15030087N
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19905 FIG TREE CT
CONTRACTOR: CASELLA RONALD J
PERMIT NO: 15030087
AND MARY A
OWNER'S NAME: CASELLA RONALD J AND MARY A
19905 FIG TREE CT
DATE ISSUED: 03/13/2015
OWNER'S PHONE: 4082577208
CUPERTINO, CA 95014-2314
PHONE NO:
JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL E]
❑ LICENSED CONTRACTOR'S DECLARATION
INSTALL 21 (N) LIGHT FIXTURES THROUGHOUT
License Class Lic. #
KITCHEN,
LIVING RM, DINING RM & OFFICE
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: $12000
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 31630078.00
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
1 AST CALLED INSPEC ION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
City in consequence of the
3
costs, and expenses which may accrue against said
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
918.
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
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,
Business & Professions Code)
1, 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. 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 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, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agen • Date:
permit is issued.
1
I 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
918.
Signatu Date / /S�
CUPERTINO
4
GENERAL PERMIT APPLICATION D M E P
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-32556� misc
(408).777-3228 • FAX (408) 777-3333 •_buildinp(cDcupertino.org
❑ PLUMBING ❑ MECHANICAL Jr ELECTRICAL [—]MISCELLANEOUS
PROJECT ADDRESS
APN # 3
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STREET ADDRESS
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CITY, STATE, 7IP C FAX
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STREET ADDRESS
CITY, STATE, ZIP
FAX
OWNER ❑ OWNER -BUILDER -• -❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LIC # 7 / •Q
i
COMPANY NAME
E-MAIL
FAX r
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
PROJECT IN WILDLAND ❑ YES
PROJECT IN ❑ YES
IS THE BLDG AN ❑ YES
BUILDING: ❑ COMMERCIAL _
URBAN INTERFACE AREA ❑ NO
FLOOD ZONE ❑ NO _
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
TOTAL VALUATION;
n EIVED B -
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property o behalf. I have ad 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 comp licable local
ordinances and state laws relating to ilding construction. I autho • e presentatives of Cupertino to enter the above -id e tified p op/ erty�for inspection purposes.
J t �
Signature of Applicant/Agent
Date: -
SUPPLEMENIVAL INFORMATION REQUIRED
oF�icE IjsE oi\LY ��,
' OVER TkIECOUNTE
FLP12E5S` ,. .
LARGES
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MEPMiscApp_2011.doc revised 06121/11
CITY OF CUPERTINO
rrr 1V40•1rT1%4 A rrnlD RITIT TITATC DlVlClnN
APPLIANCE / EQUIP TYPE
1' 1JL
ADDRESS: 19905 fig tree ct
DATE: 03/13/2015
REVIEWED BY: MELISSA
ii
APN: 316 30 078
BP#•
EVALUATION: 1$12,000
*PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
SFD or Duplex
#
PENTAMATION 1 REAP11
PERMIT TYPE: i
USE:
Permit Fee:
WORKINSTALL
21 N LIGHT FIXTURES THROUGHOUT KITCHEN LIVING RM DINING RM & OFFICE
SCOPE
PME Unit Fee:
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Fixtures, Lighting
1BREMFIXT
21
#
$78
Permit Fee:
SUI)IV. ITrs/) P'ee
PME Unit Fee:
$78.00
PME Permit Fee:
$48.00
(.Olnsti-mchon Tax:
Administrative Fee: 1ADMIN
$45.00
Work Without Permit? ® Yes (2) No
$0.00
TOTALS::
ti _
$78.00..'
Strong Motion Fee: IBSEISMICR
$1.56
Select an Administrative Item
,Wch. Plan Check
Afech, PermitFee:
Oilier Alcch. Insp
Is1`Ic'cI2. It2S77. /"ee:
Plumb. PIon Check
Elec. Plan Check 1 0.0 1 hrs $0.001
Plumb. Permit Fee: Elec. Permit Fee: ]EPERMIT
Other Plumb Insp. Other Elea Insp.0.0 hrs $48.00
Plumb. hasp. Tee: Liec- hzsp. Fee:
NOTE: This estimate does not inetuae fees aue to otner vepartmenw tae �[unno,ag, 1 ���•� •• �• - •• »•----•� -•• _. _ ____ ___,
_n.-zt. ,...,J ,. ..6, n noAss,•.fn !'n"mrt tho Dont far addn'1 info.
,utstrtct, etc . i nexe eea are ,ivacu u,i ue-P--
.-FEE ITEMS (Fee Resolution 11-053 a.. 7/1/13)
FEE
FEE
QTY/FEE
MISC ITEMS
Plan C heJ Fee:
Suppl. P(.., 1`C'.E
PME Plan Check:
$0.00
Permit Fee:
SUI)IV. ITrs/) P'ee
PME Unit Fee:
$78.00
PME Permit Fee:
$48.00
(.Olnsti-mchon Tax:
Administrative Fee: 1ADMIN
$45.00
Work Without Permit? ® Yes (2) No
$0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
$1.56
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
�a
$221.56
$0.00f y TONAL FEE:
$221.56
Revised: 02/14/2015
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408)777-3228 • FAX (408)777-3333 • buildinga-cupertino.or4
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:
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.)
fy--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 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. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may
v r-otect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
11 4. 1 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
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.
(V, 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.
ARL7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family
esidential 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.
PC 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.
OwnerBuilderForm 2010.doc revised 04/14/10
9. 1 understand I 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.cslb.ca.gov for more information about licensed
nco//n��tra�� ctors.
r� 0. 1 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.
4L11. 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 issuer of this -form: immediately of any additions, deletions, or changes to any of the
ififormation 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 maybe 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 civi[court. 1tis 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 at.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 signatwm 4e
Property Owner's Signature: Date: / iS
---------------------------------------------------------------------------------------------------------------------------------------------
(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:
OwnerBuilderForm 2010.doc revised 04/14/10
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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: A744urPERMIT # Z AO I
OWNER'S NAME: (Iy/L �/4A,-A- IPHONE#
GENERAL CONTRACTOR: -1 ;,' ie
ADDRESS:
*Our municipal code requires all businesses
NO BUILDING FINAL OR FIN O
GENERAL CONTRACTOR AND. LL 1
BUSINESS LICENSE.
I am not using any sub ntractors:
Please check applicable subcontractors
LICENSE #
CITY/ZIPCODE: Ale.-O–N j6L�iS Cf ZO-J� j?
in the city to have a City of Cupertino business license.
AINSIONS) WILL BE SCHEDULED UNTIL THE
VE OBTAINED A CITY OF CUPERTINO
i Date
complete the following information:
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 A
0z
Sheet Rock
Tile /- 7siL�
Date
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: 19-320S Pk,.jy
PERMIT # ( 150 t 010-1
OWNER'S NAME: Mo1Io UZ„
PHONE # Af 0k)--97-( - 5�s
GENERAL CONTRACTOR: I Ie vccv\ Cch > y, -4i -o.
BUSINESS LICENSE # 110 c0 901
ADDRESS: (9qp C7;b•s 1{w a
CITY/ZIPCODE: iM-,
*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
Please check applicable subcontractors and complete the following information:
Date
Owner / Contractor Signature
2 r2 15
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
o S„ , �, J . I b,,
Electrical
Excavation(ba-
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
„; tc� ly(,t c1�. 1,- c
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner / Contractor Signature
2 r2 15
Date
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: J k y c ,' e Gr•
PERMIT # L
OWNER'S NAME: PpiaIg c�o J _ e -/K944/7
PHONE # yo ,*-- Z -1 -I zO S'
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 INSPECTIONS) 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
Please check applicable subcontractors and complete the following information:
Date
/ Contractor Signature
i.3 /3—
Date
f�
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
12 i= C L G T2 I G
'
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
/ Contractor Signature
i.3 /3—
Date
f�