10080215 CITY OF CUPERTINO BUILDING PERMIT
ILDING ADDRESS: 19872 MERRITT DR CONTRAC"OR:LAIMA BALTUSIS AND PERMIT NO: 10080215
DANIEL IVERSON
NER'S NAME: LAIMA BALTUSIS AND DANIEL IVERSON 19872 MERIiITT DR
DATE ISSUED:08/30/2010
CUPERTIN O,CA 95014 PHONE NO:
vNER'S PHONE: 4084462493
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r PLUMB
ense Class Lic.# MECH r RESIDENTIAL r COMMERCIAL r
ntractor Date
JOB DES(;RIPTION:NEW LIGHTS IN HALLWAY&LIVING ROOM ON DIMMER
ereby affirm that I am licensed under the provisions of Chapter 9 SWITCH PE t TITLE 24 COMPLIANCE PER 2007CBC
mmencing with Section 7000)of Division 3 of the Business&Professions
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.
gave and will maintain Worker's Compensation Insurance,as provided for by Sq,Ft Floo•Area: Valuation:$1500
ction 3700 of the Labor Code,for the performance of the work for which this
rmit is issued. APN Numt er:31630025.00 Occupancy Type:
APPLICANT CERTIFICATION -
;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 PERMIT EXPIRES IF WORK IS NOT STARTED
>on the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
demnify and keep harmless the City of Cupertino against liabilities,judgments,
fists,and expenses which may accrue against said City in consequence of the 180 -DAYS FROM LAST CALLED INSPECTION.
anting of this permit. Additionally,the applicant understands and will comply
ith all non-point source regulations per the Cupertino Municipal Code,Section .r �y- Date:
18 Issued by: ' '
•ature Date
OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs s'.call be inspected prior to any roofing material being installed.If a roof is
hereby affirm that I am exempt from the Contractor's License Law for one of installed w ithout first obtaining an inspection,I agree to remove all new materials for
he following two reasons: inspection.
,as owner of the property,or my employees with wages as their sole compensation, Date:
till do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant:
lusiness&Professions Code)
,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
onstruct the project(Sec.7044,Business&Professions Code).
hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
leclarations:
have and will maintain a Certificate of Consent to self-insure for Worker's I have res d the hazardous materials requirements under Chapter 6.95 of the
'ompensation,as provided for by Section 3700 of the Labor Code,for the Californi;i Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
merformance of the work for which this permit is issued. complian:e with the Cupertino Municipal Code,Chapter 9.12 and the Health&
f have and will maintain Worker's Compensation Insurance,as provided for by Safety Cc de,Section 25532(a)should I store or handle hazardous material.
Addition:kIly,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 contamin ants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with 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 Health&Safety Code,Sections 25505,25533,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 Owner r authorized agent:
�+d iC/ Date: �t�Le _�y 2
become subject to the Worker's Compensation provisions of the Labor Code,Imust --T
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
�x�
APPLICANT CERTIFICATION I hereby..ffirm 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 for whict this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building constriction,and hereby authorize representatives of this city to enter
the above mentioned property for inspection purposes.(We)agree to save Lender', Address
dmify 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
with all non-point source regulations per the Cupertino Municipal Code,Section I underst mnd my plans shall be used as public records.
9.18.
.,� Licensed Professional
Signature
.71-,"4 "r Date
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 31630025. 00
DATE ISSUED. . . . . . . : 08/30/2010
RECEIPT #. . . . . . . . . : BS000011325
REFERENCE ID # . . . : 10080215
SITE ADDRESS . . . . . : 19872 MERRITT DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : LAIMA BALTUSIS AND DANIEL IVER
ADDRESS . . . . . . . . . . : 19872 MERRITT DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : LAIMA BALTUSIS
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 1, 500. 00 1 . 00 0. 00 1. 00 0 . 00
1BREMFIXT NO. FIXTURES 9. 00 63 .00 0. 00 63 . 00 0. 00
1BREMRECEP NO. OUTLETS 2 . 00 42 .00 0 . 00 42 . 00 0 .00
1EPERMITFE 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 190 . 00 0. 00 190 .00 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 190 . 00 VISA
---------------
TOTAL RECEIPT 190 . 00
VOICE ID DESCRIPTION VCICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY
505 FINAL ELECTRICAL 512 FINAL HANDI-CAP
f--IN
CITY OF CUPE.RTINO
C1TY Of
CUPEKTINO GENERAL BUDDING
PERMIT APPLICATION FORM
Date.
J
Build' Address: _
TT '� G G« iL'i f/�0 C""
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes No
r1JA (Exterior work only) Yes ❑ No If es, rw wide letter from HOA
ame: Phone#:
: Phone:
Fax: y�� 1��
Contractor License#: Z Yi
Cupertino Business License#
Contact: Phone:
Fax:
ttesidential Commercial
Job Description:
Sw , �
Building Permit Info:
' BldgElect C51PlumbMech El
❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/VI B, N-HT, V-B [�--
Valuation: Square Footage:
Project Size: Large ❑ N:ajor ❑
Green Building: Please complete relevant portion of the Careen B ' ding/LEED Checklist& attach it
to the application or if applicable, include in plan set & the sheet index.
'oints Achieved:
For help, contact Build it Green at www.builditgreen.or%
Revised 07/14/09
3
CITY OF CUPE RTINO
FEE ESTIMATOR- BUIL,DING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: `VALUATION: Iso
'PERMIT TYPE: Electrical Permit PLAN CHEC K TYPE: Alteration/Addition/Repair
TO PENTAMATION
PRIMARY T 11. 1 REAP11
USE: SFD or Duplex 17,(A)RA RL 1. PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY BP FEES
Fixtures, Lighting 1BREMFIXT 9 $63
Recep/Switch/Outlets 1BREMRECEP 2 $42
TOTALS: $105.00 n,tgl-
Mai?C b k Elec.Plan Check 0.0 hrs $0.00
bt,,.;`,_ Pcrnul Fcc Elec.Permit Fee: IEPERMIT
Other Elec.Insp. 0.0 hrs $42.00
Phimb. bop. I.0
NOTE: Thesefees are based on the preliminaty in ormation available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS(Fee Resolution 09-051 Eff 7'1/10) FEE QTY/FEE MISC ITEMS
P/ol;
Str/i1;/. 1'C FCCI F-]
PME Plan Check: $0.00
Nu/"1
PME Unit Fee: $105.00
PME Permit Fee: $42.00
C'ow,rrii,ion 1c;_t
Work Without Permit? 0 Yes 0 No $0.00
Travel Documentation Fee: ITRAVDOC $42.00
Select an Administrative Item
BIdyStds Commission Fee: $0.00
SI
40
.00$189.00 $0.00Q`iLE z 189.00
..
Revised: 8/17/2010
Mn r Air Quality and Finishes
" 1 IAQ/Healtll pts y--yes 0
2.Use Low VOC,Water-Based Wood Finishes. 2 IAQ/Healtl i pts yeses 0
31AQ/Healtr 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/Healt i pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Healti pts y=yes 0
41AQ/Healti.pts yeses 0
8.Use FSC Certified Materials for Interior Finish 4 Resource pts y--yes
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y--yes; 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y--ye
0
1 1 1
N.Flooring
1.Select FSC Certified Wood Fiooring B Resource pts y--yes 0
2. i ;FJoa�t+9 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/Healt i 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 Resource pts y=yes 0
Total Points Available: 1401 1301 57
Total Points Project Received: 01 0 0
G:data/progslgreenbuldngguide ines/remodelerstgresnpointsfina1212.04protected.xls
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 950'4-3255
CUPERTINO (408)777-3228• FAX(408)777-3333•buildin a cuoertino.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 DDRESS7;-7APN-2',/ , BP# �vz1
OWNER NAME OWNEft ADDRESS
cAi�y ciusrD ✓tne /g -7.z
DESCRIPTION OF WORK:
/ .4fs , -1
We are providing you with an Owner-Builder Acknowledgment and 'nformation 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 INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
v�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 properly 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 cn my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an O Nner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
IC'e 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 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.
—';�? 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.
'? 5. 1 understand if I employ or otherwise engage any persors, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an"employer" under state and federal law.
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 under::tand 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 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 performed under contract with a licensed general building Cor tractor.
'J� 8. 1 understand as an Owner-Builder if I sell the property fol which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent oNner(s)that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04/14110
1 understand I may obtain more information regarding my obligations as an "employer"from the Internal
Revenue Service, the United States Small Business Administratio i, 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.
�X 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
I 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 Conti actors'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 and:rstand 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 the property owner's driver's license,
form notarization, or other verification acceptable to the city may be req Vired to be presented when the permit is issued
to verify the property owner's si nature.
Property Owner's Signature: Date:
------------------------------------------------------------------------------------ ---- -----------------------------------------
- ---
(NOTE: The following Authorization Form is required to be completed t y--the----p-roperty 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 the ad Jress 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