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10050122 CITY OF CUPERTINO :3UILDING PERMIT BUILDING ADDRESS: 10467 PLUM TREE LN CONTRACTOR:DADDARIO ROOFING PERMIT NO: 10050122 OWNER'S NAME: NADER VAHDAT 1734 WILLA WAY DATE ISSUED:05/14/2010 VNER'S PHONE: 4086216487 SANTA CRUZ,CA 95062 PHONE NO:(831)476-9109 LICENSED CONTRACTOR'S DECLARATION JO:3 DESCRIPTION: RESIDENTIAL El COMMERCIAL[J License Class C " j �( Lic.# (30 '7 '3 RE.ROOF TEAR OFF SHAKE INSTALL NEW PLYWOOD Ar"D Contractor (alae—tr i G' i p'i1�r Date S-/I— 2a(D LI:+ETIME COMP CLASS A 25 SQ 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:$11380 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 APN Number:31633106.00 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 n granting of this permit. Additionally,the applicant understands and will comply Isst ed by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature yr7 Date(9S—(y_ IOW All roofs shall be inspected prior to anyroofingmaterial being �� instt lied without first an inspection,I agree to remove all new mateed.If a rials isof alsfor insp action. v OWNER-BUILDER DECLARATION Signature of Applican Date: — /11_Qe,0 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) I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I ha''e read the hazardous materials requirements under Chapter 6.95 of the Cali ornia Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three mai'tain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&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 matt rial. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air c3ntaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will naintain 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 permit is issued. Owner or authorized agent: � � Date:OS/g—fold 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 hen by 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.) Lenc er'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 upon the above mentioned property for inspection purposes.(We)agree to save '�mnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION is,and expenses which may accrue against said City in consequence of the I and:rstand 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. Signature Date CITY OF CUFERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM COPY # : 1 Sec : Twp: Rng: Sub: Blk: Lot : APN • 31633106 . 00 DATE ISSUED • 05/14/2010 RECEIPT # • BS000010406 REFERENCE ID # . . . : 10050122 SITE ADDRESS • 10467 PLUM TREE LN SUBDIVISION CITY • CUPERTINO IMPACT AREA OWNER • NADER VAHDAT ADDRESS • 10467 PLUM TREE LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2021 RECEIVED FROM • EDGAR MONTOYA CONTRACTOR • EDGAR MONTOYA LIC # 26245 COMPANY • DADDARIO ROOFING ADDRESS • 1734 WILLA WAY CITY/STATE/ZIP . . . : SANTA CRUZ, CA 95062 TELEPHONE • (831) 476-9109 FEE ID UNIT QUANTITY AMOUVT PD-TO-DT THIS REC NEW BAL 1BCBSC VALUATION 11, 380 . 00 1. 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 11, 380 . 00 1 .20 0 . 00 1 .20 0. 00 1REROOFRES SQ FEET 25 . 00 325. 00 0 . 00 325 . 00 0 . 00 TOTAL PERMIT : 327 .20 0 . 00 327 .20 0 . 00 METHOD OF PAYMENT AMOUNT :REFERENCE NUMBER CREDIT CARD 327.20 vi3a TOTAL RECEIPT : 327.20 VOICE ID DESCRIPTION VOICE ID DESCRIPTION 601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL 604 ROOF IN-PROGRESS 605 FINAL REROOF CITY OF ` CITY OF CUPERTINO REROOF CUPERTINO PERMIT APPLICATION Date: APN#31 33 16� - C)L' (75_ 1 - • /a Building Address: L 10107 1 I,.ti„v► 1-rt.e Phone #: Owner's Na e: ‘2,,C va�da-} I- b itiocd 6 y07 HOA: Yes ❑ No Q],.---If yes, provide letter from HOA Phone #: S3' '76 cil a q Contractor: Fax#: (Oct(11.4-1 b IF:`"el Fax License #: Cupertino Business License #: Type of Roof Covering: Existing: ''roposed: ❑ Built-Up Roof ❑ Bu Up roof ❑ A phalt Shingles �/ sphalt Shingles ood Shakes ❑ Wood Shakes ❑ Wood Shingles ❑ Wood Shingles ❑ Other (Specify) ❑ Other (Specify) Number of existing coverings a Provide I.C.C.E.S. Report# a To be Removed a Provide Mfgr. Installation Specs. Job Description: a D S 14.a.tC-�. v),54-0( ( ( Vicki piwd , A Z-;je. 4-; e 6- Si 4- o `'l 25 class A- Residential Commercial f l Green Building: Please complete relevant portion of the Confirmed w t ion Planning Dept. if Green Building Checklist & attach it to the application or if there are any Ei applicable, include in plan set & the sheet index. Valuation: f ill '300 I Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy: 97/ ignaturp' --"------------- Revised 02/05/09 CITY OF \e.,// CITY OF CUPERTINO �St.,9ss REROOF CUPERTINO FEE SCHEDULE Number of Fee ID Fee Description Fee Permit Type Squares Group 1REROOFCOM Re-roof Commerc.al B 1COMMLROOF 1BCBSC Cal Bldg Standares B ALL PERMIT TYPES Commission Fee 1BSEISMICO Seismic Commercial B Z 1REROOFRES Re-roof Residenti 11 B 1SFDWLROOF f 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICRE Seismic Residential B 1REROOFMRES Re-roof Multi-Family B 1MFDWLROOF 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICRE Seismic Residential B 1BUSLIC Business License B JF PJH Resources Energy .64ID1Health M.Indoor Air Quality and Finishes 1.Use Low/No-VOC Paint 1 IAQ/Health pts y=yes 0' 2.Use Low VOC,Water-Based Wood Finishes 2 IAO/Health pts y=yes 0 3.Use Low/No VOC Adhesives 3 IAD/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 6 IAQ/Health pts y=yes 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0 7.Seal all Exposed Partiolebcard or MDF 4!AO/Health pts y=yes _ 0 B.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 lAQ/Healthis - es P Y-Y 0 N.Flooring ■ 0 0 0 1.Select FSC Certified\Wood Flooring B Fesource pts y=yes 0 2.Use Rapidly Renewable Flooring!Materials 4 Resource pts y=yes 0 3.Use Recycled Content Ceramic Tiles 4 R esource pts y=yes 0 4.Install Natural Linoleum in Place of Vinyl . 5 I,Q/Health pts y=yes 0 5.Use Exposed Concrete as Finished Floor 4 R:source pts y=yes 0 6.Install Recycled Content Carpet with Low VOCs 4 R:source pts y=yes 0 • 0 0 0 • I Total Points Available: I 1401 1301 571 M Total Points Project Received: t.'9 01 01 01 • e.--- ------ .771/ d.s--- /4(-- 2o/ G:data/progslgreenbuik'ingguidelines/remodelers/graenpointsfina1212D4pmtecled.zls Building Department City Of Cupertino 10300 Torre Avenue 41 19, Cupertino, CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: 10 7 (P rp(uVV1 ..1-0.2_4" 4 PERMIT# 10056 I�-�— OWNER'S NAME: Ogd,Q r vatxclak- PHONE # 408 62/— 69 ' GENERAL CONTRACTOR: epa eocF;v�5 BUSINESS LICENSE# ADDRESS:1 t fey Coi, ;.�d I a 4.....„44. I-� e-_ CITY/ZIPCODE: Cc1 r 4e A 4. Lit C 5c l(, *Our municipal code rewires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACT'JRS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: d S— Ili— ft,e0 ignatu re Date Please check applicable subcontractors and complete th e following information: SUBCONTRACTOR BUSINESS N&ME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum /Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting /Wallpaper Paving Plastering tubing 0,1ur Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date CITY OF CUPERTINO Bt.ILDING PERMIT • CONTFACTOR:LEON TORREY PERMIT NO: 10050052 BUILDING ADDRESS: 19940 PORTAL PL DATE ISSUED:05/04/2010 901 FEItNGROVE DR OWNER'S NAME: LEON TORREY PHONE NO: NEWS PHONE: 4084464718 CUPEF TINO CA,CA 95014-4664 ❑ LICENSED CONTRACTOR'S DECLARATIONBUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class Lic.# r MECH RESIDENTIAL r COMMERCIAL Contractor Date JOB DESCRIPTION:REAPIR OF SHOWER&FLOORING;NO RE-ROOF& NO I hereby affirm that I am licensed under the provisions of Chapter 9 STRUC TURAL (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. Valuation:$5000 I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:36945010.00 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 to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE indemnify OR d and keepharmless the rCupertino yinst liabilities,sjudgments,the 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 (�'/� Dated (`� with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: �� 9.18. Signature Date __ 11113 RE-ROOFS: BUILDER DECLARATION All r)ofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspi:ction. I,as owner of the property,or my employees with wages as their sole compensation, Date: will do the work,and the structure is not intended or offered for sale(See.7044, Signature of Applicant: Business&Professions Code) I,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 affirmnsunder penalty of perjury one of the following three declarations: I hi yereaHAZARDOUS MATERIALS DISCLOSURE pter 5 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,ardous aSect ons 25505525533r ls andrequirementundea25534.91 will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Ad litionally,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 car taminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance wit the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall He alt' &Safety Cod• ctions 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's /_1 Compensation laws of California. If,after making this certificate of exemption,I Ov%�,o horize�- / Date:_ / (� become subject to the Worker's Compensation provisions of the Labor Code,I must0 , �/ forthwith comply with such provisions or this permit shall be deemed revoked. CO TRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is fo: which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Li nder's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address ' unify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may acc - against said City in consequence of the ARCHITECT'S DECLARATION granting of thisp,, it.Additio . (,the applicant understands and will comply with all non-poi source regul. i'ns per the Cupertino Municipal Code,Section I i inderstand my plans shall be used as public records. 9.18. 8 Licensed Professional Signature N t .,IL Date Q CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lct: APN • 36945010 . 00 DATE ISSUED • 05/04/2010 RECEIPT # • BS000010322 REFERENCE ID # . . . : 100500E2 SITE ADDRESS • 19940 PORTAL PL SUBDIVISION CITY • CUPERT]NO IMPACT AREA OWNER • LEON TORREY ADDRESS • 901 FELNGROVE DR CITY/STATE/ZIP . . . : CUPERT]NO CA, CA 95014-4664 RECEIVED FROM • LEON E TORREY CONTRACTOR LIC # *OWNER* COMPANY • LEON TORREY ADDRESS • 901 FEF'_NGROVE DR CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4664 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 1INSPREIFE HOURS 2 . 00 2!;2 . 00 0 .00 252 . 00 0. 00 1TRAVDOC FLAT RATE 1 . 00 x:2 . 00 0 . 00 42 . 00 0. 00 TOTAL PERMIT : 295 . 50 0 . 00 295 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER CHECK 295 . 50 #3:_98 TOTAL RECEIPT : 295 .50 CITY OF C1 PERTINO (IL ADDITION/REMODEL CUPETINO PERMIT APPLICATION FORM APN # U(vcxjDate: Is a 2"d unit being added? Yes ❑ No 1.If yes, please fill out the permit application for 2"d unit. Buil.'�,Atddress: . 4 PC424- CrJeEerr� 1�l MailingAddress (if v(J different from buildin addess rfr VC' rr/Q0 wners Name: Phone 4ciz.G Contractor: Phone#: ��b—� —� ! � 3 © al Fax #: Contractor License#: Cupertino Business License#: Contact: Phone#: L- Fax #: Building Permit Info: Bldg. Elect. ❑ Plumb. Mech. ❑ Hillside ❑ Job Description: Addition-What is being added?(Be Specific): What is being remodeled (not including addition)? t _—[P/q (-7t)(),,iffe_ ige tr=--cocierf Remodel Includes Re-Roof: Yes ❑ No r yes list number of squares Remodel Includes Structural: Yes ❑ No Do you have the pre-application planning approval? Yes ❑ No ❑ If yes, please provide a copy of your planning appr oval letter. Planners name: Square Footage: Addition: Porch: Deck: _ Garage: Detached Attached Remodel: Kitchen Bath Other Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-B [� 1 Valuation: r Please check this box if the project is a second-story addition ❑ Project Size: Express ❑ Standard ❑ Large ❑ Major Please complete relevant portion of the Green Building Checklist& attach it to the application or if applicable. Green Building Points Achieved: include in plan set& the sheet index. ***For Office Use Only*** Over-the-Counter ❑ Revised 07/06/09 CITY OF CUPERTINO a ADDITION/REMODEL CUE CITY IZTJ INO FEE SCHEDULE Quanti Fee ID Fee Description Fee Group Type S. Ftt3' Permit T 1R3SFDADD ADDITIONS Long g Range PL Planning/Residential Planning/R IR3INSP Dwellings Inspections B 111111111111111 1R3PLNCK Dwellings plan check B IIIIIIIIIIIII 1R3REPINSP Dwellings Repeat B Ins•ection B 1R3REPPLNC Dwellings Repeat Plar Check B 1R3HINSP Dwellings Hillside inspection B 1R3HPLNCK Dwellings Hillside plan MIIIIIIIIIII check B 1R3HREINSP Dwellings Hillside .1111111111111111111111 Re eat Ins ection B IR3HREPLNC Dwellings Hillside 11111111111111 Re.eat Plan Check B 1R3ALTINSP Dwellings Alternate MIIIIIIIIIII Materials Ins section B 1R3ALTPLNC Dwellings AlternateIIIIIIIIIIII Materials Plan Check. P 1PCESS Cesspool INIIIIIIIIII 1PPRSEWG Ea. Private Sewage P .111111111111111111 Disposal SystemMI P 1PRSEWER Sewers 1111111111111111 Lawn Sprinkler/Bac<flow P IBPSPRINK . _ ..1 1BPWSVCS Main Water Service P IIIINIIIIIII MIMUM 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee11111111 B IBSEISMICRE SeismicResidential 1111111111111111 1REROOFRES Residential Re-roo E Each B 100 SF IIIIIIIIIIIII CITY OF CUPERTINO ADDITON/REMODEL FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type Sq Ft 1MECPLNCK Stand Alone Mechanical M Pln Ck(hourly 1PLMPLNCK Stand Alone Plumbi:ig P Pln Ck (hourly) 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICRE Seismic Residential B 1 TRAVDOC Travel &Document Ilion B 1BUSLIC Business License B T2`2 nJ pre 'l /2 G INPUT esnurr-es Energy iADlHealfh M.indoor Air Quality and Finishes 1.Use Low/No-VOC Paint 1 IAQJHealth pts y=yes 0 2.Use Low VOC,Water-Based Wood Finishes 2 IAQ,Health pts y=yes 0 3.Use Low/No VOC Adhesives 3 IAa Health pts y=yes 0 4.Use Salvaged Materials for Interior Finishes 3 Res)urce pts y=yes 0 5.Use Engineered Sheet Goods with no added Urea Formaldehyde 6IAQ'Health pts y=yes 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ'Health pts y=yes 0 7.Seal all Evoseel Particleboard or MDF 4 IAQ'Health.pts y=yes 0 B.Use FSC Certified Materials for Interior Finish 4 Res ource pts y=yes 0 9.Use Finger-Jointed or Recycled-Content Trim 1 Res ource pts y=yes 0 10.Install Whole House Vacuum System 3 IACilHealth pts y=yes 0 U 0 0 hl.Flooring 1.Select FSC Certified Wood Flooring B Resource pts y=yes 0 2.Use Rapidly Renewable Flooring!►iaterials 4 Resource pts y=yes 0 3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0 4.Install Natural Linoleum in Place of Vinyl . 5 IAQ'Health pts y=yes 0 5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0 6.Install Recycled Content Carpet with Low VOCs 4 Res)urce pts y=yes 0 • Total Points Available:I I 1401 1301 571 1 Total Points Project Received: 0—I 01 01 01 L .7201/4.../ . clity T, a)16 G:data/progslgreerbuild _guidelineslramodelers/gre= tsfinal212'•proteotad.zls RESIDENTIAL PROJECT COVER SHEET Assessor's Parcel Number: ,. 1- `D(0 CJ Name of owner. AMIk. _ �. \ i fc6U �VProject address. I ��� (oiP-T? ci Contactp erson. _ TCA`-- Phone. Fax. 4 .41Ap -�•_ -� .„--,c( Net square footage of lot. ' Existing Proposed Square footage: First floor: Second floor: Garage: TOTAL: Are there at least two 10 foot by 20 foot clear spaces inside the garage? Y---<"---N Is privacy protection planting required for the project? Juild it Green Total Points I �� On what floor(s) is work being done? Brief descri.tio of work. L P r ycf.,„----/no E�crt. 2007 CFC q(Y -N)2C 07 CMC (Y-N) O Code editions: 2007 CBC � N) �(1 2007 CPC c 9 N)2007 NEC (Y -N) '+ r't1j wE L� Effective 1/1/0A, CITY OF CUf'f Hi INi,r ;4,1 ` ANfJ OHHUINANCES DATE l0 SlG This set of plan,and spe, ifu;abr,ns MUST be kept On the pr;,at all times and it is unlawful to make any changes or alterations on same without written permission from the fiurlding Department. City of Cupertino. The stamping of this plan and specifications RECEIVED SHALL NOT be held tr permit or to be an approval of the vro?.,tiorn,,f any provisions 3 of any City Or fir.rnc.e or `..tate Law MAY0 2010 Plan Review Process Work Book Page-8-Revised 8/05/08 \�\+\// OWNER-BUILDER DISCLOSURE FORM 1�fJ COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION /4„,„-i-,.p,\ 10300 TORRE AVENUE•CUPERTINO, CA 9E 014-3255 (408)777-3228•FAX(408)777-3333•buildincracupertino.ora 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: SITE Fgse ,.-o 'x ,pr--APN;, ^ BP# OWAI R NAME WNER A DRES' .� cr.. _� 77� 0( AD (9 l�'°� 1C- DESCRIPTION OF WORK: ES l` J 7T( 1 ,5t-ick..... 11 O ' We are providing you with an Owner-Builder Acknowledgment aid 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 permitti ig authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRE4TIONS: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 /itcoverage 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 f't construction and are not hiring a licensed Contractor to assume this responsibility. 3. I understand as an "Owner-Builder" I am the respon;ible party of record on the permit. I understand that I may L` otect myself from potential financial risk by hiring a licens'sd Contractor and having the permit filed in his or her ff.n e instead of my own. /, 4. I understand Contractors are required by law to be I censed and bonded in California and to list their license nu bers on permits and contracts. 5. I understand if I employ or otherwise engage any pE rsons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollar:; ($500), including labor and materials, I may be c'-I-idered an"employer" under state and federal law. if 6. I understand if I am considered an "employer" uncle-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 u iderstand my failure to abide by these laws may subject to serious financial risk. ci7. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family 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 i erformed under contract with a licensed general building Contractor. 8. I 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. OwnerBuilderForm_2010.doc revised 04/14/10 9. I understand I may obtain more information regarding my obligations as an "employer"from the Internal eL"-- venue Service, the United States Small Business Administratiol,the California Department of Benefit Payments, and the Califomia 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.cslb.ca.gov for more information about licensed c rectors. 10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I a the party legally and financially responsible for proposed construction activity at the site address listed above. t11. I agree that, as the party legally and financially responsit le for this proposed construction activity, I will abide all applicable laws and requirements that govern Owner-BuildE rs as well as employers. 12. I agree to notify the issuer of this form immediately of anal 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 to un lerstand 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 Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their we rkers' 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: Lender Address Before a building permit can be issued,this form must be comp eted 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 may be required to be presented when the permit is issued to verify the property owner's signat Property Owner's Signature: e 2 .1 Date: rim -2cy (NOTE: The following Authorization Form is required to be complet€d by the property owner only when designating an agent of the property owner to apply for a construction permit for 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 apply for, :,ign, 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 m.y be required •• be presented when the permit is issued to verify the property owner's signature. gril��- x(47, -� Date: Property Owner's Signature: : �_r..— OwnerBuilderForm 2010.doc revised 04/14/10