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10060042 CITY OF CUPERTINO BUILDING PERMIT CONTRACTOR:SALTZMAN DAVID A AND PERMIT NO:10060042 ;ILDING ADDRESS: 11000 MARIA ROSA WAY KRISTINYi M DATE ISSUED:06/08/2010 JWNER'S NAME: SALTZMAN DAVID A AND KRISTINA M CUPERI INO CA, 95014-4720 PHONE NO: OWNER'S PHONE: ELECT PLUMB CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG 0 LICENSED COMMERCIAL Lie.# METH RESIDENTIAL License Class Date JOB D'ASCRIPTION:DEMO 7ACCUZI,INCLUDES ELECTRICAL&PLUMBING Contractor 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 Valuation:$2000 Compensation,as provided for by Section 3700 of the Labor Code,for the Sq Ft Floor Area: performance of the work for which this pensationit is tInsurrance,as provided for by I have and will maintain Worker's Comp Occupancy Type APN Piumber:35618002.00 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION IS NOT STARTED I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORKIT ISSUANCE OR correct.I agree to comply with all city and county ordinances and state laws relating `WITHIN 180 DAYS OF PERM to building construction,and hereby fornsauthorize ectionrpurposeseS of th(We)agree to saveis city to r upon the above mentioned property P ]g0 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, against said City in consequence of the �Ld costs,and expenses which may accrue ag 1. ant understands and will comply Date granting of this permit. Additionally,the app Issu:d by,� ah all non-point source regulations per the Cupertino Municipal Code,Section 8. Date Signature RERE_R _ rial being installed.if a roof is All i oofs shall be inspected prior to any roofing mate OWNER-BUILDER DECLARATION inst died without first obtaining an inspection,I agree to remove all new materials for insf ection. I hereby affirm that I am exempt from the Contractor's License Law for one o Date: the following two reasons:or my employees with wages as their sole compensation, Sig iature of Applicant: I,as owner Oft c property, will do the work,and the structure is not intended or offered for sale(Sec.704 , ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contr s to HAZARDOUS MATERIALS DISCLOSURE ofessions Code). "� construct the project(Sec.7044,Business&Pr I hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements under and Chapter 6.9I of the maintain Code,Sections 25505, declarations: P ter 9.12 and the Health& rnia Section 3700 of the Labor Code,for the cc mpliance with the Cupertin should I storeoorehand Chapter material. I have and will maintain a Certific Sec f Consent to self-insure for Worker's C`fe y Code, d QSection 25532(a) Compensation,as provided for by S ty or devices which emit hazardous air provided for by Additionally,should I use equipment ll performance of the work for which this permit is issued. Area Air Chapter 9.12 and the have and will maintain Worker's Compensation Insurance,as p c mtaminants as defined by the BaMunicipal ode,Chapteragement District w� I maintain compliance with the Cupertino Section 3700 of the Labor Code,for the performance of the work for which this I maintain ealth&Safety Code,Sections 25505,25533,and 25534. permit is issued. r+� r I certify that in the performance of the work for which this permit is issued,I shall Date: ZS not employ any person in any manner so as to become subject to the Worker's t)�vey� o r authorize agent: his cate of Compensation laws e California. If,aftersa onnrng provisions ons of the Labor Codte,I must II CONSTRUCTION LENDING AGENCY P become subject to the Worker's Comp g for the performance of work's forthwith comply with such provisions or this permit shall be deemed revolted/ I hereby affirm that there is a construction lendin agency APPLICANT CERTIFICATION \v/ for which this permit is issued(Sec.3097,Civ C.) ation Is rtify that I have read this application and state hat the eii above and state laws relating Lender's Name :ect.I agree to comply with all city and county to building construction,and hereby authorize representatives of this ee osave er Lender's Address upon the above mentioned property for inspection purposes.(We) g indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply I understand my with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional L re CITY OF CUPERrINO PERMIT RECEIPT OPERATOR: TraciC 3 ITEMS OF 3 COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot : APN 3561800 - 00 DATE ISSUED. . . . . . . : 06008/20183 RECEIPT #• • " ' 1006004:? REFERENCE ID # • • SITE ADDRESS 11000 M.%RIA ROSA WAY SUBDIVISION • • • . . . : CUPERTIVO CITY . . . . . . . . . . . . IMPACT AREA • • • • • • OWNER SALTZMAN DAVID A AND KRISTINA ADDRESS 95014-4720 CITY/STATE/ZIP CUPERTINO CA, RECEIVED FROM VICKI I,YNN GEERS CONTRACTOR LIC # *OWNER* COMPANY . . . . . . . . . . : SALTZMIN DAVID A AND KRISTINA r ADDRESS . . . . . . . . . . 95014-4720 CITY/STATE/ZIP : CUPERT'--NO CA, TELEPHONE . . . . . . . . . UNIT QUANTITY AMOU\IT PD-TO-DT THIS REC --NEW-BAL- FEE ID ---------- ---------- ---------- 0 . 00 -------- ---------- ---------- 1 .00 0 . 00 1 . 00 1BCBSC VALUATION 2, 000 . 00 0 . 00 0 . 50 0 . 00 2, 000 . 00 0 .50 0 .00 1BSEISMICR VALUATION 1 . 00 126 .00 0 . 00 126 . 00 --------- STAFFTIM HOURS -- - ---- ----- ------0 .00 127 . 50 0 . 00 127 . 50 TOTAL PERMIT : METHOD OF PAYMENT AMOUNT REFERENCE NUMBER --- ------------ -------- ----- CREDIT CARD 127_50 75065B ------ TOTAL RECEIPT 127 .50 -- VOICE ID DESCRIPTION VOICE ID DESCRIPTION --- 704 DEMO OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT 95014-3255 3ILDING DIVISION 10300 70RRE AVENUE•CUPERTIN ry �C (408)777-3228•FAX(408)777-3333• 5 CUPERTINO Dear Property Owner(s): as been submitted in your name listing yourself as the builder of the property An application for a building permit h improvements specified at: BP# APN v �� I � SITE ADDRESS ^ , Q��4 c�, I O NER ADDRESS a A " J R NAME DESCRIPTION OF WORK: � Acknowledgment and Information ification Form to make you aware of You with an Owner-Builder me nd permit issued in your name as the Owner-Builder. We We are providing y you may incur by having of each provision, signed,and your responsibilities and possible risk issue a building permit until you have read, initialed your understanding will not i address indicated. Air agent of the owner cannot execute this notice unless returned this form to us at our official approval of the permitti�g authority. you,the property owner, obtain the prior tatement below tc signify you understand or verify this information.) • WNER'S ACKNOWLEDGMENT AND V FiIFICATION OF lN=ORMATIO (DIRECTI S: Please read and initial eachproperty owner obtain an"Owner- of of unlicensed persons is to have the prop Y 1. I understand a frequent p owner is providing his or her own labor and material Builder" building permit that erroneously implies that the property in uries sustained by Owner-Builder, may be held liable and subject to seofin My home homeowner insurance may not personally. I, as an to ees while work ing on my property. an unlicensed person and his or her rl m willfully acting as an Owner-Builder and am aware of the limits of my provide coverage for those mlur insurance coverage for injuries to workers on my property. d to ] ned by ro ert owners unless they are responsible for 2. 1 understand building permits are not require torb assume t s responsibility. Ve onstruction and are not hiring a licensed C of record on the permit. I understand that I may n , responsible party the permit filed in his or her I understand as an otentialOfinanca IIra k by hiring a licensed Contractor and having protect myself fromp name instead of my own. wired by law to be licensed and bonded in California and to list their license are re 4. 1 understand Contractors q num rs on permits and contracts. otherwise engage any perso50ns, other than California llmateeals , I may bes, and the "1 ! 5. 1 understand if I employ or including labor v total value of my construction is at least five hundred dollars ($ 0), considered an"employer" under state and federal law. te to 6. 1 understand if I am considered an"employer" under state and federal law, I must register with the state and 6_�_! rovide workers' compensation disability insura these laws mayce, and usubject Vernment, withhold payroll taxes, P af:o understand my failure to abide byferal government, I unemployment compensation for each me to serious financial risk. performed by CaliforniaContractors' Stato License Law, an owner-Builder fsale, ulessho builds all work single-family rfor rk VPe�idential 7. I understand under calendar year, or all of the work structures cannot legally bbedr of structuresedoes ntot exceed four within any licensed subcontractors and the num general building Contractor. is performed under contract with a licensed g be held liable for ert for which this permit is issued I may latent construction 8. I understand as an Owner-Builder if I sell the p open, t owners)that result from any or personal injuries sustained by any 04/12/10 any financial defects in the workmanship or materials. ON�nerBuilderFor•m_2010.doc revised m r obligations as an"employer"from the Internal understand 1 may obtain more information regarding Department of Benefit Payments, o unders�and I may contact the California Contractors' State Service, the United States Small Businessa sdministraiion,the California ep ion about licensed Revenue Senn , at 1-800-321-CSCR (2752) or www.cslb.�a.gov for more informat and the California DiBsion of Industrial Accidents. License Board (CSLB) contra tors. permit applied for in my name, and understand that l to an proposed construction activity at the following address: 10. I am aware of and consllly responsible for propr building p am the party legally and financia y — sible for this proposed construction activity, I will abide art legally and financially respoii 11. 1 agree that, as the party l e all that govern Owner-BL ilders as well as employers. of the \L� by alt applicable laws and req protect the public. If *nforMation � ' suer of this form immediately o any additions., deletions, or changes to an 12. I agree to notify the is regulated by laws designed to P be unable to I have p the Contractors' State License Board may against unlicensed provided on this form. Licensed contractor., are rem taint;Your only remedy g you contract with someone who does ou may sustain as aeesult of a complaint, If assist you with any financial loss Y is also important for you t� understand that if an u li held Gable for damages. be in civil court. It our ro erty, you may whether or not Contractors mayis ou will be responsible for verifying employee of that individual or fir Ider and inju w sh'to hire Contractors, compensation insurance coverage. you obtain a permit as Owner those Contractors are properly licensed and the status of the it workers' se complete the following construction lending agency information .) CONSTRUCTION LENDING AGENCY permit is issued (p1RECTIONS: Plea for tie p I hereby affirm that there is a constru tion lending a9 ency performance of the work for which this (Sec 3097 Civ.) / Lender Ac dress: _— Lender Name: the property owner and this form must be completed and signed by ermit can be issued, of the property owner's driv mi Iscissued to Before a building p onsible for issuing the permit. Note:A copy resented when the p returned to the agency resp agency is required to be p form notarization, or other verification acceptable to the ag pate: veri the ro ert owner's si Hata e. , Signature of property owner: uired to be completed by the property owner only when designating an AUTHORIZATION OF AGENT TO ACT ON PR OPERTY 01PINER'S BEHALF RUTH Authorization Form is (NOTE: The following 1 for a construction permit for the Owner-Budder agent of the property owner to appy persona responsibility, I hereby Owner, the execution of which I understand is my p to obtain an aents Excluding the Notice to Property to ap�lY for, sign, and file the documents necessary authorize the following p erson(s) to act as my 9 ( ) owner-Builder Permit for my project. Scope of Construction Project (or Description of Work): c2S Project Location or Address: ✓ Tel No Name of Authorized Agent: Address of Authorized Agent: stedabove ersonally filled out the perjury that I am the property ow Her for the address,s driver-'license, form notarization,dpor other I declare under penalty of p 1 ry 01 the ow property required to be pre:ented when the permit is issue d to verify the p p Y above informationta�le to the agency is rertify its equir e:A copy verification accep signature. Date: Property Owner's Signature: Oivi7.erBuilderForm_2010.doc revised 04112/10 06/08/10 15:45 FAX 650 843 8777 SALTIRE SAN:)ERS Q001 VIA FACSIMILE (408) 777-3333 June 8, 2010 To Whom It May Concern: I hereby give Vicki Geers permission to pull a demo permit on my behalf with respect to 11000 Maria Rosa Way in Cupertino. If you have any questions, please feel free to call me at(650) 843-3336. Thank you. Best regards, 4Z� David A. Saltzman CITY OF CUPERTINO CUPEkTINO GENERAL BUILDING PERMIT APPLICATION FORM 1006500LP2-- APN # ,,l 00 Z---.., Date: czoBuildin Address: ATTP - Mailin A dress (if different from building address): Are Hazardous Materials being used as part of this project? Yes No HOA: (Exterior work only) Yes ❑ No If yes, rovide letter from HOA wner's Nam : Phone#: 4 C tractor: , w ' Phone: p l (Q Fax: Contractor License #: 2-4 0 g Jc 2-a S Cupertino Business License#: ontact: e Phone: A., 1 Fax: `� l Residential Fly> Commercial ❑ Job Description: ,-Lw o J00e Building Permit I fo: Bldg Elect Plumb El--- Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B [ R --�? Valuatio Square Footage: &D-V Project Size: Expressa Standard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it to the application or if applicable, ir.clude in plan set& the sheet index. Points Achieved: For help, contact Build it Green at www.buildit reen.or Revised 07/14/09 S"fliM.- CITY OF CU.PERTINO ITY OF GENERAL BUILDING APPLICATION CUPEkTINO FEE SCHI.�jDULE 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 windows) 1 WINMEWSTR New Window-structural shear B wall/masonry (includes plan ck fee) IEPERMITFEE Electrical Pennit Fee E 1MPERMITFEE Mechanical P,;rmit Fee M 1PPERMITFEE Plumbing Pernit Fee P IELCPLNCK Stand Alone l;lectric 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 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES / 1BSEISMICR Seismic Residential B I 1BSEISMICO Seismic Commercial B 1 TRAVDOC Travel &Do,;umentation B 1BUSLIC Business Lie-nse B 5of 5