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10080165 CITY OF CUPERTINO BUILDING PERMIT CONTRA CTOR:SUSAN FUJIMOTO PERMIT NO: 10080165 BUILDING ADDRESS: 22321 CUPERTINO RD IWNER'S NAME: SUSAN FUJIMOTO 22321 CU'ERTINO RD DATE ISSUED:08/23/2010 4ER'S PHONE: 4082553309 CUPERT NO,CA 95014 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r— PLUMB r .icense Class Lic.# MECH r RESIDENTIAL r COMMERCIAL r 'ontractor Date JOB DESCRIPTION:REPLACE 19 WINDOWS&1 SLIDING DOOR; [hereby affirm that I am licensed under the provisions of Chapter 9 NON-STR UCTURAL,BEDROOMS MEET 207 EGRESS 'commencing with Section 7000)of Division 3 of the Business&Professions REQUIRE MENTS 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. I have and will maintain Worker's Compensation Insurance,as provided for by Valuation:$15000 Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft FI Dor Area. permit is issued. APPLICANT CERTIFICATION APN Nu mber:32616082.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, W(THIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply 18 D YS FROM ST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 2,5 / 9.18. Issued b Date: Signature Date �J OWNER-BUILDER DECLARATION RE-ROOFS: 1 hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: I installer l without first obtaining an inspection,I agree to remove all new materials for 1,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Signatt re of Applicant: Date: Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the Califo-nia Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain performance of the work for which this permit is issued. compl ance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air permit is issued. contai ninants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maint iin compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Healtli&Safety Code,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,I Owner or author agent: become subject to the Worker's Compensation provisions of the Labor Code,I must � Date: i 3 /0 forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above in is I here Dy affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating Lend er's Name rmit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter urn the above mentioned property for inspection purposes.(We)agree to save Lender's Address reify and keep harmless the City of Cupertino against liabilities,judgments, c 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 with all non-point source regulations per the Cupertino Municipal Code,Section I and erstand my plans shall be used as public records. 9.18. �U74 �— Signature W Date 'F /0 Lice rsed Professional CITY OF CUPERTINO CUPElZT1NO GENERAL BUILDING PERMIT APPLIC.A TION FORM APN # Date: 5 —1 6 - U (3 2 Building Address: ,273Z1 Mailing Address (if different from building address): Are Hazardous Materials being used as part of this proj,;ct? Yes No HOA: (Exterior work only) Yes ❑ No ,❑ If yes, p rovide letter from HOA Owner's Name: Phone 408 2SS-330 1 Contractor: Phone: q 7- ue'2 31-4 A kVna((er u"j,vic(OCIL" +����Y Fax: yo y 17 z5-- Contractor License#: 5 3 1 6f 1 Cupertino Business License#: Contact: i Phone: Fax: Residential Commercial � 1 door htd,.avvv,s 19 ) 4- Job Description: i A) CPl d o,,-)s la�'e vn e n%f' ►�c h- 5 h'u�'�''`rw� r vti`` f1 u o 1 r e V Building Permit Info: ' Bldg Lam" Elect ❑ Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 5 1-A, 1-B ❑ IPIII/V-A ❑ II/III B, IV-HT,V-B [� Valuation: Square Footage: # 15- Project 5_Project Size: Ex ress E�/ Standard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green B ' ding/LEED Checklist& attach it to the application or if applicable, include in plan set & the sheet index. hints Achieved: �II For help, contact Build it Green at www.buil$itgreen.or Revised 07/14/09 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 22321 cupertino road D kTE: 08/23/2010 REVIEWED BY: Larry S APN: BP#: *VALUATION: 1$15,000 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex OVER THE PENTAMATION I BfKfW USE: COUNTER. 0 Yes E)No PERMIT TYPE: WORK SCOPE OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. s.f. R-3 (Custom) II-B,111-B,IV,V-B 0 $0.00 $0.00 TOTALS: 0 $0.00 $0.00 MECH,HOURLY ® Yes (D No PLUMB,HOURLY 0 Yes E) No ELEC HOURLY 0 Yes Q No Lfc,:h. Plan f'hmt b. Plan(1w("A f c. Phzrr Cherds �t�cLP -rtul f'c>r: I'Ir;rrr,. f'c'rt,i;Je: L;lI'�.rrrrit ht,r.. Li xEa-1FIr�s,> r Imp, l�a NOTE: Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info, FEE ITEMS (Fee Resolution 09-05I a.. 7/1"'1 0) FEE QTY/FEE MISC ITEMS Plan Check Fee: 1SUPPKFEE $0.00 19 # Window/Sliding Glass Door Suppl. PC Fee: 0 Reg. 0 OT 1.0 hrs $126.00 $632.00 1WINREP Replacement PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Feer Reg. 0 OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Con.,arrrciion Tax Acoustical Fee: 0 Yes 0 No $0.00 Work Without Permit? 0 Yes 0 No $0.00 Planning Fee: $0.00 Select a Non-Residential 71-0 C 00Crrrrr�rrrtrrti0l] l�ir�'�S_ Building or Structure Strong?Motion Fee: IBSEISMICR $1.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $128.5 $$632.00 TOTAL FEE: $760.50 Revised: 8/17/2010 CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lc,t: APN 326160f2 . 00 DATE ISSUED. . . . . . . : 08/23/,' 010 RECEIPT #. . . . . . . . . BS00003.1256 REFERENCE ID # . . . : 10080105 SITE ADDRESS . . . . . : 22321 CUPERTINO RD SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : SUSAN FUJIMOTO ADDRESS . . . . . . . . . . : 22321 CUPERTINO RD CITY/STATE/ZIP . . . : CUPERT:=NO, CA 95014 RECEIVED FROM . . . . : SUSAN A FUJIMOTO CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : SUSAN 'FUJIMOTO ADDRESS . . . . . . . . . . : 22321 CUPERTINO RD CITY/STATE/ZIP . . . : CUPERTCNO, CA 95014 TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY AMOU\TT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ----- ----- ---------- ---------- ----- 1BCBSC VALUATION 15, 000. 00 1. 00 0. 00 1. 00 0 .00 1BSEISMICR VALUATION 15, 000 . 00 1 .50 0 .00 1. 50 0 . 00 1SUPPKFEE HOURS 1. 00 126 . 00 0. 00 126 . 00 0 .00 1WINREP EACH 8 19. 00 632 .00 0 .00 632 . 00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 760 .50 0 .00 760.50 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 760 .50 VISA --------------- TOTAL RECEIPT 760 .50 STORMWATER POLLUTION CONTROL AND NOISE CONTROL COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING DFFICIAL Ai'F'ft(tVF[) 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 IN ACCORDAN(A M i H r rA[ t:ITY OF CUPERTINO (408)777-3228 • FAX(408)777-3333•buildin ERTINO CODES AND ORDINANCES gugertino � DATE �I�3 f/o - _ e_­, GENERAL INFORMATION SIGNED___.- � his set of plans and specificatioInM US be kept on the job at all times,and it is All construction work must meet certain conditions related to maintauiti"l*nwim w*aWigq;i&4epAg public ft�whealth and safety. This policy described the two most common inqu' "men� f' C�perti�Do Fater Pollution Control and Noise Control. The stamping o this plan=specifications SHALL NOT be held to permit or to be an approval of the violation of any provisions STORMWATER POLLUTION CONTROL of any City Ordinance or State Law. State law requires that the City of Cupertino, along with 12 other Silicon Valley cities, Santa Clara County and the Santa Clara Valley Water District control stormwater pollution. Educating local residents and businesses and enforcing stormwater pollution control laws are key parts of the City's compliance efforts. Stormwater pollution prevention: It' up to us In.northern Santa Clara Valley, storm drains flow directly to local creeks and into the San Francisco Bay without going through a water filtering/treatment process. ;3tormwater pollution is a serious problem for wildlife dependent on our waterways, for people living near streams and baylands, and for the local water supply. Common sources of stormwater pollution include; • Dripped oil, fuel, and antifreeze from vehicles and heavy equipment-, • Construction debris, including dirt, concrete and pa:nt; • Landscaping runoff containing pesticides or weed killers; and • Any material dumped or spilled into streets or Storni drains. The property owner and the contractor share ultimate responsibility for activities occurring at a construction site and will be held responsible for any environmental damage caused by subcontractors or employees. For more information on construction-related stormwater requirements, see the Stormwater Quality Regulations section of the City of Cupertino website at: http://www.cupertino org/iLidcx.aspx?.�Pagc=487 COMMUNITY NOISE CONTROL Construction noise is limited to: _ Residential daytime noise levels from compl t ,60 dBA Lit >> • �3 • Non-residential daytime noise levels from complaint site—65 dBA D.A•`lk Daytime hours are defined as beingbetween the followin hours: - € - • Weekdays—7:00am to 8:00pm 11 • Weekends—9:00am to 6:00pm Construction, other than street construction, is prohibited(n holidays, except that construction conducted by a homeowner or resident of a single family dwelling using domestic construction tools is allowed on holidays between the hours of 9:00am to 6:00pm. For more information on noise control,please refer to Chapter 10.48 of the Cupertino Municipal code, which can be accessed at http•//www.amlegal.com/cuperti io ca. Stormwater/Noise Control-2010.doc revised 08/06/10 w•ry re- 2,0 qp-78 497 4 ' S rti Z•!i C j Ntbps�1 i"�` 1-2ti1:Xr - ' ' - :tet T�txO ��=•' ,�� G2.jV6+C. � Z,,.. � � tiot►fl O _eeo i . tt h - J t t1 —Tv INY 10 '1WK, vE v\� i lot, iV'1 ��. ane 4• A�j :_ __—..�___��_. �IrJ �Pt — .00" �_.. Ao Tyr.ft b I � _ ! � ( 1 6P! Q 0 •MM N ' v i✓1'► 7 CL Vi- N' Q �p r Y'� N � M �J�„�AvkfL;G C N $, ,► �' 10 P�E(71�+vr1h- _ foM+-► u o � � I ► t �•� f Sts 3� --���'-:._.... t I X© cr StA VI (el LAOe OF t•n%oT L V P' I. W'1 Mer natio n•� OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTME14T• BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 15014-3255 (408)777-3228- FAX(408)777-3333- buiidi x1(C�cuDertino.org CUPERTINO Dear Property Owner(s): An application for a building permit has been submitted in your lame listing yourself as the builder of the property improvements specified at: SITE ADDRESS 7APN BP# Z2 i 1 Cu 4,vr-0 }Pbao� 7 OWNER-NAME OWNER ADDRESS DESCRIPTION OF WORK: r �b CC 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-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. fin agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitt ng authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) `'X 1. 1 understand a frequent practice of unlicensed persc ns 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 :ubject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while workilg on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as e n 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 5ible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensod 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. 1 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 dollar: ($500), including labor and materials, I may be considered an"employer" under state and federal law. t; 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. -"�7. 1 understand under California Contractors' State Liconse Law, an Owner-Builder who builds single-family residential 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 does lot exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 8. I understand as an Owner-Builder if I sell the proper 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 04114110 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.cslb.ca.gov for more information about licensed contractors. ✓ 10. 1 am aware of and consent to an Owner-Builder buildinc permit applied for in my name, and understand that I am the party legally and financially responsible for proposed corstruction activity at the site address listed above. 11. 1 agree that, as the party legally and financially respons ble for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builc ers 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 Co itractors'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 u iderstand that if an unlicensed Contractor or employee of that individual or firm is injured while working on yo it property,you may be held liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractc rs, 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 lending 41gency information.) I hereby affirm that there is a construction lending agency for the p arformance 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 completed 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 may be required to be presented when the permit is issued to verify the property owner's si nat Property Owner's Signature: Date: p z3 v -------------------------------------------------------------------------------•------------------------------------------------------------- (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 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, 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 tl-e address listed above and I personally filled out the above information and certify its accuracy. Note:A copy of the prop arty owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented rthen the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderForm 1010.doc revises}04/14110