14050096 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7373 FALLENLEAF LN CONTRACTOR:FALLEN LEAF SS LLC PERMIT NO: 14050096
OWNER'S NAME: FALLEN LEAF SS LLC 66 E SANTA CLARA ST DATE ISSUED:05/15/2014
OWNER'S PHONE: 4083093519 SAN JOSE,CA 95113 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
UNIT 25-DEDICATED CIRCUIT TO MOCROWAVEMOOD
License Class Lie.# &
REPLACE ALL(E)OUTLET RECEPTACLES
Contractor Date
—
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:$600
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 WI 180 OF VIIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter SPECTION.
upon the above mentioned property for inspection purposes. (We)agree to save 180 D
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ssued by: Date: S
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,SectiQif-
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:
7hby affirm that I am exempt from the Contractor's License Law for one of
wing two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
eroftheproperty,or my employees with wages as their sole compensation,
he work,and the structure is not intended or offered for sale(Sec.7044,
&Professions Code)
ner 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
P�tperformance
arations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
e and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
pensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by t Bay Area AirVu.ality Management District I
of the work for which this permit is issued. will maintain compliance with t Cupertino M cpal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by
the Health&Safety C±TRUCTIO!NLE
EINGAGENCY
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized aDat'
2.1
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 C
Compensationlaws 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 expense 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' ourc egulati s per the Cupertino Municipal Code,Section Licensed Professional
918.
Signature Date
GENERAL PERMIT APPLICATION � MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 MISC
CUPERTINO (408)777-3228•FAX(408)777-3333•building(cDcupertino.org
PLUMBING OWCHANICAL C&LECTRICAL MISCELLANEOUS
PROJECT ADDRESS APN# Q
161
OWNERNAME F CLLe PHO gap
MAII
'.✓ J
STREET ADDRESS �OfCITY, STATE,Z FAX
CONTACT NAME ` PHONEE-MAIL
STREET ADDRESS /}� /�_ CITY,STATE, GC;6 CA
FAX
" ( v ►I�
❑OWNER ,y'J�Q}a'NER-BUII.DEP ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHTI'ECT ❑INGINEF,R ❑ DEVELOPER 11 TENANT
--7CONTRACTOR 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 FAMQ.Y PROJECT IN WBALAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
na r\eA l Le- 4- �A-C
TOTAL VALUATION:
By my signature below,I certify to each o e following: I am property owner or authorized ent to ac ro o s behalf. I have read this
application and the information I have pr ded is co t. I have ad the Description of Work and verify it is acc agree to comply with all applicable local
ordinances and state laws relating to buil g Astro . I an resentatives of Cupertino to enter the above-idem_i, pop rty for inspection purposes.
OrSignature of Applicant/Agent: Date: I5
S LEMENTAL INFO TION REQUIRED OFF ICE usE oro Y
W Q OVER-THF CUUNTER:
EXPRESS
FISTANDARD
' LARGE
17 MAJOR
MEPMiscApp_201 1.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 7373 FALLENLEAF LN#25 DATE: 05/15/2014 REVIEWED BY: MELISSA
APN: 359 27 025 BP#: EVALUATION: $600
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY PENTAMATION 1 REAP 1
USE: SFD or Duplex PERMIT TYPE: i
WORK DEDICATED CIRCUIT TO MOCROWAVEMOOD & REPLACE ALL E OUTLET RECEPTACLES
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Appliances 1 ERESAPP 1 # $24
Recep/Switch/Outlets 1BREMRECEP 15 # $47
TOTALS: $71.00
t.
1lh?ivh. Elec.Plan Check 0.0 hrs $0.00
Fee: T r`u nh. F'c ,ir Fee Elec.Permit Fee: 1EPERMIT
t�tr'':c� PIt �h rosin Other Elec.Insp. 0.0 hrs $47.00
f hinih Insp. Fee: I if,f Inu 1""'c'
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 Eff. 7/7/13) FEE QTY/FEE MISC ITEMS
Plan "",hucl, Fc
5zf wl, PC!-,(?e
PME Plan Check: $0.00
/'C:m-iif
LI/Jj j. his") I''C'e
PME Unit Fee: $71.00
PME Permit Fee: $47.00
t,tlPtS11i1t'Lt(37 Lt7:3".`
Administrative Fee: 1ADMIN $44.00
Work Without Permit? 0 Yes (E) No $0.00
Travel Documentation Fee: I TRA VDOC $47.00 i
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
'yIO�AT5 $210.50 $0.00 TOTAL FEE: $210.50
Revised: 04/01/2014
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(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 ADDRESSAPN
-N-7- FaUm��`-"k I
OWNER NAME OWNER A DRES
aC
DESCRIPTION OF WORK: 40
.r\
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 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
pe 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
i ur nce coverage for injuries to workers on my property.
9naeI understand building permits are not required to be signed by property owners unless they are responsible for
nstruction and are not hiring a licensed Contractor to assume this responsibility.
I 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
nstead of my own.
I understand Contractors are required by law to be licensed and bonded in California and to list their license
fuemployment
ers on permits and contracts.
. 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
ered an"employer" under state and federal law.
. 1 understand if I am considered an"employer' under state and federal law, I must register with the state and
l government,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
Ae to serious financial risk.
tntial
. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family
r 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
i erformed 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
n financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
de ects in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04/14/10
9.1 understand I may obtain more information regarding my obligations as an"employer'from the Internal
R enue Service,the United States Smail Business Administration,the California Department of Benefit Payments,
a 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 cslb.ca.gov for more information about licensed
t ctors.
10-1 am aware of and consent to an Owner-Builder building permit applied for in my name,and understand that I
t e party legally and financially responsible for proposed construction activity at the site address listed above.
1..I agree that,as the party legally and financially responsible for this proposed construction activity, 1 will abide
pplicable laws and requirements that govern Owner-Builders as well as employers.
11 agree to notify the issuer of this form immediately of any additions, deletions,or changes to any of the.
of ation I have provided on this form.Licensed contractors are regulated by laws designed to protect the public If
Y. coritract with someono who does not have a license,the Contractors'State License Board may be unable to
assist you wjth�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 vefifying 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 or Issuing thp permit. Note:A copy of the properly owner's drivers license,
form notarization,or other verficatiorit71
bie fo the city may be required to be presented when the permit is issued
to verifythe roe ownefs sl n
Property Owners Signature: Hate:
----------------------------------------------- -- -- ----- ----------y-- ----- ------ -------y------------9- ---g------(NOTE: The following Authorization Form is nr iced to be completed b fhe pro rty owner on/ when desi natio an
agent of the properly owner to apply for a construction permit forthe 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
Ownsr 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 filed out the
above information and certify its accuracy_Note.A copy of the property owner's driver's license,form notarization, or other
ver cation acceptable to the 7:,,Z:u1md to be presented when the permit is issued to verify the property owners
signature.Property Owner's Signature: C'"^ Date:
OwnerBvWerForm 3010 doc redsed 0?/14!10
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C O P E RT 1 N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: PERMIT# U
OWNER'S NAME: PHONE#
GENERAL CONTRACTOR: 4 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 informations
G/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
ement Finishing
Electrical SS
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/C tractor Signature Date