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13110090 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7373 FALLENLEAF LN. CONTRACTOR:FALLEN LEAF SS LLC PERMIT NO:13110090 OWNER'S NAME: FALLEN LEAF SS LLC 66 E SANTA CLARA ST DATE ISSUED:11/13/2013 OWNER'S PHONE: 4083093519 SAN JOSE,CA 95113 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 0 COMMERCIAL License Class Lie.# APT#28-INSTALL(1)20 AMP CIRCUIT FOR MICROWAVEMOOD.ADD 1 (1)CAN LIGHT IN KITCHEN. Contractor Date UPDATE ALL OUTLET RECEPTACLES FOR I hereby affirm that I am licensed under the provisions of Chapter 9 GFCl/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:$800 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 WITHIN 0 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, // 9 costs,and expenses which may accrue against said City in consequence of the Issued b Date: �/y,914J granting of this permit. Additionally,the applicant understands and will comply Y' 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: her by affirm that I am exempt from the Contractor's License Law for one of the f (lowing two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,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, siness&Professions Code) owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE nstruct 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. 1 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 uper in o Mu 'cipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio 25505 5533 nd 34. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent Date/ Pf milt is issued. ertify that in the performance of the work for which this permit is issued,I shall Mot employ any person in any manner so as to become subject to the Worker's CONSTRUCTION L ING AGENCY ompensation 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 p it.Additionally,the applicant understands and will comply with all non-po' t ource regulatierithe Cupertino Municipal Code,Section Licensed Professional 9.18. Signat Date If r GENERAL PERMIT APPLIGATIDN 'v' r r COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 O� CUPERTINO (408)777-3228•FAX(408)777-3333•buildin4CaD-cupertino.orcl �`, MISC \3 PLUMBING ONECHANICAL ELECTRICAL MISCELLANEOUS PROJECT ADDRESS' � t �� APN# OWNER NAME L LL PHONE E-MAIL STREET ADDRESS CITY,STATE, 4fA( �l CONTACT NAME Y`� PHONE O G qn7- E-MAIL STREET ADDRESS � CI1 Y,STATE,Z 6 / JF�JC� �! (� ❑OWNER OW EP BUILDER ❑ OwNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E•MAH. FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECUENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CrrY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMIIX PROJECT INWIIALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK \ +- a n TOTAL VALUATION: C RECEIVEDX j By my signature below,I ce4hav f 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 informativi d is corre . I have ad the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws reling nstructi . I orize representatives of Cupertino to enter the above-iidentified property for inspection purposes. Signature of Applicant/Agen Date: VUPPLEIIENTrORMATION REQUIRED p i77�'JI�LJI � 4 �'rr AIA{�B CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 7373 fallenleaf In unit#28 DATE: 11/13/2013 REVIEWED BY: Mendez APN: BP#: "VALUATION: $800 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY SFD or DuplexI- I PENTAMATION 1REAP10 USE: p PERMIT TYPE: WORK APT#28—INSTALL N 20 AMP CIRCUIT FOR MICROWAVE/HOOD.ADD 1 N CAN LIGHT IN SCOPE KITCHEN. UPDATE ALL OUTLET RECEPTACLES FOR GFCI/GROUNDING IN SERIES A,fech.Plan Check Phcmb.Plan Check Elec.Plan Check 0.0 hrs $0.00 ,�fech.Pernit Fee:: Plumb.Permit Fee: Elec.Permit Fee: IEPERMIT F,_h •Y0.0ech.Insp. Other Plumb Insp. Other Elec.Insp. hrs $47.00.Insp. Fee: Plumb. hrsic.Fee: Elec.Insp.£ee: NOTE:This estimate does not include fees due to other Departments(Le.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 De t or addn'l info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = # Electrical Suppl.PC Fee: (F) Reg. ® OT [_0_,0_1hrs $0.00 $47.00 IBREMRECEP Recep/Switch/Outlets PME Plan Check: $0.00 F-T-1 Electrical Permit Fee: $0.00 $70.00 1 IBREAff= Fixtures,Lighting Suppl. Insp.Fee-.0 Reg. ® OT 0 0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $47.00 Co nsiruction :Tear: 777 Administrative Feer 1ADMIN $44.00 Work Without Permit? ®Yes (E) No $0.00 0 Advanced Planning Fee: $0.00 Select a Non-Residential 0 Travel Documentation Fee: ITRAVDOC $47.00 Building or Structure Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 41tic a . 7.00 $13950 $11 „ �� $256.50 �� � . Revised: 10/01/2013 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333•building(akupertino.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_ I APN BP# OWNER NAO N R ADDRESS I'LL 1 DESCRIPTION OF WORK: 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.) A1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner- r"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 thoseinjuries. I am willfully acting as an Owner-Builder and am aware of the limits of my. in ur nce coverage for injuries to workers on my property. IneI understand building permits are not required to be signed by property owners unless they are responsible for struction and are not hiring a licensed Contractor to assume this responsibility. 1 understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her stead of my own. 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license Insiners on permits and contracts. 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the alue of my construction is at least five hundred dollars($500), including labor and materials, I may be dered an"employer" under state and federal law. 6. I understand if I am considered an"employer" under state and federal law, I must register with the state and Velpral 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 t serious financial risk. 7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family r dential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by li ns edd subcontractors and the number of structures does not exceed four within any calendar year, or all of the work ii 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 financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction fects in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 9.I understand 1 may obtain more information regarding my obligations as an'employer"from the intemai Re enue Service,the United States Small Business Administration,the California Department of Benefit Payments, a the California Division of Industrial Accidents. I also understand l may contact the California Contractors'State License Board(CSLB)at 1-800321-CSLB(2752)or www cslb.ca.gov for more information about licensed I ors, I am aware of and consent to an Owner-Builder building permit applied for in my name,and understand that I party legally and:financially responsible for proposed construction activity at the site address listed above. I agree that,as the party legally and financially responsible for this proposed construction activity, I wilt abide plicable laws and requirements that govern Owner-Builders as well as employers. 1 agree to ns�fify the issuer of this form immediately of any additions, deletions,or changes to any of the. ion.1 have provided on this form.Licensed contractors are regulated by laws designed to protect the public I€ tract with sorneon�who does not have a license,the Contractors'State License Board may be unable to assist you with-any finarioir.0 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} 1 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 perrnit 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 veriScatfon acceptable to the city may be required to be presented when the permit is issued to verify the proeti&owner's s! nature. Property Owner's Signature: Date: -------- -------- ------------------------------------------------------------- ------------------------------------------------------------- (NOTE: The following Authorization Fane is required to be completed by the propertyowner 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 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 or Address: Name of Authorized Agent: Tel No Address of Authorized Abent: 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 diive?s license,form notarization, or other verification acceptable to the city m be required to be presented when the permit is issued to verify the property owne>'s signature. Property Owner's Signature: Date:. .�3r 1"5 OwnelBuilde)Form 2010 doc revised 04/14110 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 NAMT:r, I J.e PHONE# t GENERAL CONTRACTOR: '--f,) fir BUSINESS LICENSE..# ADDRESS: r' 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 INSPECTIONS) WILL: BE: SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINEDA 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 ty �,53 0 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 ractor Signature Date