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10080121 CITY OF CUPERTINO BUILDING PERMIT ILDING ADDRESS: 10399 MERRIMAN RD APT B CONTRAC"OR:KURT TAKARA PERMIT NO: 10080121 VNER'S NAME: KURT TAKARA 10399 MER OMAN RD APT B DATE ISSUED:08/18/2010 NER'S PHONE: 4089961351 CUPERTIN O,CA 95014 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG t— ELECT I— PLUMB r ense Class Lic.# MECH I- RESIDENTIAL r- COMMERCIAL ntractor Date JOB DESCRIPTION:REPLACE EXISTING GAS LINES FROM GAS METER TO ereby affirm that I am licensed under the provisions of Chapter 9 THE �mmencing with Section 7000)of Division 3 of the Business&Professions HOUSE de and that my license is in full force and effect. ,ereby affirm under penalty of perjury one of the following two declarations: ave and will maintain a certificate of consent to self-insure for Worker's mpensation,as provided for by Section 3700 of the Labor Code,for the rformance of the work for which this permit is issued. ave and will maintain Worker's Compensation Insurance,as provided for by Valuation:$100 ction 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floo.Area: rmit is issued. APPLICANT CERTIFICATION APN Numl er:34229028.13 Occupancy Type: ;ertify that I have read this application and state that the above information is rrect.I agree to comply with all city and county ordinances and state laws relating building construction,and hereby authorize representatives of this city to enter ion the above mentioned property for inspection purposes. (We)agree to save PER VIIT EXPIRES IF WORK IS NOT STARTED demnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR ms,and expenses which may accrue against said City in consequence of the anting of this permit. Additionally,the applicant understands and will comply 180 ''3AYS FROM LAST CALLED INSPECTION. ith all non-point source regulations per the Cupertino Municipal Code,Section 18. �� [V ' a Issued by:,. �-'' Date: ignature Date OWNER-BUILDER DECLARATION RE-ROOFS: hereby affirm that I am exempt from the Contractor's License Law for one of All roofs sl call be inspected prior to any roofing material being installed.If a roof is he following two reasons: installed w.thout first obtaining an inspection,I agree to remove all new materials for as owner of the property,or my employees with wages as their sole compensation, inspection. rill do the work,and the structure is not intended or offered for sale(Sec.7044, Date: lusiness&Professions Code) Signature of Applicant: ,as owner of the property,am exclusively contracting with licensed contractors to onstruct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER hereby affirm under penalty of perjury one of the following three leclarations: HAZARDOUS MATERIALS DISCLOSURE have and will maintain a Certificate of Consent to self-insure for Worker's :ompensation,as provided for by Section 3700 of the Labor Code,for the I have rev d the hazardous materials requirements under Chapter 6.95 of the >erfortnance of the work for which this permit is issued. California L Health&Safety Code,Sections 25505,25533,and 25534. I will maintain d for by complian,:e with the Cupertino Municipal Code,Chapter 9.12 and the Health& have and will maintain Worker's Compensation Insurance,as provide Safety Code,Section 25532(a)should I store or handle hazardous material. >ection 3700 of the Labor Code,for the performance of the work for which this Additiom lly,should I use equipment or devices which emit hazardous air )ermit is issued. contamin ants 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 maintain 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 Health (SajCode,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,I Owne a ed a w become subject to the Worker's Compensation provisions of the Labor Code,I must Date: 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 information is I hereby ffirm 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 for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save -unify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address and expenses which may accrue against said City in consequence of the granting of ' p rmit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non- in sou egulations per the Cupertino Municipal Code Section 9.18. r r I understurd my plans shall be used as public records. Signattve Date `U Licensec Professional CITY OF CUPERT::NO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 34229028 . 3 DATE ISSUED. . . . . . . : 08/18/201D RECEIPT #. . . . . . . . . BS000011236 REFERENCE ID # 10080121 SITE ADDRESS . . . . . : 10399 MERRIMAN RD APT B SUBDIVISION . . . . . . . CITY CUPERTINC IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : KURT TAKPRA ADDRESS . . . . . . . . . . : 10399 MERRIMAN RD APT B CITY/STATE/ZIP . . . : CUPERTINC , CA 95014 RECEIVED FROM . . . . : TAKARA FI.MILY LIVIN CONTRACTOR LIC # *OWNER* COMPANY . . . . . . . . . . : KURT TAKF.RA ADDRESS 10399 MERRIMAN RD APT B CITY/STATE/ZIP . . . : CUPERTINC , CA 95014 TELEPHONE . . . . . . . . FEE IDUNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ------- --- ---------- 1BCBSC VALUATION 100. 00 1 .00 0. 00 1. 00 0 .00 1PGASRES OUTLETS 1. 00 63 .00 0. 00 63 . 00 0 .00 1PPERMITFE FLAT RATE 1. 00 42 .00 0. 00 42 . 00 0 .00 1TRAVDOC FLAT RATE 1. 00 42 .00 0. 00 42_ ------ 00 0_00 ----- TOTAL PERMIT 148 .00 0 .00 148. 00 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -- CHECK 148 . 00 #1379 --------------- TOTAL RECEIPT 148 .00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION __ _ -------- ---------------------------- -- --------------- 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 506 GAS TEST 507 FINAL PLUMBING CITY OF CITY OF CUP ERTINO REPIPE/SEWER/MAIN SERVICE CUPERTINO PERMIT APPLICATION FORM APN # �� � � Date: a Building Address: /� � � /✓'�1 12 o A D ni Owner's Name: �1,112 %1ZAMPhone#: �/ Contractor: Phone#: Fax#: Contact: Phone#: �, �j�j Fax#: Contractor License#: Cupertino Business License#: Job Description: pep k-Ce �K��f i✓! J liS ��/j�S N✓l 1 � `Vkf' T42 J Residential Commercial ❑ Valuation: Project Size: Express Standard❑ Large ❑ Mz jor Green Building: Please complete relevant portion of the ,Syreen Building Checklist& attach it to the application or if applicable,include in plan set&the she-t index. Green Building Points: Quantity Fee ID Fee Description Fee Permit Type Group 1PCSEWER Commercial building P 1CPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe pe:-fixture P 1CPRP 1 PGASCOM Commercial Gas Piping; System P 1-4 Outlets 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICOM Seismic Commercial P Revised 01/07/09 CITY Of CITY OF CUPEATINO REPIPE/SEWER/MV►IN SERVICE FEE SCHEDULE CUPERTINO Quantity Fee ID Fee Description Fee Permit Type Group 1BCBSC Cal Bldg Standards Corrmission B ALL PERMIT f Fee TYPES I 1BSEISMICR Seismic Residential P J 1PRSEWER Residential building P 1RPSS sewer/sanitary sewer 1PRREPIPE Residential re-pipe per fxture P 1RPRP 1BPWSVCS Water Service P 1CPWS or 1RPWS 1PPRSEWG Private Sewage Disposal System P 1PCESS Cesspool P 1BPWATER Install/alter Water Pipe P 1 BPFIXTURE Plumbing Fixture P 1PGASRES Residential Gas Piping ;System P 1-4 Outlets 1 BPGAS Gas Piping System 5+ Outlets P ' 1 PPERMITFEE Plumbing Permit Fee Is nuance P 1 PLMBLNCK Plumbing Plan Check P 1PLMBINSP Other Plumbing/gas Ins p. P ' 1 TRAVDOC Travel &Documentatic n Fee B 1BUSLIC Business License B OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 (408)777-3228- FAX(408)777-3333• buildina(d)coertino.org 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 ADDRESS ! 3 q� KJ �/�/ ,!]- I � APN BP# OWNER NAME / ,--"I /c/� �1N OWNER ADDRESSjC)✓7jgq {�/�61�/r-I/�Itf� 1� DESCRIPTION OF WORK: SPL C / /A)e [ /YI We are providing you with an Owner-Builder Acknowledgment and Ir formation Verification Form to make you aware of your responsibilities and possible risk you may incur by having this p:rmit 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 agont of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting a ithority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFOR DATION (DIRECTIONS:Please read and initial each statement below to sign fy you understand or verify this information.) 111. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Builder" building permit that erroneously implies that the propert,,owner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable and subje;t to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working oil 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. I understand building permits are not required to be sign:d by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to asSLme this responsibility. 3. 1 understand as an "Owner-Builder" I am the responsible 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 name instead of my own. �-I• 4. 1 understand Contractors are required by law to be licen:;ed and bonded in California and to list their license numbers on permits and contracts. .tf. 5. 1 understand if I employ or otherwise engage any persor s, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars (WO), including labor and materials, I may be considered an"employer' under state and federal law. � 6. I understand if I am considered an "employer" under stare and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' co npensation 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 License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with the intent tc 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 property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent )wner(s)that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm 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.csib.czi.gov for more information about licensed contractors. 10. 1 am aware of and consent to an Owner-Builder building n my name, and understand am the party legally and financially responsible for proposed const uc ion acUv ty at lied for Ithe site address listed above.that I i�l-11. 1 agree that, as the party legally and financially responsik le for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as':employers. L 1 12. 1 agree to notify the issuer of this form immediately of ani,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 :omplaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to unc erstand 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 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: 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 theproperty owner's driver's license, form notarization, or other verificati acce table to the city may be required to be presented when the ermi is issued to verifythe roe owner's sin r . Property Owner's Signature: D Date: agent of the property wing Authorization y Form is required to be completed Ily the property __._'__"-' ,y owner only when designating an 9 p p rty owner to apply for a construction permit for the Owner Builderj AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I under:tand 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: - -w Name of Authorized Agent: Tel No Address of Authorized Agent: I declare under penalty of perjury that I am the property owner for the ad tress 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 presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderForm_2010.doc revised 04/14/10