/''�1#�1 V t��,f �. � � �� a�� -� �� c�� ; � . _ , � �� :� ;� ��.�... ��'"��1 � � _ _-.. �� s � *�„.�,,�"�°° .t � . `5 -� � �� -��. � �fl.� `S '��_? �� i�"n ' . . . n oor r u rry an n�s es 1.l�se i.�owiNo-'��C:Paint 1 IAC�/tiea th pts y�es � 2.Use Low VOC,N►ater-8ased�Nood Finishes 2 IAt�/Heelth pts y=yes � . � 3,Wse L�wlJ�ca��C Adhesirces 3 lA�/He�Ith pts y=yes . . � 4,Use Salvaged Materiafs for Interi�r Finishes 3 Resource pts y=yes � 5.Use Engineered Sheet Goods with no added UrEa Forma{dehyde 6lAQ1He�Jth pts y=yes 0 6.Use Exterior Grade Plywood for Interior Uses 1 IA(�1He�lth pts y=yes � 7 �eal.�l��+a� ---_-- - - 4 IAl?lHe��t�ts - as � 6.Use FSC Certified Materia{s for Interi�r Finish 4 Resour�:e pts y=yes � 9.Use Finger-Jointed or Recycled-Content Trim 1 Resour�:e pts y=yes � 0 10.Install Whole House Vacuum System 3 lAQ1He alth pts y=yes � _ 1 1 i N.Ffooring - 1.Select F5C Certified Wo�d Flooring 8 Resourc: pts y=yes 0 2.l�s2�api�y�a�en�ahfe�looripg Nlat�rials 4 Resouro 3 pts y=yes 0 3.Use Recycled Content Ceramic Tiles 4 Res�urc; pts y=yes o 4.Install Natural Linoleum in Place of Vnyl . 5 IAQ/He;dth pts y=yes � 5.Use Exposed Concrete as Fnished Floor 4 Resourc: pts y=yes � 6.Install Recycled Content Carpet with Low VOCs 4 Res�ur�e pts y=yes 0 _ � 1 i TQtal oints Available: 140 130 57 Tatal Roints Pro'ect Received: --� � �� , G:data/ptog�lgreenbuldngg�delines/2modelerslgreenpointsfina121204proteotedxis