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10060061 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10260 STERLING BLVD CONTRACTOR:NANCY NIEBEL PERMIT NO: 10060061 OWNER'S NAME: NANCY NIEBEL 10:!60 STERLING BLVD DATE ISSUED:06/10/2010 OWNER'S PHONE: 4082570329 CL PERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JC B DESCRIPTION: RESIDENTIAL El COMMERCIAL License Class Lic.# INSTALL SEWER CLEAN OUT 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. Ihereby affirm under penalty of perjury one of the following two declarations: Y 4 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. Sq.Ft Floor Area: Valuation:$70 1 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 APN Number:37524022.00 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 r/ Is 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: '-ignature Date Al l roofs shall be inspected prior to any roofing material being installed.If a roof is in:talled without first obtaining an inspection,I agree to remove all new materials for in:pection. OWNER-BUILDER DECLARATION Si;nature of Applicant: Date: 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) 1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I I lave 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 m rintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: H-alth&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 in iterial. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the ai-contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. w II maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this O ner or authorized agent:�C k,nn . � _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 Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I I ereby 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 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 emnify 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. Signaturecn�nRLIO Date C) su i June 7,2010 ' City of Cupertino Building Department 10300 Torre Avenue Cupertino, CA 95014-3255 Subject: Building Permit Request for Sanitary Sewer Cleanout at 10260 Sterling Boulevard,APN#375-24-022,Cupertino,CA 95014 i To Whom It May Concern: Please be advised that the proposed new reque:;t as referenced above will not have any adverse impact on the City of Sunnyvale's sanitary sewer system. According to latest City of Sunnyvale records,the existing sewer l iteral is at 20 feet north of the south property line. Please call me if you have any questions at(408)730-7616. f E Very truly yours, Marvin Rose Director of Public Works Eric Gonzales,P.E. Civil Engineer . s cc: Mr. Claudio Hunger(Property Owner) CITY OF CUE ERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Iot : APN . . . . . . . . : 37524C22 . 00 DATE ISSUED. . . . . . . : 06/10/ 2010 RECEIPT #. . . . . . . . . : BS000( 10603 REFERENCE ID # . . . : 10060( 61 SITE ADDRESS . . . . . : 10260 STERLING BLVD SUBDIVISION . . . . . . CITY CUPER-INO IMPACT AREA . . . . . . OWNER NANCY NIEBEL ADDRESS 10260 STERLING BLVD CITY/STATE/ZIP . . . : CUPER-INO, CA 95014 RECEIVED FROM . . . . : CLAUD=:O HUNGER CONTRACTOR . . . . . . . : LI(: # *OWNER* COMPANY NANCY NIEBEL ADDRESS 10260 STERLING BLVD CITY/STATE/ZIP . . . : CUPER-INO, CA 95014 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ----------- ---------- ---------- ---------- 1BCBSC VALUATION 70 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 70 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 1PRSEWER UNITS 1 . 00 21 . 00 0 . 00 21 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 ---- ------ ---------- ---------- ---------- TOTAL PERMIT 106 . 50 0 . 00 106 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- - ------------------- CHECK 106 . 50 2L79 --------------- TOTAL RECEIPT 106 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION im 10300 TORRE AVENUE-CUPERTINO, CA f5014-3255 CUPERTINO (408)777-3228- FAX(408)777-3333• bukdr ar>cuae Linc,.Drc 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 ADD ESS ��flla( APN BP# /vim 37,F- 24 -D 'D D OWNE,R NAME %�� � OWNER ADDRE:S102 DESCRIPTION OF WORK: k f� �f CICPQ Du We are providing you with an Owner-Builder Acknowledgment E nd Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having t-iis 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. Ai 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. I 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 working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as a i 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 respon:;ible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a IicensE!d Contractor and having the permit filed in his or her name instead of my own. _1,4. 1 understand Contractors are required by law to be li sensed 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 sons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. CQ:3,6. 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 workerscompensation disability insurance, and contribute to unemployment compensation for each "employee." I also urderstand my failure to abide by these laws may subject me to serious financial risk. &7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with the inter t 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 properti 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. OwnerBuilderForm 2010.doc revised 04/14/10 I understand I may obtain more information regarding my obligations as an"employer"from the Internal Revenue Service,the United States Small Business Administ-ation,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.csib.ca.gov for more information about licensed contractors. e5l�, 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 ;onstruction 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-builders as well as employers. A-12. I agree to notify the issuer of this form immediately cif 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 of a complaint.Your only remedy against unlicensed Contractors may be in civil court. It is also important for you io understand that if an unlicensed Contractor or employee of that individual or firm is injured while working or,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 the it 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: C /cer 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. ,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 signature. Property Owner's Signature: 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 fc r the Owner-Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of whicl- 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): ,p Project Location or Address: 0 Z 0 of 6O S�� �c ``S ��y� - c_'u� 6,F - z�\R^ Name of Authorized Agent: lat4a1 i 0 //u X49 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 preseided when the permit is issued to verify the property owner's signature. Date: Z/OProperty Owner's Signature: � �� Ou,l7ei-Buildel-Foi-n1_2010.doc revised 04114110 CITY OF CL PERTINO REPIPE/SEWER/ 4AIN SERVICE CUPEkTINO PERMIT APPLICATION FORM /GoLp0oul APN # Date: QTS - Z4 - 0?-?- 00 61.1t) /i0 Building Address: 10260 4--le-' 1lo lv� Owner's Name: Phone#: Contractor: J O&f a-eir Phone#: ? �� / Fax #: � Cal Contact: el/ Contact: Cjca�cc>j�v Phone#: 404 6,9/ L6J.f Fax #: — Z O/ DO 31- Contractor License#: Cupertino Business License#: Job Description: Residential Co nmercial ❑ Valuation: 70 Project Size: Express Z Standard Large ❑ Major Green Building: Please complete relevant portion of tie Green Building Checklist& attach it to the application or if applicable, include in plan set& the ,-heet index. Green Building Points: Quantity Fee ID Fee Description Fee Permit Type Group 1PCSEWER Commercial buildin; P 1CPSS sewer/sanitary sewe- 1BPREPIPE Commercial re-pipe per fixture P 1CPRP I PGASCOM Commercial Gas Piping System P 1-4 Outlets 1BCBSC Cal Bldg Standards '—ommission B ALL PERMIT Fee TYPES IBSEISMICOM Seismic Commercial P Revised 01/07/09 CITY Of CITY OF CU PERTINO L191 REPIPE/SEWER/ 4AIN SERVICE FEE SCHEDULE CUPERTINO Quantity Fee ID Fee Description Fee Permit Type Group 1 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES I 1BSEISMICR Seismic Residential P 1 1PRSEWER Residential building P 1RPSS sewer/sanitary sewer 1 PRREPIPE Residential re-pipe p-,r fixture P 1RPRP lBPWSVCS Water Service P 1CPWS or 1RPWS 1 PPRSEWG Private Sewage Disp sal System P 1PCESS Cesspool P 1 BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas Pipnig System P 1-4 Outlets 1 BPGAS Gas Piping System 5+ Outlets P I 1PPERMITFEE Plumbing Permit Fee Issuance P 1PLMBLNCK Plumbing Plan Chec'.c P 1 PLMBINSP Other Plumbing/gas Insp. P 1 TRAVDOC Travel &Document-tion Fee B 1 BUSLIC Business License B