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10050114 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10421 E ESTATES DR COIN TRACTOR:SMITHSON ROBERT C PERMIT NO: 10050114 AND SUSAN D "VNER'S NAME: SMITHSON ROBERT C AND SUSAN D 10421 EAST ESTATES DR DATE ISSUED:05/12/2010 v vVNER'S PHONE: 4082573689 CUPERTINO,CA 950144505 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATIONf— BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# r— MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE TANK WATER HEATER IN GARAGE (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:$800 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 permit is issued. APN Number:36913046.00 Occupancy Type: APPLICANT CERTIFICATION 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Issu-.d try: " " '? " Dater-f-'/-'� Z—w 9.18. S;-nature Date RE-ROOFS: OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is insta led without first obtaining an inspection,I agree to remove all new materials for I hereby affirm that I am exempt from the Contractor's License Law for one of inspt ction. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Sign tture of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). — I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I ha-e read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's CalFornia Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safe y Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Add tionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this cont tminants as defined by the Bay Area Air Quality Management District I will permit is issued. mair tain compliance with the Cupertino Municipal Code,Chapter 9.12 and the th�ty Cod ections 5505, 5 I certify that in the performance of the work for which this permit is issued,I shall Heal533,and 25534. 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 te: become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I herby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for v hich this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address the above mentioned property for inspection purposes.(We)agree to save tnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply I unc erstand my plans shall be used as public records. with all non-point rce regu io s pert Cupertino Municipal Code,Section 9.18. Lice ised Professional Signatur ate ��D CITY OF CU?ERTINO 5 ITEMS OF 5 PERMIT R:]CEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: :Jot: APN . . . . . . . . : 36913 )46 . 00 DATE ISSUED. . . . . . . : 05/12 /2010 RECEIPT # . . . . . . . . . : BS000 )10395 REFERENCE ID # . . . 10050L14 SITE ADDRESS . . . . . : 10421 E ESTATES DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERCINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : SMITH3ON ROBERT C AND SUSAN D ADDRESS . . . . . . . . . . : 10421 EAST ESTATES DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4505 RECEIVED FROM . . . . : ROBERT C SMITHSON CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : SMITH3ON ROBERT C AND SUSAN D ADDRESS . . . . . . . . . . : 10421 EAST ESTATES DR CITY/STATE/ZIP . . . : CUPERPINO, CA 95014-4505 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMO--TNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---- ------ ---------- ---------- ---------- 1BCBSC VALUATION 800 . 00 1. 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 800 . 00 0 .50 0 . 00 0 . 50 0 . 00 1PPERMITFE FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 1PRWHEATR UNITS 1 . 00 25 . 00 0 . 00 25 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00 ---- ------ ---------- ---------- ---------- TOTAL PERMIT L10.50 0 . 00 110 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- - ------------------- CHECK 110 .50 #7564 --------------- TOTAL RECEIPT 110 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER OWNER-BUILDER DISGLQ: URE �ORI41[ �tiPER'l�INO �"--a %-mac-=4X 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 ---)7 � S APN BP# 7 OWNER NAME OWNER ADDRESS U� O DESCRIPTION OF WORK: 6;�& 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, initialel 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 permit ing authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRE O S. 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 an Owner-Builder and am aware of the limits of my ins ra5ce 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 th o truction and are not hiring a licensed Contractor to assume this responsibility. 1<�K13. I understand as an "Owner-Builder" I am the respor sible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her ni Vead of my own. 4. 1 understand Contractors are required by law to be icensed and bonded in California and to list their license Z on permits and contracts. understand if I employ or otherwise engage an arsons other than California licensed Contractors and the P YYP > total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be co ide ed an "employer" under state and federal law. 6. I 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 worker:3' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject m s rious financial risk. 7. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family rZi residential structures cannot legally build them with the intE nt 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 rfo med under contract with a licensed general building Contractor. 40/8. 1 understand as an Owner-Builder if I sell the prope ty 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. ON•nerBuilderForm 2010.doc revised 04/12/10 AX9. 1 understand I may obtain more information regarding my obligations as an "employer"from the Internal Revenue Service, the United States Small Business Admiristration, 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.-slb.ca.gov for more information about licensed cont ct s. a consent to an Owner-Builder bUildin permit applied for in m name, and understand that I 10. I am aware of and 9 P PP Y ami e arty leg a nanciaallyy resp grt le for proposed construction activity at the following address: A�Xi1 agree that, as the party legally and financially re:ponsible for this proposed construction activity, I will abide by4111,pplicable laws and requirements that govern Owner-Builders as well as employers. 12. 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 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 res jlt 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 )n 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 their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction len Jing 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: Lender Address: 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 ;,mNote:A copy of the property owner's driver's license, form notarization, or other verification ac ble toe c� e presented when the permit is issued to verify the property owner's si nature. , Signature of property owner: Date: l �' 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 fir the 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 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 owner's driver's license, form notarization, or other verification acceptable to the agency is required to be presente d when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: 0Yt-77.erBuildei-F01772 2010.doc revised 04/12/10 CITY OF CUPERTINO ` WATER HEATER CUPEkTINO PERMIT APPLICATION FORM APN # Date: 2 � v Building A dress: /dV�Z / Z-:- Z57-X 7-el i2 Owner's Name: Phone #: i� Contractor: Phone #: Fax #: Cupertino Business License #: Contractor State License #: Contact* Phone #: �W-2 5 �9— .70-57 Fax #: Building Permit Info: Bldg ❑ Elect El Plumb Mech ❑ Residential ©� Commercial ❑ Job Description: Strapped ❑ On Platform ❑ Bonded ❑ New Location ❑ Replacement Valuation (cost of project): �� Project Size: Express Et- --Standard ❑ Lar€;e ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Green Building Points achieved: Revised 03/10/10 CITY OF CUP ERTINO WATER HEATER CUPEkT]NO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Permit Type Group 1PCWIEATR Commercial Watei B PCWHEATR HeaterNent 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICOM Seismic Commercial B 1PCSWHTR Commercial Solar B PCSWHTR Thermal Water Htr 1 PRWHEATR Residential Water B PRWHEATR HeaterNent 1PRSWHTR Residential Solar B PRSWHTR Thermal Water Htr 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICRE Seismic Residential B 1 PPERMITFEE Plumbing Permit P 1 TRAVDOC Travel & B Documentation 1BUSLIC Business License B M.Indoor Air Quality and Finishes 1.Use Lo%No-VOC Paint 1 IAD Health pts y=yes 0 2.Use Low VOC,Water-Based Wood Finishes 2 IAQ Health pts y=yes 7T7 0 3.Use Low/No VOC Adhesives 3 IAQ"Health pts y=yes 0 4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0 5.Use Engineered Sheet Goods with no added Urea Formaldehyde 61AQ'Health pts y=yes 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ Health pts y=yes 0 7.Seal all Exposed Particleboard or MDF 4 IAQ'Health. pts y=yes 0 8,Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0 9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0 10.Install Whole House Vacuum System 3 IACIHeafth pts y=yes Miiim6md N.Flooring 1.Select FSC Certified Wood Flooring 8 Resc urce pts y=yes 0 2.Use Rapidly Renewable Flooring Materials 4 Rescurce pts y=yes 0 3.Use Recycled Content Ceramic Tiles 4 Resc urce pts y=yes 0 4.Install Natural Linoleum in Place of Vinyl 5 IAGHealth pts y=yes 0 5.Use Exposed Concrete as Finished Floor 4 Resc urce pts y=yes 0 6.Install Recycled Content Carpet with Low VOCs 4 Resc urce pts y=yes 0 1 A- 1 1 1 Total Points Available: 1 1401 130 57 Total Points Project Received: 0 0 0 r/Pz le) G:data/proas/greenbuildin iguidelines/remodelers/greenpointsfinal2.12.04protected.xis