10070096 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7463 TIPTOE LN CONTRACTOR:DOVETAIL DESIGN& PERMIT NO: 10070096
CONSTRUCTION
^WNER'S NAME: JOHN SHELCHUK 7463 TIPTOE LN DATE ISSUED:07/14/2010
.>WNER'S PHONE: 4153785989 CUPERTINO,CA 95014 PHONE NO:(408)255-3379
❑ LICENSED CONTRACTOR'S DECLARATIONF
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH RESIDENTIAL r- COMMERCIAL�
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVAL OF EXISTING REAR SHED ROOF.REFRAME
(commencing with Section 7000)of Division 3 of the Business&Professions NEW
Code and that my license is in full force and effect. T-0 EAVE. INSTALL BEAM BRACKETS FOR FUTURE
TRELLIS
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. Sq.Ft Floor Area: Valuation:$1500
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:35928005.00 Occupancy Type:
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, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
S;-nature Date Issued by: Date:
Id" OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code. C
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the followivolfree
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
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 read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by
compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this
Safety Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District 1 will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I Health&Sa e, eC[tatrs Vj505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must-
forthwith comply with such provisions or this permit shall be de me ( Date: 7/O� enf: 7;2 / ro
APPLICANT CERTIFICATION L CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above in ormation is
correct.I agree to comply with all city and county ordinances and state laws relating I hereby affirm that there is a construction lending agency for the performance of work's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
the above mentioned property for inspection purposes.(We)agree to save Lender's Name
,nify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source r a ions er the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18.
I understand my plans shall be used as public records.
Signature__��/J___/`
Date—7/14/Jo -
Licensed Professional
CITY OF CUPERTINO
2 ITEMS OF 2 PERMIT' RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Bl}:: Lot:
APN 35`.328005 .00
DATE ISSUED. . . . . . . : 07,14/2010
RECEIPT #. . . . . . . . . BS1)00010857
REFERENCE ID # . . . : 10)70096
SITE ADDRESS 7453 TIPTOE LN
SUBDIVISION . . . . . . .
CITY CU?ERTINO
IMPACT AREA . . . . . .
OWNER JOIN SHELCHUK
ADDRESS 7463 TIPTOE LN
CITY/STATE/ZIP CUPERTINO, CA 95014
RECEIVED FROM JOHN SHELCHUK
CONTRACTOR JOHN SHELCHUK LIC # 25154
COMPANY DOVETAIL DESIGN & CONSTRUCTION
ADDRESS . . . . . . . . . . : 7463 TIPTOE LN
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE (408) 255-3379
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ---------- -----
1BCBSC VALUATION 1, 500 . 00 1 .00 0 . 00 1. 00 0 . 00
1STPLNCK HOURS 1 . 00 126 . 00 0 .00 126 . 00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 127 .00 0 . 00 127 . 00 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- ------------------
CREDIT CARD 127 .00 VISA
---------------
TOTAL RECEIPT 127 . 00
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: DATE. REVIEWED BY:
APN: BP#: l (1 C( *VALUATION: 1$1,500
PERMIT TYPE: Building Permit PLA v CHECK TYPE: Alteration /Addition / Repair
PRIMARY OVER THE
APPLICATION 1 R3SFDADD/REM
USE: SFD or Duplex COUNTER? 0 Yes No TYPE:
MECHANICAL 0 Yes O No PLUMBING Q Yes Q No ELECTRICAL Q Yes O No
xW
O �
3 �
OCCUPANCY TYPE: TYPE OF FLR.AREA PC FEES PC FEE ID BP FEES BP FEE ID
CONSTR.
R-3 (Custom) II-B,111-B,IV,V-B $0.00 $0.00
TOTALS: 0 $0.00 $0.00
NOTE: These fees are based on the preliminary information available and are onl an estimate. Contact the De t or addn'1 info,
FEE ITEMS (Fee Resolution 09-051 Etf.' '7/09) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $(1.00 Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: O Reg. () OT 0.0 hrs $(1.00
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee:O Reg. 0 OT 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Acoustical Fee: 0 Yes O No $0.00
Work Without Permit? Q Yes O No $0.00 O
Planning Fee: $0.00 Select a Non-Residential O
Building or Structure
Strom Motion Fee: IBSEIS� $).50 1.0 hrs Standard Hourly Rate
Bldt= Stds Commission Fee: 1BCBSC $1.00 $126.00
SUBTOTALS: $1.50 $126.00 TOTAL FEE: $127.50
Revised: 6/30/2010
CITY OF CUPERTINO
OF
CUPEl�T1NO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # Date:-
Building
aterBuilding Address:
q103 -/)P701, L�d Lv' E',Iwo
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes No
HOA: (Exterior work only) No 01, If --es, provide letter from HOA
O er's e: Phone#:
N � 15--
Contractor: Phone:
1& T S F o r
Fax: lo$ - 75--5-- 3 3-7
Contractor License#: ALS
Cuertino Business License#:
Contact: � Phone: �!l
"-)e J tiizeFax: -Joe, 2SS•3
Residential Commercial
Job Description: 7)g�'10✓�� o` -) �itA�' SJd rvz>F
fG !n S'ri1,-, ` d LArl 'B94qCk 4'�, of .
Building Permit Info:
' Bld -rf-~ Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT,V-]3 :: _
Valuation: Square ootage:
Project Size: Express Standard ❑ Larg
e Q Ma ori ❑
Green Building: Please complete relevant portion of the Green Bu' ding/LEED Checklist& attach it
to the application or if applicable, include in plan set& the sheet index.
''oints Achieved:
eor help, contact Build it Green at www.builditgreen.or �
Revised 07/14/09
s
RESIDENTIAL PROJECT COVER SHEET
Assessor's Parcel Number: S� SUS+
Name of owner. A��AU &F,
Project address. X9,3 t
Contact person. io,tj -Phone. 3�f3•
Fax. -IDS - 2,S` 33�
Net square footage of lot.
Existing Proposed
Square footage: First floor: _ ug At'cURr)AN�, f Vffi,l THE CITY OF
Second floor: CUPERTINO CODE�,AND ORDINANCES
Garage: — -----"` -l- -.--/4,-,
TOTAL: _
his set of plans and specifications MUST
Are there at least two 10 foot by 20 foot clear spaces inside the garage?'�l�ept on the lob at all times and it is
unlawful to make any changes or alterations
on same without written permission from
Is privacy protection planting required for the project? Y N the Building
Department,
sfCii�no.Te stamping of plan and pefica
SHALL NOT be held to permit or to be an
wild it Green Total Poi approval of the violation of any provisions
of any City Ordinance or State Law.
On what floor(s) is work being done? ( _
Brief description of work. --9F-'2OVF_ ��'�� S�G�
tAJc, )n5 T^- ,- u CIA"I �QG Cka fS --o -?�v v2� ? 2�Lt_ S
Code editions: 2007 CBC d)N)2007 CFC (Y -N)2007 CMC (Y-N)
2007 CPC (Y-N)2007 NEC (Y -N)
Effective 1/l/08 '
Plan Review Process Work Book Page-8-Revised 8/05/08
Al
19
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OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228- FAX(408)777-3333•`�i�in�i �a��i� -�-�
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 PDRESS AP N �� BP#��lv 7,:!::)((P, Gv 71
OW ER NAMF., OWNER ADDRESS
DESCRIPTION OF WORK: elF �n�, S�'� Q F �L r3c t 5 k( 2 t_U
1 -Y SC6C - "r F!_-,-rz/r-E i
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 indicated. An agent of the owner cannot execute this notice unless
you,the property owner, obtain the prior approval of the pe-mitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement belt w to signify you understand or verify this information.)
understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Builder"building permit that erroneously implies that th; 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.
x� 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
l'-X�the construction and are not hiring a licensed Contractor to assume this responsibility.
3. I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
rotect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
4. 1 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
j 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.
6. 1 understand if I am considered an "employer" L nder state and federal law, I must register with the state and
9- f?d eral government,withhold payroll taxes, provide wo-kers'compensation disability insurance, and contribute to
unemployment compensation for each "employee." I al 30 understand my failure to abide by these laws may subject
me to serious financial risk.
S 7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures c oes not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general budding Contractor.
I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
ny financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
(/1177eTBuilderF01771 2010.doc revised 04114110
. I understand I may obtain more information regarding my obligations;as an "employer"from the Internal
venue Service, the United States Small Business PArninistration,the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I al:3o understand I may contact the California Contractors'State
License Board(CSLB)at 1-800-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed
contractors.
�� I am aware of and consent to an Owner-Builder building permit applied for in my name,and understand that I
the party legally and financially responsible for proposed construction activity at the site address listed above.
11. 1 agree that, as the party legally and financia ly responsible for this(proposed construction activity, I will abide
all applicable laws and requirements that govern C wner-Builders as welVas employers.
. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
*12
mation I have provided on this form. Licensed coitractors are regulated by laws designed to protect the public. If
ontract with someone who does not have a licer se, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as 3 result of a complaint: Your only remedy against unlicensed
Contractors may be in civil court. It is also important f)r you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while woi king 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 he responsible for verifying whether or not
those Contractors are properly licensed and the statu 3 of their workers'compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following constructicn lending agency information.)
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 permit. Note:A copy of the property owner's driver's license,
form notarization, or other veriticn acc le t e-r-*ty may be required to be presented when the permit is issued
to verifythe property owner's natu e.
Property Owner's Signature: - Date:
-- ------------------�-:------------------:------- ------------------------ - --- - - - - -
(NOTE: The following Authorization Form is required to tie completed by the property owner only when designating an
agent of the property owner to apply for a construction pE rmit 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: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property cwner for the address listed above and I personally filled out the
above information and certify its accuracy. 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 T resented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
6�4,nerBuilderForm 2010.doc revised 04/14/10