11050075 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21702 COLUMBUS AVE CONTRACTOR:CAROL&BRYAN MILLER PERMIT NO: 11050075
OWNER'S NAME: CAROL&BRYAN MILLER 21702 COLUMBUS AVE DATE ISSUED:05/11/2011
0"17ER'S PHONE: 4082551318 CUPERTINO,CA 95014 PHONE NO:
G LICENSED CONTRACTOR'S DECLARATIONr
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH f- RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:BATHROOM REMODEL NON-STRUCTURAL,REPLACE
(commencing with Section 7000)of Division 3 of the Business&Professions SHOWER,
Code and that my license is in full force and effect. VANITY,WATER CLOSET,NO ELECTRICAL,NO LIGHTING,
NO MECHANICAL
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
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$11770
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:35618046.00 Occupancy Type:
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
indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date Issued :B� ,. =!_,.---- Date:
�[ OWNER-BUILDER DECLARATION
(Thereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
yconstruct the project(Sec.7044,Business&Professions Code).
hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
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 read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must
Ow er or a th ��ed ager
forthwith comply with such provisions or this permit shall be deemed revoked. �£ �� y M't-� Date: �� If
�7� r
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the performance of"ork's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
C' and expenses which may accrue against said City in consequence of the Lender's Address
a of this permit.Additionally,the applicant understands and will comply
WIL.,all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18.
Z G(' I understand my plans shall be used as public records.
Signature L�'C l i LIs.�VC sC. Date
Licensed Professional
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35618046. 00
DATE ISSUED. . . . . . . : 05/11/2011
RECEIPT #. . . . . . . . . : BS000013430
REFERENCE ID # . . . 11050075
SITE ADDRESS . . . . . : 21702 COLUMBUS AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : CAROL & BRYAN MILLER
ADDRESS . . . . . . . . . . : 21702 COLUMBUS AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : CAROL A MILLER
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : CAROL & BRYAN MILLER
ADDRESS . . . . . . . . . . : 21702 COLUMBUS AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 11, 770 .00 1. 00 0. 00 1. 00 0 .00
1BSEISMICR VALUATION 11, 770 .00 1. 18 0 . 00 1 .18 0. 00
1INSPMIS HOURS 3 . 00 378 . 00 0 . 00 378. 00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 380 . 18 0 . 00 380 .18 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 380 . 18 VISA
---------------
TOTAL RECEIPT 380. 18
i D�5 (D
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
GUPKT1NO 1
(408)777-3228• FAX(408)777-3333•buildino&cuoertino.org
❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS Ve_ APN
OWNERNAME ,A✓� ( d B M L lCOY PHONE �el-` C E-"r♦'iL C 54 i 1-ba-
STREETADDRESS �C �. CITY, STATE,ZIP FAX �� +
CONTACT NAME C PHONE ;z'! 3 1 E-MAIL s q-.
STREET ADDRESSr� CITY,STATE, ZIP FAX
OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARC mcr ❑ENGINEER ❑ DEVELOPER ❑TENANT
rte_ ` µ`eS LICENSE TYPE BUS.LIC#CONTRACTOR NAME LSE NUMBER Q �
COMPANYNAME E-MAIL
FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME f LICENSE NUMBER BUS.LIC#
COMPANY NAME / E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
t� ►^►-� w. r -_ Q l r v, l ter-(
�( ,l k e N 6"L,t cn, c=,
-
EXISTINGUSE PROPOSED USE CONSTR.TYPE ORIES
EXISTG NEW FLOOR DEMO TOTAL
r
AREA AREA AREA NET AREA �+ -`�-„e a ,
1.
M., s
BATHROOM KITCHEN OTHER 411t,
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: ❑ DETACH w
� .
❑ ATTACH
N DWELLING UNITS: IS A SECONDUNIT ❑YES SECOND STORY ❑YES
BEING ADDEDTNO ADDITION? NO $-
A
PRE-APPLICATION ❑ YES ffYES,PROVIDE COPY OF PLANNER'S NAME: REE` tBY r a Fps; r y'( [�+a* C�` ,.�
PLANNING APPL N ❑NO PLANNING APPROVAL I.ErCER
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
_New SFD or Multifamily dwellings: Apply for demolition Permit for
�ER�T�EfltflER.��: ��BTITIC:D11V'f:1LeC�Rts�'13r`w ,^
existing building(s). Demolition permit is required prior to issuance of building
ww
permit for new building. ExritEss P� LitY v
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure Q;sTAND�RD �}'P[1BratCv�roRTes,.
form if any Hazardous Materials are being used as part of this project.
❑ LARGE s k
z,
_Copy of Planning Approval Letter or Meeting with Planning prior to IvrAaoR. f�L£,sAI'IBiItY 5EwEli DISTRICT
submittal of Building Permit application.
EC-:"SENiiioivti
BldgApp_2011.doc revised 03/16/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 21702 columbus ave. DATE: 05/11/2011 REVIEWED BY: bobs.
191APN: BP#: "VALUATION: Iso
"PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition �
PRIMARY PENTAMATION I
USE: SFD or Duplex PERMIT TYPE:
WORK bathroom remodel non structural replace shower, vanitV , water closet no electrical no lighting, no
SCOPE mechanical.
7777
- -------- Li
NOTE. Theseees are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info,
FEE ITEMS (Fire Resolution 09-051 I ff t,I-0 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Select a Misc Bldg/Structure
Suppl.PC Fee: E) Reg. 0 OT F60 hrs $0.00 or Element of a Building
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee-E) Reg. 0 OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
F
Acoustical Fee: 0 Yes (E) No $0.00 0
Work Without Permit? 0 Yes G No $0.00 E)
Planning Fee: $0.00 Select a Non-Residential E)
Building or Structure 0
Strong Motion Fee: $0.00 3.0 hrs Inspections
Bldg Stds Commission Fee: $0.00 $378.00 IINSPMIS Standard Inspections
SUBTOTALS: $0.00 $378.00 TOTAL FEE: $378.00
Revised: 04/29/2011
PROJECT DATA - RESIDENTIAL
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
CUPRT1NC? (408)777-3228• FAX(408)777-3333•building aecugertino.oro
�a
PROJECT ADDRESS �7 APN#
OWNER G Q��� o, ►J C1` PHOS SS 1 3C7E, YYL► �r C��rc ,C�
STREET ADDRESS C STATE,ZIP FAX -#�
� A� 4 Srbl
APPLICANWIAME ,t PHONI:-- E-MAIL
STREET ADDRESS C=,STATE, ZIP FAX
21 dc�_Z�
OWNER u-OWNER-BUELDER ❑ OWNER AGENT ❑ CONTRACTOR ❑coNTRAcroR AGENT ❑ ARaM= ❑ENGINEER ❑ DEVELOPER ❑ TENANT
p
AV
>«u
EXISTING USE(S): PROP(T S):
OCCUPANCY(S): TYPE OF PARCEL
CONSTRUCTION: U/BAREA:
FIRE Y N WUI AREA: Y N FLOOD AREA: Y NsIESMIC AREA: Y N
SPRINKLERS:
Existins Proposed
Floor Area: First Floor: s.f. s.f.
Second Floor: s.f. f.
Garage s.f. _. ___.._..s,f . .
TOTAL: s.f. s.f.
Are there at least two 10 feet by 20 feet clear spaces inside the garage? > N
-----\
Is privacy protection planting required for the project? jY��-3� ....
Governing Codes: 2010 California Building Code(based on the 2009 International Building Code)
2010 California Residenti UlQWOlI`VKd }MitI Residential Code)
2010 California Plumbing Cod@W(%V§X200QL&fiffbWPlumbing Code)
2010 California Mechanical Code(b �niform Mechanical Code)
2010 California E c�e4based on e 0 ternational Electrical Code)
i o a an specifications CRUST be kept at the
2010 California En o
� sin cin tr +' � 't is unlawful to make any
2010 California Green cr same or to deviate
Cupertino Municip f1pom without approval from the Building Official.
The stamping of this plan and snecifications SHALL.NOT
be heid to pern it or te. �e an riprproval of the violation
of any provisions of any City Ordinance or Sate Law.
BY ��'t�-- QW /—
DATE -r'/ I f ProjectData-Residential.doc revised 03/09/11
PERMIT NO. /f/O 770 77
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OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX (408)777-3333• buiidina5cuoertrno.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 ADDRESS APN BP#
OWNER NAME Va l Li•Y a i1 i I t�' OWNER ADDRESS
DESCRIPTION OF WORK: v%. r P CL e--
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, 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.)
00-1: 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
insurance coverage for injuries to workers on my property.
C*-'2. I 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.
O*A3. I 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.
0-4 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
CW` -5. I 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 dollars($500), including labor and materials, I may be
considered an "employer' under state and federal law.
0-1'`"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.
c-4v"-7. I 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 Contractor.
I 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 owner(s)that result from any latent construction
defects in the workmanship or materials.
amerBuilderForm 2010.doc revised 04114/10
Q4 ,9. I 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.ca.gov for more information about licensed
contractors.
C�0. 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.
b--11. 1 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.
(, t" 12. 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 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 understand 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.)
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 required to be presented when the permit is issued
to verify the property owner's si nature.
Property Owner's Signature: -d- '� t- �-' Date: 5 1
---------------------------------------------------------------------------------------------------------------------------------------------
(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 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 may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
GYvneBuilderFOrnt 2010.doc revised 04114/10