10050121 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10139 BYRNE AVE CONTRACTOR:GAIL J.HUGGER, PERMIT NO: 10050121
TRUSTEE
OWNER'S NAME: GAIL J.HUGGER,TRUSTEE 10 39 BYRNE AVE DATE ISSUED:05/14/2010
NNER'S PHONE: 4082526133 CL PERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
License Class Lic.# RESTORE 20 SQ FT BACK TO GARAGE SPACE
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
performance of the work for which this permit is issued. Sq Ft Floor Area: Valuation:$250
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
At N Number:35711009.00 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
granting of this permit. Additionally,the applicant understands and will comply Is,ued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section _
9.18.
RE-ROOFS:
Signature Date Al roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
�
OWNER-BUILDER DECLARATION
Sil;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 ave read the hazardous materials requirements under Chapter 6.95 of the
Cv lifornia Health&Safety Code,Sections 25505,25533,and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three m-Ontain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: HE 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 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. wi l maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by thr Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this O
Owner or authorized ager D'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 h.-reby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. we rk'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
,,non the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
lemnify and keep harmless the City of Cupertino against liabilities,judgments,
-fists,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 Li,;ensed Professional
9.18.
Signatu, - Date
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Iot:
APN . . . . . . . . : 35711( 09. 00
DATE ISSUED. . . . . . . : 05/142010
RECEIPT # . . . . . . . . . : BS000C10405
REFERENCE ID # . . . : 100507.21
SITE ADDRESS . . . . . : 10139 BYRNE AVE
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : GAIL HUGGER, TRUSTEE
ADDRESS . . . . . . . . . . : 10139 BYRNE AVE
CITY/STATE/ZIP . . . : CUPER7'INO, CA 95014
RECEIVED FROM . . . . : HAZEL V. FRETWELL
CONTRACTOR . . . . . . . : LIC: # *OWNER*
COMPANY . . . . . . . . . . : GAIL HUGGER, TRUSTEE
ADDRESS . . . . . . . . . . : 10139 BYRNE AVE
CITY/STATE/ZIP . . . : CUPER—INO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ----- ----- ---------- ---------- ----------
1BCBSC VALUATION 250 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 250 . 00 0 . 50 0 .00 0 .50 0. 00
1INSPMIS HOURS 1 . 00 :.26 . 00 0 . 00 126 . 00 0. 00
----- ----- ---------- ---------- ----------
TOTAL PERMIT :.27. 50 0 . 00 127 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- -- ------------------
CHECK 127. 50 1£;O 1
---------------
TOTAL RECEIPT 127.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
704 DEMO
CITY OF CUPERTINO
DEMO
CUPEkTINO PERMIT APPLICATION FORM
1065 01 2 j
APN# Date:
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Building Address:
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Mailing Address (if different from building address):
Owner's Name: Ga t god` e t- - �,-4sFete Phone11-1 ;1:
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Contractor: Phone
Fax:
Contractor License #:
Cupertino Business License#:
Contact: Phone:
Fax:
Residential Sq Footage v Commercial ❑ Sq Footage
Job Description:Aewve ow--f-ek 1.52 xa:o-11 wt �i r - r �-� me(1 uE-
Valuation: !K e--,ieYa Y6,
Project Size: Express 0'' Standard ❑ Large ❑ Major ❑
Please complete relevant portions of the Green 1 uilding Checklist & attach it to the application
or if applicable, include on the plan set & the shcet index.
Quantity Fee ID Fee Description Fee Group_ Permit Type
1DEMORES Demo-Residential B 1SFDWL-DEM
1DEMOPRES Pool Demo Residential B 1SFP00L-DEM_
r 1BCBSC Cal Bldg St�mdards B ALL PERMIT
Commission Fee TYPES
1BSEISMICRE Seismic Res:.dential B
' Revised 01/07/09
OWNER-BUILDER DISCL0:3URE FORM
COMMUNITY DEVELOPMENT DEPARTME VT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228-FAX(408)777-3333-build ng@cupertino.org
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 API BP#
OWNER NAME OWNER ADDRESS
ci0/3 c� N
DESCRIPTION OF WORK: n
CJ
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, initialed 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 permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF IPJFORMATION
(DIRECTIONS:Please read and initial each statement below t,:)signify you understand or verify this information.)
I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
uilder" 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. 1 understand building permits are not required to bE! signed by property owners unless they are responsible for
t e construction and are not hiring a licensed Contractor tc assume this responsibility.
_k I understand as an "Owner-Builder' I am the responsible party of record on the permit. I understand that I may
p ote myself from potential financial risk by hiring a licensed 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. I understand if I employ or otherwise engage any parsons, other than California licensed Contractors, and the
t tae value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employee' under state and federal law.
Tom. 1 understand if I am considered an "employer" undE-r 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 L nderstand 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
r sidential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures doe: not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
t8. I 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 subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderFonn 2010.doc revised 04/12/10
I 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.cslt).ca.gov for more information about licensed
contractors.
-10. 1 am aware of and consent to an Owner-Builder build ng permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the following address:
1. 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-Bl ilders as well as employers.
korm
2. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
ation 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 to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on lour 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 their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lendin;7 agency information .)
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: Lender Addross:
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. Nate:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the agency is required to be presented when the permit is issued to
verify the property owner's signature.
Signature of property owner: Date: i
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
(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 rhe Owner-Builder).
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 owner's driver's license, form notarization, or other
verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signatur Dater y�`'
OwnerBuilderForm_2010.doc revised 04/12/10