10060128 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20025 DE PALMA LN CON TRACTOR:JEAN&AGNES POMMIER PERMIT NO: 10060128
OWNER'S NAME: JEAN&AGNES POMMIER 2002'DE PALMA LN DATE ISSUED:06/21/2010
!NER'S PHONE: 4089967552 CUP�RTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUI--DING PERMIT INFO: BLDG ELECT I— PLUMB
License Class Lic.# MECH RESIDENTIAL r— COMMERCIAL
Contractor Date
JOB DESCRIPTION: WINDOW RREPLACEMENT LIKE FOR LIKE NO
I hereby affirm that I am licensed under the provisions of Chapter 9
STRi rCTURE
(commencing with Section 7000)of Division 3 of the Business&Professions CHA,IGES,BEDROOMS TO MEET EGRESS REQUIREMENTS PER
Code and that my license is in full force and effect. 2007
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.1't Floor Area: Valuation:$10625
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is API` Number:36932054.00 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, ;HERMIT 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.
Date Issued b Date:
Signature y:
uu 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 i oofs shall be inspected prior to any roofing material being installed.If a roof is
I,as owner of the property,or my employees with wages as their sole compensation, inti lied 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, insp xtion.
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to Sigr ature of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code). /Jr�
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
performance of the work for which this permit is issued. I ha ve read the hazardous materials requirements under Chapter 6.95 of the
Cal fornia Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by
con pliance 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 I 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 Hei Ith&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must
Owner an
forthwith comply with such provisions or this permit shall be deemed revoked. zed agent:
Date: 06
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
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 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 vhich this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
-mnify and keep harmless the City of Cupertino against liabilities,judgments,
,and expenses which may accrue against said City in consequence of the Lender's Address
gianting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18.
I ur derstand my plans shall be used as public records.
Signature �� Date 0111 /
Licensed Professional
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # : 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 3693201-4 . 00
DATE ISSUED. . . . . . . : 06/21/::010
RECEIPT #. . . . . . . • • : BS0000:-0669
REFERENCE ID # . . . : 100601:?8
SITE ADDRESS 20025 :)E PALMA LN
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER JEAN & AGNES POMMIER
ADDRESS . 20025 DE PALMA LN
CITY/STATE/ZIP CUPERTINO, CA 95014
RECEIVED FROM AGNES A POMMIER
CONTRACTOR LIC # *OWNER*
COMPANY . . . . . . . . . . : JEAN & AGNES POMMIER
ADDRESS . 20025 DE PALMA LN
CITY/STATE/ZIP CUPERTINO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC --NEW-BAL-
---------- -------------
----------
----
1BCBSC VALUATION 10, 625 . 00 1 . 00 0 .00 1 . 00 0 . 0
1BSEISMICR VALUATION 10, 625. 00 1 .10 0 .00 1 .10 0 . 00
1WINREP EACH 8 1. 00 :180 .00 0 . 00 380 . 00 ------ -- --
TOTAL PERMIT
382 .10 0 . 00 382 .10 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
-----------------
--------------- - --------------
CREDIT CARD 382 . 10 VISA
---------------
TOTAL RECEIPT 382 .10
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333- Duiid no5cuoemn3.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 "�, APS 7
BP
OWNER NAMEJ ,I / pO OWNER ADDRESS //
JCcz/� Q /Yn�l lc�i?1T/rer- 2-80,25- ins L��ne
DESCRIPTION OF WORK: �n�pry �Gcxmc�
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, initialeJ 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 permit ing authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF IN FORMATION
(DIRECTIONS:Please read and initial each statement below tc, signify you understand or verify this information.)
�, ' 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 work ng 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. 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 responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensad 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 PE rsons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollar:;($500), including labor and materials, I may be
considered an"employer" under state and federal law.
4'7 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 worker:'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.
,47. 1 understand under California Contractors' State Licimse Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the inte it 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 buildinc 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 subsequ,:nt owner(s)that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04/14/10
04�_9. 1 understand I may obtain more information regarding my obligations as an"employer"from the Internal
Revenue Service, the United States Small Business Adminir,tration,the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB)at 1-800-321-CSLB (2752)or www.c:;lb.ca.gov for more information about licensed
contractors.
f ' 10. 1 am aware of and consent to an Owner-Builder bui ding permit applied for in my name, and understand that I
am the parry legally and financially responsible for proposed construction activity at the site address listed above.
11. 1 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-13uilders as well as employers.
.R!t 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractc rs are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, this Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a resu t 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 Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of th air workers'compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lencing agency information.)
I hereby affirm that there is a construction lending agency for t-ie performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Ad Jress:
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 ma y be required to be presented when the permit is issued
to verify the property owner's si nature
Property Owner's Signature: Date: O6/22oiy .
- - -- -- -- ---- ---- -----------------------------=--------- - - ---------------W-tj----------------------------------------
(NOTE: The following Authorization Form is required to be cor ipleted by the property owner only when designating an
agent of the property owner to apply for a construction permit f�r the Owner-Builder).
AUTHORIZATION OF AGENT TO ACTON 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 owner 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 presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Gate:
OwnerBuilderForn: 1010.doc revised 04/14/10
14-SM, CITY OF CUPERTINO
CITY Of
CUPEkTINO GENERAL BUILDING
PERMIT APPLI(:ATION FORM
APN # - (0 9 3 C.:5-4 Date: 06 12 1 1 2 ol o
,
Building Address:
0015` (7C P,4LMA LANE, Cclrc7zTcvu , � cJ57&/c.f
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this pi-oject? Yes ❑ No LT
HOA: (Exterior work only) Yes ❑ No ❑If Yes, provide letter from HOA
Owner's Name: __-_ _ 1 Phone#: 408) _
Cont ctor: Phone:
a ' ix:
C Zntractor License#:
Cupertino Business License#:
Contact: Phone:
Fax:
Residential Commercial ❑
Job Description: (ill`.x{ovv rePlhcelneAl- - f•jC-e ,�� 1 re
ret vt-✓ �r Zp 0 7
Building Permit Info:
Bldg E3- Elect ❑ Plu nb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B [l/ --.3
Valuation: Square Footage:
Project Size: Express QlStandard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of 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.builditgreen.-Lr
Revised 07/14/09
CITY OF CUPERTINO
CITY OF GENERAL BUILDING APPLICATION
CUPEt�T1N0
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 Nvindows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/masonry ;includes plan ck fee)
I EPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechanical Pormit Fee M
1PPERMITFEE Plumbing Pen-nit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck(hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1PLMBLNCK Stand Alone Plumbing Pln Ck(hrly) P
1 STPLNCK-(3 Hr Min Standard Plar. Check (when no E/M/P) B
when not over counter) hourly-stand clone
1 BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
/ TYPES
1BSEISMICR Seismic Residential B-
1BSEISMICO Seismic Commercial B
1 TRAVDOC -Travel &Do,:umentation B
1 BUSLIC Business Lic-,nse B
5 of 5