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13100043CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21053 CHRISTENSEN DR CONTRACTOR: SOUGOUMARANE PERMIT NO: 13100043 SHANMUGANANDAM AND SUG OWNER'S NAME: SOUGOUMARANE SHANMUGANANDAM AND SUG 21053 CHRISTENSEN DR DATE ISSUED: 10/04/2013 OWNER'S PHONE: 4089730346 CUPERTINO, CA 95014 PHONE NO: JOB DESCRIPTION: RESIDENTIAL � COMMERCIALU ❑ LICENSED CONTRACTOR'S DECLARATION BATHROOM REMODEL, 38 SQ FT OBTAIN PERMIT FOR License Class Lic. # UNPERMITTED WORK BEING DONE ADD SHOWER TO (E) Contractor Date BATHROOM M,E,P'S I hereby affirm that I am licensed under the provisions of Chapter 9 (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: $8000 1 have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 32654004.00 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 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 WITHIN 180 DAYS OF PERMIT 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 DAY M LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, Q costs, and expenses which may accrue :against said City in of the Issued by Date: 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. 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 (Sec.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. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(x) 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 3700 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 the Cupertino Municipal Code, Chapter 9.12 and ' I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sec s 255059 533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: \ Date• 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 CONSTRUCTION LENDING AGENCY Compensation laws of Cal ifornia. If, after making this certificate of exemption, I 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.) Lenders 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 Cupertino 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 permit. Additionally, the applicant understands and will comply with all non -point sourc regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature: 0_9 Date \J J CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • building a(-cupertino.org ��3 g ❑ NEW CONSTRUCTION ❑ ADDITION C&ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS CA APN # OWNER NAME HONE E -MAIL STAT TREET ADDRES ITY, E Z �'h�<<fe�nce� cIP U FAX l-c- CON NAM P ONE �I E -MAIL 34L tL�ckA. Lk TREET ADD S C Y, STATE, FAX ❑ OWNER ❑ OWNER - BUILDER ❑ OWNERAGENT ' ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME f 1 LICENSE NJ, MBER i, _ t I LICENSE TYPE I BUS. LIC # ni YAI�{Y N ,< ��' ` K .V� \ POSE USE CONSTR C -M lL V C 1 \ Q<l C 1* v 31 �_ .. MAD A`DDRES n ( �1TYQ AT DI� n (f T -(7- Yoo n-\ PHONE 7 &l/ 7 -7 , F C r ARCHITECT/ENGINEER. NAME LICENSE NUMBER TYPE BUS. LIC # COMPANY NAME VALUATION($) E -MAIL NEW FLOOR FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK \ 11 p a AREA AREA L o,(A 1ln IS TING USE POSE USE CONSTR TYPE #STORIES -(7- Yoo n-\ USE TYPE OCC. SQ.FT. VALUATION($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM jj,,-- KITCHEN OTHER REMODEL ARE /��S,.T{� 1TAR`E` REMODEL AREA REMODEL AREA PORCH AREA DECK A TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑YES n SECONDSTORY ❑YES BEING ADDED? I NO ADDITION? ®NO PRE - APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YESfW TOT ION: PLANNING APPL # _ONO PLANNING APPROVAL LETTER EICHLER HOME? ® NO 0 c> C' By my signature below, I certify to each of the following :, I am the property owner or authorized t to act on the property owner's behalf. I aver Is application and the information I have provided is correct. I have read the Description of Work an verify it is accurate. I agre ' a applicable local ordinances and state laws relating to Ilding con traction. I authorize representatives of Cupertino to enter the above- entified roperty for inspection purposes. V r Signature of Applicant/Ag Date: Do SUPPLEMENTAL INFORMATION REQUIRED OW - ? C1 L New SFD or Multifamily dwellings: Apply for demolition permit for _ existing building(s). Demolition permit is required prior to issuance ofbuildmg a permit for new building. _ Commercial Bidgs: Provide a- completed Hazardous Materials Disclosure aYiu. ICo, form if any Hazardous Materials -are being used as part of this project. Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. G' `vvER nts tu�al BldgApp_2011.doe revised 06121111 11 CITY OF CUPERTINO 10101 1ccrrYX4 A rPnn — 112TTTT ."-FN(_' DIrVlQlON imADDRESS: 21053 CHRISTENSEN DR DATE: 10/04/2013 REVIEWED BY: APN: BP #: "VALUATION: $8,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION 1 R3SFDREM PERMIT TYPE: USE: WORK BATHROOM REMODEL 38 SQ FT OBTAIN PERMIT FOR UNPERMITTED WORK BEING DONE SCOPE I ADD SHOWER TO (E) BATHROOM M,E,P'S iWch. Plana Check 11ech. PenuitFee: Other ;ilec +h. Insj,�. I i3ech. Insp. Fee. NOTE: This estimate does not include. are based Plumb. Plea Check F_lec —Plan (..heck Plumb. Permit Fee: Elec. Permit Fee: Chlrer Plumb Insp. Other Elec. Ins /s. Li 1 Plumb. Irrsl ).. Fee: Elec, Insp. Fee: due to other Departments (La Planning, Public Works, Fire, Sanitary Sewer District, School FEE ITEMS (Fee Resolution 11 -053 Eff. 7/1/13 Plan Check Fee: Suppl. PC Fee: Reg. Q OT ro .0 hrs PME Plan Check: Permit Fee: Suppl. Insp. Fee-.0 Reg. .0 OT 0,0 hrs PME Unit Fee: PME Permit Fee: Consir action Tax: A (hn in istratl ve ./' e e: Work Without Permit? 0 Yes (E) No Advanced Planning Fee: Travel Documentation Fees; Strong Motion Fee: IBSEISMICR Bldg Stds Commission Fee: IBCBSC •mation available and are omy an esumart~ wntuct WE uept FEE QTY/FEE I MISC ITEMS $0.00 = s.f. Remodel, Bath (< =300 sf) $0.00 $626.00 IREMRESBAT $0.00 $0.00 $0.00 $0.00 $0.00 Revised: 10/01/2013 glum iWch. Plana Check 11ech. PenuitFee: Other ;ilec +h. Insj,�. I i3ech. Insp. Fee. NOTE: This estimate does not include. are based Plumb. Plea Check F_lec —Plan (..heck Plumb. Permit Fee: Elec. Permit Fee: Chlrer Plumb Insp. Other Elec. Ins /s. Li 1 Plumb. Irrsl ).. Fee: Elec, Insp. Fee: due to other Departments (La Planning, Public Works, Fire, Sanitary Sewer District, School FEE ITEMS (Fee Resolution 11 -053 Eff. 7/1/13 Plan Check Fee: Suppl. PC Fee: Reg. Q OT ro .0 hrs PME Plan Check: Permit Fee: Suppl. Insp. Fee-.0 Reg. .0 OT 0,0 hrs PME Unit Fee: PME Permit Fee: Consir action Tax: A (hn in istratl ve ./' e e: Work Without Permit? 0 Yes (E) No Advanced Planning Fee: Travel Documentation Fees; Strong Motion Fee: IBSEISMICR Bldg Stds Commission Fee: IBCBSC •mation available and are omy an esumart~ wntuct WE uept FEE QTY/FEE I MISC ITEMS $0.00 = s.f. Remodel, Bath (< =300 sf) $0.00 $626.00 IREMRESBAT $0.00 $0.00 $0.00 $0.00 $0.00 Revised: 10/01/2013 CUPERTINO OWNER- BUILDER DISCLOSURE FORIii'I COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • building a)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 C r APN BP# WNER N N Sl�' � SvG� o, pp i g DESCRIPTION OF WORK: O 6 K 033 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.) 1. 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 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. ") 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. O4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the tot I 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. 9�_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. _91,7. 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 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 an financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerBuilde7FOrrm 2010. doe revised 04114110 9. I understand l may obtain more information regarding my obligations as an "employer" from the Internal evenue 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.csfb.ca.gov for more information about licensed contractors. 4!4,10. I am aware of and consent to an Owner - Builder building permit applied for in my name, and understand that I am the parry legally and financially responsible for proposed construction activity at the site address listed above. 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. 12. 1 agree to notify the iissuer 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 completei 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 verifv the Property owner's sianature. Property Owner's Signature: gal i Date: la ( Lc I r `z, - ---------4----------------------------------------------------------------------------------------------------- - NOTE- -The -- follow--ing -- Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply fora 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)Ito 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: Address of Authorized Agent: Tel No 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: I Date: Oi4 neiBaiilderFo7m1 2010.doc revised 04114110 i1r I CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21053 CHRISTENSEN DR CONTRACTOR: SOUGOUMARANE PERMIT NO: 13100043 SHANMUGANANDAM AND SUG OWNER'S NAME: SOUGOUMARANE SHANMUGANANDAM AND SUG 21053 CHRISTENSEN DR DATE ISSUED: 10/04/2013 OWNER'S PHONE: 4089730346 CUPERTINO, CA 95014 PHONE NO: JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIALE] ❑ LICENSED CONTRACTOR'S DECLARATION BATHROOM REMODEL, 38 SQ FT OBTAIN PERMIT FOR License Class Lic. # . UNPERMITTED WORK BEING DONE ADD SHOWER TO (E) Contractor Date BATHROOM M,E,P'S I hereby affirm that I am licensed under the provisions of Chapter 9 REV # 1 ADD 2ND BATH REMODEL & RECONFIGURE TO (E) (commencing with Section 7000) of Division of the Business & Professions MASTER BATHROOM. (NO PREVIOUS IVPECTIONS) - ISSUED Code and that my license is in full force and effect. 11/14/13 RE\ /' I u Y 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: $8000 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 32654004.00 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 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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter 180 DAY. Olt'LLi M INSPECTION. upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the Issu ate It hqh-� 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. - OOFS: 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. Ey 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) I, as owner of the property, am exclusively 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 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, 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 3700 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 the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505, 2 33, and 25534. j Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Date:�� 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I 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 Cupertino 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 permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. ((� 0 Date �` Signature` (1\ CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISIOI 10300 TORRE AVENUE - CUPERTINO, CA 95014 -3255 CUPERTINO I (408) 777 -3228 • FAX (408) 777 -3333 • buildinolaDcupertino.org ❑ NEW CONSTRUCTION n ADDITION I I AT.TF.R ATTnM / TI U.PNIMMM I nVr P IECT SS .. Sp�e�i S�Vi Y C �l l , APN # /� — 5 1 0 0 7 p ^'�� OWNERNA , , n �'• I �� S PHONE �Vh U {z N 13 C�3 6 ' Q co-, q t 5Tu�S ET 9D S � �hS emn IT'Y, STATE, P ._ Ct FAX w � � ho - p( C ONTACT NAME y\ a� tN& �� U 's'k Q\r �d I CkV STREET DRESS O Cvyt h�h Y, STATE, ZIP_ /� � +'P C7 C. Vi � [ FAX 91 OWNER ❑ OWNER - BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENAIrr CONTRACTOR NAME 3 01_ ,, C e, C n LIC SE Nj B LICENSE TYPE BUS. LIC # COMP ? M FAX C3,_)S , l �C C \ J;R=DD)LESS STATE , A �' J . PHONE -H ` --�. / (1- / (� ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK „n � ` � � � `� � � •� � t� Q%ky 7STING USE P OPOSED USE CONSTR TYPE #STORIES USE TYPE OCC. C •� M SQ.FT. VALUATION ($) EXISTG -p , ' NEW FLOOR DEMO TOTAL AREA AREAS - AREA NETAREA BATHROOM KITCHEN OTHER REMODEL fi REMODELAREA REMODELAREA PORCH AR8A7 DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ ATTACH I # DWELLING UNITS: IS A SECOND UNrr ❑ YES SECOND STORY ❑ YES BEINGADDED? ❑NO ADDITION? []NO PRE - APPLICATION El YES IF YES, PROVIDE COPY OF PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER IS THE BLDG AN ❑YES EICHLER HOME? ❑ NO C $y; TOTAL VALUATION: !� 6 By my signature below, I certify to each of the following: I am the property owner or authorizdngent to act on the property owner's beha 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 buil constructi n. I authorize representatives of Cupertino to enter the above` - identified perty for inspection purposes. pr Signature of Applicant/Agent: C LEA Date: M ( 15 SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP VER- THE COUNTER 1:1 BUILDING PLAN REVIEW _ New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure El STANDARD 1-1 PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR El SANITARY submittal of Building Permit application. SEWER DISTRICT ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06121111 , CITY OF CUPERTINO VVV i'i err7M A rrn12 — 12ITII.11INf DIVIgION W11ADDRESS: 21053 CHRISTENSEN DR — DATE: 11/14/2013 REVIEWED BY: MELISSA APN: 326 54 004 BP #: *VALUATION: $20,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex 1 R3SFDRE i PERMIT TYPE. USE: Remodel, Bath (< =300 sf) 1REMRESBAT WORK REMODEL & RECONFIGURE E MASTER BATHROOM. hrs $0.00 SCOPE C -- o.- X/ech. flan Check Plumb. Plant Check Elec. Plan Check Lfech. Pernail Fee: Plumb. Permit fee: flee. Permit Pee: F11,1,'ch. Nlech. Insp. Chlter Plumb Insp. Oilier Elec. Insp. Insp. lee: Plumb. Insp. Tee: Elec. Insp. Fee: NOTE. This estimate does not include-fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School D' Th s are based on the relimina in ormadon available and are onl an estimate. Contact me ue t or aaan i in o. . e ee tstnct, etc es FEE ITEMS (Fee Resolution 11 -053 E . 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = s.f. $626.00 Remodel, Bath (< =300 sf) 1REMRESBAT Suppl. PC Fee: iq Reg. ® OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-0 Reg. Q OT O.0 I hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 f:onswuction Tax Administrative 1' ee: 1 0 Work Without Permit? ® Yes (E) No $0.00 Advanced Planning Fee: $0.00 Select a Non - Residential Building or Structure 0 0 7�ravel Doerrtrtc�ntrx/'ion Tees: � Strong Motion Fee: IBSEISMICR $2.00 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 - $626.00 TOAL�FE Revised: 10/01/2013 CITY OF CUPERTINO UUw TCT7M A rPnD — RTTTT .11TNf_ illVlClnN imADDRESS: 21053 CHRISTENSEN DR DATE: 11/14/2013 REVIEWED BY: MELISSA MISC ITEMS . APN: 326 54 004 BP #: 13100043 *VALUATION: Suppl. PC Fee: Q Reg. 0 OTT 00 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: $0.00 PENTAMATION PERMIT TYPE: i WORK REV # 1 ADD?2ND BATH REMODEL & RECONFIGURE TOE MASTER BATHROOM. NO SCOPE I PREVIOUS INSPECTIONS 14eech. Plan ('leak Plumb. Plan Check Flec, Plan Check Liec61. Perrrtil Fee. Plumb, Permit Fee: flee. Permit I'ee: 9ther rIkch. Insp. Other Plumb Insp. Li Other Elec. Insp. Heck Insp. Fee: Plumb. lisp. Fee., Elee. Insp, Fee: NOTE: This estimate does not inctuae fees aue to otner ueparrments (Le. riunning, rnunc ....,>v�, • �, �•.••..w• r ��• -� - -�• •� -.. District, etc.). These Pes are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 11 -053 E . 711113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg /Structure or Element of a Building Suppl. PC Fee: Q Reg. 0 OTT 00 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-.0 Reg. ® OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction :Tax.- Administrative .Fee: E) Work Without Permit? 0 Yes (F) No $0.00 Advanced Planning Fee: $0.00 Select a Non - Residential E) Building or Structure 7rIlvel DocumentationT'ees: Strong Motion Fee: $0.00 Select an Administrative Item Bldg Stds Commission. Fee: $0.00 $0.001 $0.00 = $0.00 Revised: 10/01/2013 44\4 14 � 566flc- '- Ke.wwdlo-1 I I IS N (Z q17-J COMMUNITY DEDIELOPNIENT DEPARTMENT BUILDING DIVISION - CUPERTINO W APPROVED Z- 43 This set of plans and specifications MUST be kept at the job site during construction. it is unlawful to make any changes or alterations on same, or to deviate therefrom, without approval from the Building Official. The stamping of this plan and specifications SHALL NOT be held to permit or-ta n appro of the violation of any pro Y*&`c— an' City finance or State Law. TE CUPERTINO Building Department NOV 1 202 MMMW-J REVIEWED FOR CODE COMPLIANCE Reviewed By. a�EVISION # OFFICE Copy,,... < H HUH � NOV 14 2013 [1 4-7 �(uon�ig��e <e� �'��-ovm ��z3.s.FJ I............ 'n> Sw .� ; �� 5 C 12 yk 17 REVISION #J- CUPERTINO rluildina ne nent REVIEWED FOR CODE C_OMPUANCE Reviewed By 140q�--- OWNER- BUILDER DISCLOSURE FORM COMMUNITY, DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • building0 cuoertino.ora 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: 1 34000 vtoof C0 I APN:�; uo , yi _L9O OWNER N E__S ti A V4 -SW&I Ow VNc C0\4- Ct:R'SLQ A K&IaMt1A-e, 04 W\QS'feft ►/'' I hi6�M 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 cq frig notice u less 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.) L1. 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. 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. q=0_3. 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. q4-4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. 2 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the to al value of my construction is at least five hundred dollars ($500), including labor and materials, I may be �coonsidered 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 understand my failure to abide by these laws may subject me to serious financial risk. �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. 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 owner(s) that result from any latent construction defects in the workmanship or materials. C-AvnerBuilderFonn 2010. doe 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.ca.gov for more information about licensed contractors. 16) 10. 1 am aware of and consent to an Owner - Builder building permit applied for in my name, and understand that I a m!! the party legally and financially responsible for proposed construction activity at the site address listed above. // `- 111. 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. (4_12. 1 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 oroDerty owner's signature. n Property Owner's Signature: Date: \N I t" I ( I*p --------------------------------------------------------------------------------------------------------------------------------------------- (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: Address of Authorized Agent: Tel No 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: OwneJBuildeiFornz 2010.doc revised 04114110 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014 -3255 Telephone: 408- 777 -3228 Fax: 408- 777 -3333 JOB ADDRESS:2- Q� `R�S(e e' \ Q6t� r% (A PERMIT # 31000 OWNER'S NAME-- SM�KM\AAINA(V'DAM PHONE # ~ O GENERAL CONTRACTOR: BUSINESS LICENSE ADDRESS: CITY /ZIPCODE: *Our municipal code requires all businesses working in the city 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 -- _ Owner / Co*tr -aetor Signature iC -5 Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Co*tr -aetor Signature iC -5 Date oj\ L 6f-R, nOR (k A A y.x oc)o n1le � S,