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13080199 CITY OF CUPERTINO BUILDING PERMIT 13UILDING ADDRESS: 7373 FALLENLEAF LN CONTRACTOR:FALLEN LEAF SS LLC PERMIT NO: 13080199 OWNER'S NAME: FALLEN LEAF SS LLC 66 E SANTA CLARA ST DATE ISSUED:08/26/2013 OWNER'S PHONE: 4083093519 SAN JOSE,CA 95113 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIALS License Class Lic.# **APT#27**INSTALL(N)20 AMP CIRCUIT FOR MICROWAVE/HOOD.ADD 1 (N)CAN LIGHT IN KITCHEN. Contractor Date UPDATE ALL OUTLET RECEPTACLES FOR I hereby affirm that I am licensed under the provisions of Chapter 9 GFCI/GROUNDING (commencing with Section 7000)of Division 3 of the Business&Professions 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. Sq.Ft Floor Area: Valuation:$1000 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 APN Number:35927025.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITFIIN 180 DAYSOF P ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FRO T ED INSPECTION. indemnify and keep harmless the City of Cupertinoagainst liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the 6L granting of this permit. Additionally,the applicant understands and will comp Date: 6 with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date All roofs shall be inspected r 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. OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Scc.7044,Business&!Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will I hereby affirm under penalty of perjury'lone of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3;700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with t Cupertino unicipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sec' s 255(16,25593,and25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent- DategA permit is issued. I certify that in the performance of the work for which this permit is issued,I shall 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 CO 5TRUCTION INDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this.permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of C, ertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this rmit.Additionally, applicant understands and will comply with all non-p i source regulations r the Cupertino Municipal Code,Section Licensed Professional 9.18. Signat e Date GENERAL PERMIT APPLICATION m C r COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION r�� 10300 TORRE AVENUE•CUPERTINO,CA 950143255 �V CUPERTINO (408)777-3228•FAX(408)777-3333•building(ftuper ino.orct misc PLUMBING OWCHANICAL ARELECTRICAL MISCELLANEOUS PROJECT ADDRESS N# OWNER NAMEPHO �+ E-MAIL>S LL STREET ADDRESS STATE ZIP FAX CONTACT NAME _ 1m 'a0qzt19 E-MAIL, 1fe-If S, Lac STREET ADDRESS CITtWE ZIP I FAX ❑OWNER OWNER-BUu.DER ❑ owNERAGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHrrEcT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI FAMILY PROIECT IN WI.DIAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑NO FLOOD ZONE ❑No EICHLER HOME? ❑No DESCRIPTION OF WORK Cbrxrl TOTAL VALUATION: By my signature below,I certify to each of the following: I am the property owner or autho act on props wner's be . I have read this application and the information I have vided is corny I have read the Description of Work and verify it" Ira agree�� p y with alt applicable local ordinances and state laws relating to b ding co . I representatives of Cupertino to enter the abov Se/dVproperty for inspection purposes. Signature of Applicant/Agent f7 f C 7 S PLEMENT ORMATION REQUIRED oJcie iJst orr1,Y w ov>�Ic-T> couNe 0 �eEss" D srAMARU. U a `. "❑ LARGE, E3 -MAJOR-=" CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 7373 FALLENLEAF LN#27 DATE: 08/26/2013 REVIEWED BY: MELISSA APN: 359 27 025 BP#: "'VALUATION: $1,000 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or DuplexPENTAMATION 1 REAP10 USE: I PERMIT TYPE: i WORK INSTALL N 20 AMP CIRCUIT FOR MICROWAVE/HOOD. ADD 1 N CAN LIGHT IN KITCHEN. SCOPE UPDATE ALL OUTLET RECEPTACLES FOR GFCI/GROUNDING IN SERIES APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Recep/Switch/Outlets 1BREMRECEP 1 # $47 Fixtures, Lighting 16REMFIxT 1 # $70 TOTALS: $117 00i wu F ,Llech. Plan(Check Plumb. Plan Cheek Elec.Plan Check 0.0 hrs $0.00 1LI11%.Permit Fee: Plumb. Permit Few: Elec.Permit Fee: IEPERMIT Other,Vech.Insp. Other Plumb Insp. Other Elea Insp. Erhrs $47.00 1,ech. Insp,Fee: Plumb. Insp.Tee: Elec.Insp. Fee: NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These fees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS(Fee Resolution 11-053 E . 7/1/12) FEE QTY/FEE MISC ITEMS Plan Check Fee: Suppl. PC.'Fee PME Plan Check: $0.00 I'erinit.Fee: Sumpl. Insp Fee PME Unit Fee: $117.00 PME Permit Fee: $47.00 Cc�nstr action Tax: Administrative Fee: 1ADMIN $44.00 Work Without Permit? 0 Yes (E) No $0.00 ,1c,/vunecd Plarming Fees: Travel Documentation Fee: ITRAVDOC $47.00 i Strong Motion.Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 gig $256.50 $ . R =.Q.� Revised: 07/01/2013 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 GUPERTINt? (408)777-3228•FAX(408)777-3333•buildingCc�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 ADDRESSI APN --TP, 1 -30.30 ' 9 -L.n C1.-0 Q,_9, 2_�f=3� faL OWNER NAME .- ,�o � NER ADDRESS 'SC n� (CsV � 'SIA 7 ' ) DESCRIPTION OF WORK: G _10 \ 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.) N1. I.understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner— B der" building permit that erroneously implies that the property owner is providing his or her own labor and material p' sonally. 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 in u nce coverage for injuries to workers on my property. 2. I understand building permits are not required to be signed by property owners unless they are responsible for e nstruction 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 ect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her e instead of my own. 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license bers on permits and contracts. 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the of value of my construction is at least five hundred dollars($500), including labor and materials, I may be co sidered.an"employer"under state and federal law. tunmployment understand if I am considered an"employer" under state and federal law, I must register with the state and railovernment,withhold payroll taxes, provide workers'compensation disability insurance, and contribute to compensation for each"employee." I also understand my failure to abide by these laws may subject Rserious financial risk. I understand under California Contractors'State License Law, an Owner-Builder who builds single-family ntial structures cannot legally build them with the intent to offer them for sale, unless all work is performed by ed 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. 4understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for inancial or personal injuries sustained by any subsequent owner(s)that result from any latent construction def cts in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 *ad 1 understand I may obtain more Information regarding my obligations as an"employer"from the Internal e Service,the United States Small Business Administration,the California Department of Benefit Payments, 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 co ctors.. 10.1 am aware of and-consent to an Owner-Builder building permit applied for in my name,and understand that I e party legally and financially responsible for proposed construction activity at the site address listed above. 11..I agree that,as the party legally and financially responsible for this proposed construction activity,I will abide b Ii applicable laws and requirements that govern Owner-Builders as well as employers. 211 agree to no*the issuer of this form immediately of any additions, deletions,or changes to any of the. in ation l have provided on this form.Licensed contractors are regulated by laws designed to protect the public If Y. contract with someone who does not have a license,the Contractors'State License Board May be unable to assist you With-any financiai loss you may sustain as a result of a complaint.Your only remedy against unlicensed Contractors may be in civr'I 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 verflioadon 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: - - --------------------------------------------------re-q----uire-----fo---be---c-o-mi------ d---by-----fhe-------roper----ty--o--w--n-e--r-o--n-1-y--w- e--n--d-e---sign---a--ti---ng a-an--- (NOTE: The followingAuthorizatfan Form is d ptefepw 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 fallowing persons)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 orAddress: ►�-�` CY, LLC,� Name of Authorized Agent C Tel No A 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 drivees license,form notarization, or other verffxation acceptable to the city m tie required to be presented when the permit is issued to verity the property owner's signature. Property Owner's Signature: �"' Date:. i 0wnelBvz1de?FO)m_2010 doc revised 04114110 Building Department City Of Cupertino 10300 Torre Avenue ' ;Cupertino, CA 95014-3255 Telephone:408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR-LIST'_- JOB ADDRESS: — PERMIT#' OWNER'S NAME: PHONE# :.S'Q!;. GENERAL CONTRACTOR BUSINESS LICENSE#.,'` ADDRESS: CITY/ZIPCOD& *Our municipal code requires all businesses working in thecity to have,a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL -BE =SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A; CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information.: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical 3 3 Excavation Fencing Flooring/Carpeting "a Linoleum/Wood Glass/Glazing Heating Insulation Landscaping £` Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Own Contractor Signature Date Y