10060053 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21710 REGNART RD CC NTRACTOR:CAROLINE ANDERSON PERMIT NO: 10060053
&DOROTHY BILLARD
WNER'S NAME: CAROLINE ANDERSON&DOROTHY BILLARD 22"60 SAN JUAN RD
DATE ISSUED:06/09/2010
OWNER'S PHONE: 4085075008 CL PERTINO,CA 95014-4822 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
JCB DESCRIPTION: RESIDENTIAL COMMERCIAL0
License Class Lic.# DEMO TWO OLD STRUCTURES ON PROPERTY
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:$5000
performance of the work for which this permit is issued. Sq.Ft 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 A PN Number:35623057.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 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,sued by: 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:
;nature Date 11 roofs shall be inspected prior to any roofing material being installed.If a roof is
ii istalled without first obtaining an inspection,I agree to remove all new materials for
i,ispection.
OWNER-BUILDER DECLARATION Date:
'ignature of Applicant:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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)Q/NPI HAZARDOUS MATERIALS DISCLOSURE
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: 1ealth&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's naterial. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the sir contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.l 011 vill maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
he Health&Safety Code,S tions 25 O5,25533,and 25534.
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 Jwner or authorized agen ate: _ �v
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 hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender'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
building construction,and hereby authorize representatives of this city to enter
.in the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
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 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 Licensed Professional
9.18. II
Signatur -Date(0 (�
CITY OF CJPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35623057 . 00
DATE ISSUED. . . . . . . : 06/0 )/2010
RECEIPT # . . . . . . . . . : BS00 )010593
REFERENCE ID # . . . : 1006 )053
SITE ADDRESS . . . . . : 2171,) REGNART RD
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER CARO],INE ANDERSON & DOROTHY BI
ADDRESS 22760 SAN JUAN RD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4822
RECEIVED FROM . . . . : CARO],INE ANDERSON
CONTRACTOR L=:C # *OWNER*
COMPANY CAROLINE ANDERSON & DOROTHY BI
ADDRESS 22760 SAN JUAN RD
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4822
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---- ------ ---------- ---------- ----------
1BCBSC VALUATION 5, 000 . 00 1. 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 5, 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1STPLNCK HOURS 1 . 00 126 . 00 0 . 00 126 . 00 0 . 00
---- ------ ---------- ---------- ----------
TOTAL PERMIT 127 . 50 0 . 00 127 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 127 . 50 109
---------------
TOTAL RECEIPT 127 . 50
i
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO, CA e5014-3255
(408)777-3228- FAX(408)777-3333• buiibr 0(12u2e-120.o7c
CUPERTINO
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: �j 2 M-7.0
SITE ADDRESS APN BP
Nt(A,AME
L OWNERZA_I(A S UGL_v��U
DESCRIPTION OF WORK: �t
We are providing you with an Owner-Builder Acknowledgment;ind 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. 1,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 tc signify you understand or verify this information.)
1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
6uilder" 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 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.
2. I understand building permits are not required to be signed by property owners unless they are responsible for
e construction and are not hiring a licensed Contractor tc assume this responsibility.
'a 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 licen:,ed Contractor and having the permit filed in his or her
name instead of my own.
CL4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
CiL5. 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 dolla-s ($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 understand my failure to abide by these laws may subject
me to serious financial risk.
C&7. 1 understand under California Contractors' State Li tense Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the int3nt to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures doe 3 not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
I understand as an Owner-Builder if I sell the proporty for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04/14110
CAR-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 understand I may contact the California Contractors' State
License Board (CSLB)at 1-800-321-CSLB (2752)or www.c slb.ca.gov for more information about licensed
contractors.
�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.
X-11. 1 agree that, as the party legally and financially res:)onsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner Builders as well as employers.
OL12. 1 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 regulatedby 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 rest It of a complaint.Your only remedy against unlicensed
Contractors may be in civil court. It is also important for yoL 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 Con'ractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of tt eir workers'compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
hereby affirm that there is a construction lending agency for :he performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Ac dress:
Before a building permit can be issued,this form must be :ompleted 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 si nature.
Property Owner's Signature: Date:
---------------------------------------------------------------------------------------------------------------------------------------------
(NOTE. The following Authorization Form is required to be cot repleted by the property owner only when designating an
agent of the property owner to apply for a construction permit t:)r 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 apple 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: Date:
OxmerBuilderForm 2010.doc revised 04/14/10
CITY OF CUPERTINO
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # Date:
- 9alb
Building Addre
Mailing Address (if di rent from building address
--1 o " -YU
Are Hazardous Materials being used as part of this project? Yes No
HOA: (Exterior work only) Yes ❑ No If es, provide letter from HOA
wner's ambd4w_bA
: Phone,,N :
i c0 5v v �
ontractor: / Phone:
�t Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone:
Fax:
Residential Commercial
Job Description:
De-vN-\�b -A-
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 L-f _
Valuation: Square Footage:
Project Size: Express] - tandard ❑ 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.builditereen or
Revised 07/14/09
CITY OF CUPERTINO
tat
IOF GENERAL BUILDING APPLICATION
CUPEI�TINO FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1GENCOM
1STUCOAP Stucco Appli,;ations (up to 400 sf) B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 w endows)
1WINMEWSTR New Windov-structural shear B
wall/maso (includes plan ck fee)
IEPERMITFEE Electrical Permit Fee E
1MPERMITFEE Mechanical Permit Fee M
1PPERMITFEE Plumbing Permit 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 Plan Check (when no E/M/P) B
when not over counter) hourly-stand alone
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Res dential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel & Dc cumentation B
1 BUSLIC Business License B
I
5o-5