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10060103 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10445 BYRNE AVE CONTRACTOR:SEEMA SHENVI PERMIT NO: 10060103 OWNER'S NAME: SEEMA SHENVI 1044:;BYRNE AVE DATE ISSUED:06/17/2010 F 'PER'S PHONE: 4084609394 CUP ERTINO,CA 95014 PHONE NO: LI LICENSED CONTRACTOR'S DECLARATIONr BUI:.,DING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH r- RESIDENTIAL r- COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:NEW STUCCO(AFTR RMVING EXSTNG STUCCO (commencing with Section 7000)of Division 3 of the Business&Professions PANI:LS,APX Code and that my license is in full force and effect. 1900'',QFT&REPLACING 7 SINGLE PANE WINDOWS 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 Sq.Ft Floor Area: Valuation:$10500 permit is issued. APPLICANT CERTIFICATION APN Number:35712036.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued by:, Date: Gt �� Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All rc ofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspe tion. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) - - Signz ture of Applicant: Date: 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. Calif)rnia Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by comF liance 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. Addi:ionally,should I use equipment or devices which emit hazardous air permit is issued. conU minants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Healr h&Safety Code,Sections 25505,25533,and 25534. 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 Owner or auth agent: forthwith comply with such provisions or this permit shall be deemed revoked. , 6000 Date: �1 /10 APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for w rich this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address r and expenses which may accrue against said City in consequence of the L ig of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION wun all non-point source regulations per the Cupertino Municipal Code,Section 9.18. I un&rstand my plans shall be used as public records. Signature 4y�N Date Licer sed Professional CITY OF CUE ERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 35712C36 .00 DATE ISSUED. . . . . . . : 06/17/ 2010 RECEIPT #. . . . . . . . . BS000C10649 REFERENCE ID # . . . : 10060103 SITE ADDRESS . . . . . : 10445 BYRNE AVE SUBDIVISION . . . . . . CITY CUPE R7I NO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : SEEMA SHENVI ADDRESS . . . . . . . . . . : 10445 BYRNE AVE CITY/STATE/ZIP . . . : CUPER-INO, CA 95014 RECEIVED FROM . . . . : SEEMA R SHENVI CONTRACTOR . . . . . . . : LIC'. # *OWNER* COMPANY SEEMA SHENVI ADDRESS 10445 BYRNE AVE CITY/STATE/ZIP . . . : CUPER-INO, CA 95014 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ----------- ---------- ---------- ---------- 1BCBSC VALUATION 10, 500 . 00 1 . 00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 10, 500 . 00 1 .10 0 . 00 1. 10 0 . 00 1STUCOAPP SQ FEET 1, 900. 00 571 . 00 0 . 00 571 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 .00 1WINREP EACH 8 1. 00 : 80 . 00 0 . 00 380 . 00 0 . 00 ----------- ---------- ---------- ---------- TOTAL PERMIT 995 .10 0. 00 995. 10 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- - ------------------- CREDIT CARD 995 .10 V'-SA --------------- TOTAL RECEIPT 995 .10 OWNER-BUILDER DISCL0,3URE FORM COMMUNITY DEVELOPMENT DEPARTMEAT-BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 35014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333- oci d no5cjoeainc.orc 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 APN BP# 1044 r7 0YRtvE ave• CU PERT 1r►D C A OWNER NAME OWNER ADDRE:iS 5106101 $NE,NV I 1oU4.5 Ewlzw6 '1g1 E. GUPERtIIVO C)A DESCRIPTION OF WORK: NEW SIU CGO - EPLPI C k IN(-AIt-J0OV,)s We are providing you with an Owner-Builder Acknowledgment end Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having :his 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. P.n 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 OF INFORMATION (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) 1. 1 understand a frequent practice of unlicensed persc,ns is to have the property owner obtain an "Owner- Builder" building permit that erroneously implies that the prc,perty owner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable and :ubject 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 e n Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. 1/2. 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. ✓' 3. 1 understand as an "Owner-Builder" I am the respon 3ible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensod Contractor and having the permit filed in his or her name instead of my own. V4. 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. 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 dollarE ($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" 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 ur derstand my failure to abide by these laws may subject me to serious financial risk. `�7. 1 understand under California Contractors' State LicE!nse 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 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 any financial or personal injuries sustained by any subsequE!nt owner(s)that result from any latent construction defects in the workmanship or materials. OwnerBuilderFornt 2010.doc revised 04/14/10 ✓ 9. 1 understand I may obtain more information regarding my obligations as an "employer"from the Internal Revenue Service, the United States Small Business Administration,the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also u iderstand I may contact the California Contractors'State 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-Builder t:uilding permit applied for in my name, and understand that I am the party legally and financially responsible for propos:d construction activity at the site address listed above. --L1-1 1. 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-Builders as well as employers. 111�12. 1 agree to notify the issuer of this form immediate y 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 license, t)e 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 working on your property,',you may be held liable for damages. If you obtain a permit as Owner-Builder and wish to hire Cor tractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of t-ieir workers'compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS:Please complete the following construction lending agency information.) I 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 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 me y be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: v1 Date: 6 6 `�C�10 - - - ----------------------------------------------------------------------------- -- - --- --- ---- -- - - (NOTE: The following Authorization Form is required to be coripleted by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner-Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of whici- 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 owner fir the address listed above and I personally filled out the above information and certify its accuracy. Note:A copy of the property owner's d'river'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: OwnerBuilderFornr2010.doc revised 04/14/10 C 0144 y E!>y K N E, AV E G4:, �, 1r2�j1 e_ce— C t? l�31 ti� APPROVED INA v`7THTHE CITY F TINO CODES AND ORDINAN ES ATE GN This se of plans and specifications M ST be ke t on the job at all times and it i unlawful make or alterati me without written permission from the Building Department,City of Cupertino The stamping of this plan and specifications SH be a approval of the violation of any provision 1 of:any City Onfir)_,nce or State Law. pj�DfI X I-tI CIO ' � 0 � CITY OF CUPERTINO CUPERTINO GENERAL ]BUILDING PERMIT APPLICATION FORM APN Date: 6 l ( b 1 20( 0 1 -2 03 Building Address: 10LA45 eYKNe, RvE. C�ca ��K'F IN10 C-A Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes 0 NocQ HOA: (Exterior work only) Yes ❑ No ® If yes, provide letter from HOA Owner's Name: .5 E EM 1� S RE�W ) Phone#: U _ 4(-, Contractor: Phone: + OWN& W_ 12::.vl L�DE R Fax: Contractor License#: Cupertino Business License#: Contact: S G E t`�q 5}t ENU ► Phone: L1 p' _ 4LO - 93,J ti Fax: Residential Commercial Job Description: We W ST GL© RFtER f<.gMa\1kN61 E XtSI IN 6q S1�3c(.o PANF,LS A') ul 1900 Pit cosi n I000! 2. (2GPc.Ac\Nc� `t s�N�+tr� PAN"e Wkt4DOv5 35001 Building Permit Info: Bldg Elect ❑ Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B [r Valuation- Square Footage: IOSDO Project Size: Express ['Standard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of tb a 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.builditgreen.c r Revised 07/14/09 CITY OF CUPERTINO C U CITY OF O GENERAL BUILDING APPLICATION FEE SCHEDULE Quantity/Sf Fee ID Fee Description Fee Permit Type Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement vindows/sliding glass B door (ea 8 wi zdows) 1WINMEWSTR New Window-structural shear B wall/masonry (includes plan ck fee) IEPERMITFEE Electrical Pennit Fee E 1 MPERMITFEE Mechanical Pormit Fee M 1PPERMITFEE Plumbing Pennit Fee P 1 ELCPLNCK Stand Alone Electric Pln Ck(hourly) E 1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M 1 PLMBLNCK Stand Alone F lumbing Pln Ck(hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B when not over counter) hourly-stand a lone 1BCBSC Cal Bldg Stan3ards Commission Fee B ALL PERMIT ' TYPES I 1BSEISMICR Seismic Residential B 1BSEISMICO Seismic Commercial B 1TRAVDOC Travel &Documentation B 1BUSLIC Business Lice:ise B 5 of 5 w M.Indoor Air Ouality and Finishes 1.Use Low/NO-VOC Paint 1 IA(lHealth pts y=yes 0 2.Use Low VOC,Water-Based Wood Finishes 2 IAO,Health pts y=yes 0 3.Use Low/No VOC Adhesives 3 IAC,Health pts y=yes 0 4.Use Salvaged Materials for Interior Finishes 3 Res)urce pts y=yes 0 5.Use Engineered Sheet Goods with no added Urea Formaldehyde 6 IAO,Health pts y=yes 0 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ,Health pts y=yes 7.Seal all Exposed Particleboard or MDF 4 IAO,Health. pts y=yes 0 8.Use FSC Certified Materials for Interior Finish 4 Res)urce pts y=yes 0 9.Use Finger-Jointed or Recycled-Content Trim 1 Res)urce pts y=yes 0 10.Install Whole House Vacuum System 3 IAC/Health pts y=yes 0 1 1 N.Flooring 1.Select FSC Certified Wood Flooring 8 Resoirce pts y=yes 0 2.Use Rapidly Renewable Flooring Materials 4 Resoirce pts y=yes 0 3.Use Recycled Content Ceramic Tiles 4 Resoirce pts y=yes 0 4.Install Natural Linoleum in Place of Vinyl 5 IAQ/-lealth pts y=yes 0 5.Use Exposed Concrete as Finished Floor 4 Resoirce pts y=yes 0 6.Install Recycled Content Carpet with Low VOCs 4 Resoirce pts y=yes 0 1 ! b Total Points Available: 1 1401 130 57 Total Points Project Received: _ 1 01 01 0 �t G:data/progs/greenbuilc inc guidelines/remodelers/greenpointsfinal2.12.04protected.xls