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10060164 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10371 JOHNSON AVE CONTRACTOR:THOMAS LEIPELT PERMIT NO: 10060164 _ -OWNER'S NAME: THOMAS LEIPELT 10371 JOHNSON AVE DATE ISSUED:06/25/2010 OWNER'S PHONE: 4084223918 CUP[RTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 0 COMMERCIAL UPGRADE SERVICE PANEL License Class Lic.4 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 Valuation:$800 performance of the work for which this permit is issued. Sq.l t Floor Area: 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 APl Number:37518040.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I s s i iedl> <� Date: 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. RE-ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is insi ailed without first obtaining an inspection,I agree to remove all new materials for insl section. OWNER-BUILDER DECLARATION Sig nature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER the following two reasons: I,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) HAZARDOUS MATERIALS DISCLOSURE I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). 1'ka, I have read the hazardous materials requirements under Chapter 6.95 of the Ca lifornia Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three in.intain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Hi alth&Safety Code,Section 25532(a)should 1 store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and th:Health&Safety Code,Sections 25505,25533,and 25534. I have and will maintain Worker's Compensation Insurance,as provided for by �j — Section 3700 of the Labor Code,for the performance of the work for which this O vner or authorized aged �1}--�� —Date: 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 CONSTRUCTION LENDING AGENCY 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 I 1 iereby affirm that there is a construction lending agency for the performance of w)rk's for which this permit is issued(Sec.3097,Civ C.) forthwith comply with such provisions or this permit shall be deemed revoked'1f'1. L.-nder's Name APPLICANT CERTIFICATION Lender's Address 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 )n the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION �-mnify and keep harmless the City of Cupertino against liabilities,judgments, vests,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section L icensed Professional 9.18. w Date 4 j3 fit? Signat re �y•"P'� CITY OF CUPERrINO PERMIT RECEIPT OPERATOR: SylviaM 4 ITEMS OF 4 COPY # : 1 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 3751804C . 00 DATE ISSUED. . . . . . . BS00001(i102 RECEIPT #. . . . . . . . . REFERENCE ID # 10060164: SITE ADDRESS 10371 JOHNSON AVE SUBDIVISION . . . . . . . CITY CUPERTI40 IMPACT AREA . . . . . . OWNER THOMAS LEIPELT ADDRESS 10371 JOHNSON AVE CITY/STATE/ZIP CUPERTINO, CA 95014 RECEIVED FROM THOMAS LEIPELT CONTRACTOR LIC # *OWNER* COMPANY THOMAS LEIPELT ADDRESS 10371 JOHNSON AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW-BAL ---- __ ---- ---------- ------- ------ ----- 1 . 00 0 . 0 800 . 00 1 . 00 0 . 00 0 . 00 1BCBSC VALUATION 1 . 00 -}2 . 00 0 . 00 42 . 00 1EPERMITFE FLAT RATE 42 . 00 0 . 00 1ERT<200 UNITS 1 . 00 }2 . 00 0 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 X2 . 00 0 . 00 42 . 00 ----- ----- ---------- TOTAL PERMIT 127 . 00 0 . 00 127 . 00 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER -------------------- ----------------- --------------- CREDIT CARD 127 . 00 me --------------- TOTAL RECEIPT 127 . 00 OWNER-BUILDER DISCLOSUF:E FORM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 Is (408)777-3228• FAX(408)777-3333• �i 3 ;� ' = CUPERTINO Dear Property Owner(s): it has been submitted in your Harr a listing yourself as the builder of the property An application for a building perm improvements specified at: APN 77�_� ESITEADDRESS �v3-71 .�,o�� �� Ave.OWNER ADDRESS) 3� �� �Y�73�V A%a& ��M� �- ^Cyi DESCRIPTION OF WORK: UPG We are providing you with an Owner-Builder Acknowledgment 1 thic, pe�mitaissuedon en your Verification Form as the Owner-Builder. We your responsibilities and possible risk you may Inc y 9 of each will not issue a building permit until you have read, initialed An gent of owner cannot exe utelth s notice signed, nlessd returned this form to us at our official address In you,the property owner, obtain the prior approval of the permittinc authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFCIRMATION (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) I understand a frequent practice of unlicensed person;is to have the property owner obtain an"Owner- Builder" building permit that erroneously implies that the prop-rty owner is providing his or her own labor and material -Builder, may be held liable and su eject to seoertfin M cihom oal risk fwner's insurranceor any es sustained may not by personally. I, as an Owner an unlicensed person and his or her employees while working on my pro p Y Y 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. IT--;t 2. 1 understand building permits are not required to be s gned by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. 'r-c3k 3. I understand as an "Owner-Builder" I hminhea(cense sponsbContractorrecord having the permit filed inunderstand or her may protect myself from potential financial risk by 9 name instead of my own. uired by law to be licensed and bonded in California and to list their license 't�_4. I understand Contractors are req numbers on permits and contracts. ny pe-sons, -��5. I understand if I employ or otherwise hug total value of my construction is at least five dred dollars ($500),1 including Clabo� licensed Contractors, and the materials, I may be considered an"employer" under state and federal law. r with the state a6. I understand if I am considered an "employer"oorkees' compenr state sation onral law, I must disability insuranceeand contribute t and federal government,withhold payroll taxes, pr unemployment compensation for each"employee." I also understand my failure to abide by these laws may subject me to serious financial risk. -T-a7. I understand under California Con{hem with the intent to offer them Lic,-nse Law, an Ohbuilds for sae, unlesswork is performed by residential structures cannot legally build licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. j!!!=$. 1 understand as an Owner-Builder if I sell the prope ly for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsegi ent owner(s)that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm_2010.doc revised 04/14/10 _T__�9. 1 understand I may obtain more information regarding ray 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 understand I may contact the California Contractors'State w License Board (CSLB)at 1-800-321-CSLB (2752)or ww.cslt,.ca.gov for more information about licensed contractors. —=k 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. JD_11. 1 agree that, as the party legally and financially respo isible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. 7!�M2. 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 contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result )f 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 he responsible for verifying whether or not those Contractors are properly licensed and the status of thei-workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS:Please complete the following construction lendirg agency information.) I hereby affirm that there is a construction lending agency for thy; 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 cc mpleted and signed by the property owner and returned to the agency responsible for issuing the permit. Vote: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 si nature. L121,I d Property Owner's Signature: X71 -2--�= Date: - - -------------- ------------------------------------------------------------------------------------------------------- (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 permit 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 `or, 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 driver's license, form notarization, or other verification acceptable to the city may be required to be presen`ed when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwneiBuilderForm_2010.doc revised 04114/10 CITY OF CUPI:RTINO CITY OF CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM Date: APN # � l Building Address: Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes No HOA: (Exterior work only) Yes ❑ No If es, r ovide letter from HOA Phone#: Owner's Name: y®g. Lt 2Z 3S I Phone: Contractor: CX"—N,�`-� Fax: Contractor License#: Cu ertino Business License#: Phone: Contact: Fax: Residential Commercial Job Description: Building Permit into: El!ec Plurr b ❑ Mech ❑ tdOccupancy Type: onstruction (Usage ): n '3 ❑ II/IIUV-A UIII B, IV-HT,V-B [r \�— Square Footage: Valuation:"d ,©e� Project Size: Express��dd ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of tl�e Green Buil et& the sheetindext & attach it to the application or if applicable, ins:lude in plan s Points Achieved: IFor help, contact Build it Green at www.builditgreen.)r Revised 07/14/09 CITY OF CUPI:RTINO CITY of GENERAL BUILDING APPLIGATION CUPEkT1NO FEE SCHEDULE Fee Description Fee Permit Type Quantity/Sf Fee ID Group 1GENRES or 1GENCOM 1STUCOAP Stucco Applications (up to 400 sf) B additional stucco application 1 WINREP Replacement windows/sliding glass B door (ea 8 windi 1 WINMEWSTR New Window-st-uctural shear B wall/masonry (ir_cludes Ian ck fee) 1 EPERMITFEE Electrical Permi:Fee E 1 MPERNIITFEE Mechanical Pennit Fee M plumbing Perm t Fee P 1 PPERNIITFEE g 1 ELCPLNCK Stand Alone El.ctric Pln Ck(hourly) E 1 MECPLNCK Stand Alone MI-chanical Pln Ck (hrly) M 1PLMBLNCK Stand Alone Plumbing Pln Ck(hrly) P 1 STPLNCK-(3 Hr Min Standard Plan Zheck (when no E/M/P) B when not over counter) hourly-stand a:one 1BCBSC Cal Bldg Standards Commission Fee B ALL EP ES 1BSEISMICRRMIT t Seismic Residential B 1BSEISMICO Seismic Commercial B 1 TRAVDOC Travel &Documentation B 1BUSLIC Business Lic(,nse B 5 of 5 .Indoor AJr ouality and Finislies 0 1.U=Low!NcA'IC Pitt 1 IAQ/Hei1th pts Y=Yes 2 M/HeAh is - es 0 2.Use Low VOC,1Nater-Based Wood Finishes p y-Y 0 31AQ/He filth pts y=yes 3.Use Low'Nc>VOC Adhesives 0 4.Use Salvaged Materials for Interior Finishes 3 Resour.e pts Y--Yes 5,Use Engineered Sheet Goods with no added Urea 6 IAQ/He3p Y-y1th is es 0 Formaldehyde 0 6.Use Exterior Grade PIYwoodfor Interior Uses 1 IAQMealth pts y=yes 0 �, �er M®F 4 IAQ/HE alth pts y=yes 0 '.3sal aN Egwaad 8.Use FSC Certified tJiaterials for Interior Finish 4 Resou ce pts Y=yeS 0 9.Use Finger-Jointed or Recycled-Content Trim 1 Resou ce pts y=yes 0 10.Install Whole House Vacuum System 3 IAQ/H aalth pts Y=yes 14.Flooring 0 Y= Yes yy 1.Select FSC Certified Wood Flooring B Resour;e p 0 2.Jsa RocRocty Ren,.vraDle boring i,Aaferias 4 RBSOur:e pts Y=YeS 4 RBSour3e pts MaS 0 3.Use Recycled Content Ceramic Tiles 0 4.Install Natural Linoleum in Place of Vinyl 5 IAQIH:alth pts Y=yes 4 Resou ce is - es 0 5.Use Exposed Concrete as Finished Floor p y-y 0 6.Install Recycled Content Carpet with Low VOCs 4 Resou ce pts y=yes Totsl Points AvaE�s�Fe: 1�0 130 57 p 01 0 Tuts! Pants Project received: G:datalprogslgreenbuildinc guidelines/remodelersigreenpointsiinal2 l2.D4proteoted.xls