13050173CITY OF CUPERTINO BUILDING PERMIT.
BUILDING ADDRESS: 10497 ANSONAVE
CONTRACTOR: MARK ZAVISLAK
PERMIT NO: 13050173
OWNER'S NAMEi MARK'.ZAVI$LAK ,
10.497 ANSON AVE
DATE ISSUED: 05/22/2013
OWNER•.S PHONE, 650714207.
CUPERTINO, CA 95014
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL 13
REPLACE PLUMBING PUMP, FILTER & SEPERATION
License Class
TANK &
Contractor', Date
REPLACE (2) BREAKERS TO SUPPORTREPLACEMENT
I hereby affirm that I am licensed under the provisions of Chapter 9
PUMP
(commencing with 5ection.7000) of Div.sion 3 of the Business & Professions
AND SOLAR VALVE
Code and that 16Y license is in full force and' effect.
Ihereby'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: $2500
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 32641110.00
Occupancy Type:
Section 3700 of the:Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
I certify that I hive'read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
co, ct.,l agree to c9nip I with all city and'countyl ordinances and state laws relating
WIT 18 DAYS OF PERMIT ISSUANCE OR
to building construction,and hergby authorize representatives of this city to enter
upon theA)ove mentioned propertyf6uhispecfion purposes. (We) agree to save
180 D S OM LAST CALLED INSPECTION.
indemnify and kcep, harmless the City o£ pupertino against liabilities, judgments,
costs and expenses m ich may accrue, agauist said City in consequence of the
Issued b Date'40/ 3
y'
granting of this permit.! Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
RE -ROOFS:
Signature', Date
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Date:
!
OWNER-BUILDER'DECLARATION
Signature of Applicant:
I hereby affirm th* t I am exem t from the Contractor's License Law for one of
the following two.nei4sogs !'I. '�;
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I, as owner of e p, ope r my aIC►ploybes with wages as their sole compensation,
� i, ,, in p
,"If,!
will dolthe wor�e„and the stnicturelislnot; intended,or'offered for sale (Sce.7044,
Business & Profess ons Code) !
I; as owner of the propert�;,am ei clusiye,f contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044 Business :& Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
L !
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter9,12 andi the
declarations: ! j �, ;! ! p ! ! ;;
Health & Safety Code, Section 25532(a) should I store or handle hazardous'
I have and will maintain a Certif1.�eate ofConsent to self -insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
11:
Compensation as provided for b ' SeAim 3700 of the. Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I.
9.12
perfortiragce of th'. � k €o l whi!p�i tit l (Sgrmit as issued.
Rf!
will maintain compliance with the Cupertino Municipal Code, Chapter an
the Health &Safety Code, Sections 25505, 25533; and 25534.
I have c} wtll?nauS or. erdd p !nsaUon Insurance, as rovided for b
I� 1s ILp� p Y
Section�7, 00'ofthe�Lapor Code,' for the performance of the work for which this
Owner or authorized agen • Dati4-)2
pert l's issued.1 I I I I'.I I''
I that' in the ordnance of the work for which this permit is issued, I shall
certify pe
not em lo} fan, r of m! an ni erieos o become subject to the Worker's
,� lY t
CONSTRUCTION LENDING AGENCY
Co4npensattonlltl}v$I�€G�liforma 11f,!iaftet'making this certificate of exemption, I
becom !subject to eJ I!VS rker s Compensation provisions of the Labor Code, I must
� 1provis;onsior
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
forthwith) Coa ly w'i�tri s l plus permit shall be deemed revoked.
Lender's Name
Lender's Address
I;APPLI I AN CERTIFICATION
I certify that.1 havel.iead this''application and'state;that the above information is
correct :l 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 menti9rl property for inspection purposes. (We) agree to save
indeim>,ify andlke.ep harmless the Citylof Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
costs and expenses which: may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting' o£ this, permit Additionally,; the applicant understands and will comply
with all non point' sburce Irepulations per Fhe' Cupertino Municipal Code, Section
Licensed Professional
9 t8 l
iI
Signature! I n .i'' + Date 2 ? X13
. NJ
GENERAL PERMIT APPLICATION lo MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION DX
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 00,4
(408) 777-3228 • FAX (408) 777-3333 • building(ft oertino.ora
X PLUMBING ❑ MECHANICAL ® ELECTRICAL ❑ MISCELLANEOUS
PROJECT ADDRESS ] I j_ j C)
A
APN # S;16 - q-
- i 1 o
OWNERNAME/9�I r uI
Y `
/ck
(
PHONE (+7Q Y 1,j^�O
E-MAIL
STREET ADDRESS
s41'IiQ.
CITY, STATE, ZIP
.SQNi�
FAX
CONTACT NAME `
J
PHONE
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
FF
❑ OWNER WNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME `/ J� jl A,
,
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
/ `
ARCHrrECT/ENGINEER NAME /V
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ SFD or DUPLEX ❑ MULTI-FAMMY
BUILDING: ❑ COMMERCIAL
PROJECT IN WILDLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
7PROOJECTIN
D ZONE
❑ YES
❑ NO
IS THE BLDG AN ❑ YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
iec 'iOMA
lap AP -W f 1 4-
a
Vr
Sol Qtr Vc1U Co:1`I� bib � ICC
c&„
Lk M�i,��so-
k.
TOTAL VALUATION: ?j�V
By my signature below, I certify to each of the following: I am the property owner or authorized agent to on the property ow,par,5Jaeffalf. 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 comply with all applicable local
ordinances and state laws relating to ding construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date: O i
SUPPLE
AL INFORMATION REQUIRED
OFFICE USE ONLY
W
OVER-THE-COUNTER
❑ EXPRESS
U
❑ STANDARD
UUz
a
❑ LARGE
a
❑ MAJOR
MEPMiscApp_201 1. doc revised 06/21/11
'
ADDRESS: 10497 ANSON AVE
DATE: 05/22/2013
REVIEWED BY: MELISSA
0.0
APN: 326.41110
BP#:
"VALUATION: 1$2,500,
*PERMIT.TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair.
PRIMARY.
USE: SFD. or Duplex
PME Unit,Fee: .
PENTAIVIATION
PERMIT TYPE: 1 REAP
WORK
REPLACE PLUMBING PUMP FILTER & SEPARATION TANK & REPLACE 2 N BREAKERS TO
SCOPE.
SUPPORT REPLACEMENT PUMP & SOLAR VALVE CONTROLLER.
Mach. Plan Check Plumb. Plan Check 1 0.0 1 hrs $0.00 Elec. Plan Check 10.0 1 hrs $0.00
llech. Perwit Fee: Plumb. Permit Fee: IPPERMIT Elec. Permit Fee: IEPERMIT
Other ;t9ech. Insp.' Other Plumb Insp. E-i;s $45.00 Other Elea Insp. 0.0 hrs $45.00
Hec•h. Imp. Fee.: Plumb. hisp. Fee: Elec. Insp. Fee:
NOTE: This estimatedoesnot include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. eta). These fees are based on the preliminar
mation available and are only an estimate. Contact the Dept.for
FEE
FEE ITEMS, (Fee Resolution 11-053 Ejf. 7/1/12)
Plan Check Fee:
Suppl, PC Fee: (E) Reg: ®OT
0.0
hrs
PME Plan Check:
Permit Fee
Suppl'Insp Feed Reg:, Q'OT
0.0
hrs
PME Unit,Fee: .
$0.00
t?1VIE Permit Fee:
1PREPPIPE
cohstryctiorz TILL'
$0.00
Administrative Fee. i IADMIN
Work Without Permit? - ® Yes 6) No
Advanced Plannin�Fee:';
Travel Documentation'Fee: ITRAVDOC
Strong Motion 'Fee i 1BSEISMICR
Bldg Stds'Commission Fee: IBCBSC
mation available and are only an estimate. Contact the Dept.for
FEE
QTY/FEE
I MISC ITEMS
$0.00
1
# Electrical
$0.00
$133.00
IBREMMISC
Special Circuits
$0.00
F-1-1 # Plumbing
$0.00
$45.00
1PREPPIPE
Piping, Area
$0.00
$0.00
$90.00
$42.00
$0.00
$0.00 Select a Non -Residential
$45.00 Building or Structure
i
$0.50 Select an Administrative Item
$1.00
$178.501 $178.00 $356.50
Revised: 04/29/2013 .
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildinaC�cupertino.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 jy� 14m- 1APN 3e -
OWNER NAME /AJ r Vii_ V / OWNER ADDRESS �b
DESCRIPTION OF.WORK: lt"
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.
(DIRECTION f.Please read and initial each statement below to signify you understand or verify this information.)
A19 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 homeowners 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 verage for injuries to workers on my property.
I understand building permits are not required to be signed by property owners unless they are responsible for
t e constr tion and are not hiring a licensed Contractor to assume this responsibility.
3. I understand as an."Owner-Builder" I am the responsible party of record on the permit. I understand that.l 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.
M&A. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
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.
AA(1-6. I 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.
AAa--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.
%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.
OwnerBuildeYForm 2010.doc revised 04/14/10
�# 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. l 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.
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.
WIZ 11. I 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 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.)
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 required to be presented when the permit is issued
to verify the property owner's s4mature.
Property Owner's Signature: Date: S 2 3
--- - ------ ------ --- - - ---- ---------------------------------------------------------------------------------------------------------
(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:
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:
OwnerBuilderForn1 2010.doc revised 04/14/10