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15070172CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20455 SILVERADO AVE CONTRACTOR: THE CUPERTINO PERMIT NO: 15070172 CHAMBER OF COMME OWNER'S NAME: THE CUPERTINO CHAMBER OF COMME DATE ISSUED: 08/17/2015 OWNER'S PHONE: 4088966601 CUPERTINO CA, 950144439 PHONE NO: El LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL CHAMBER OF COMMERCE - T.I. TO RECOFIGURE AND License Class Lic. # REMODEL (E) 1379 S.F. & ADD COVERED PORCH AREA (160 S.F.) Contractor Date I hereby affirm that l=am licensed under the provisions of Chapter 9 (commencing with Settion 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 Sq. Ft Floor Area: Valuation: $18000 performance of the work for which this permit is issued. 1 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: 36939016.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. 1 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 D YS FROOM LAST CALLED INSPE TI N. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the j ►� , ��� granting of this permit.'', Additionally, the applicant understands and will comply — Issued by: Date: 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. OWN�R-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 prope=rty, 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 Cuperti nicipal Code, Chapter 9 2 an 1 have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Secti 5 5 and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Date: �7 C permit is issued. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must l 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 indemnify and keep hatrmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION 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 sour' areg tions per the Cupertino Muni cipa ode, ection Licensed Professional 9.18. S ignature Date CONSTRUCTION PERMIT APPLICATION COWIUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.org CUPERTjNO �—C ❑ NEW CONSTRUCTION ❑ ADDITION E7 ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT n PROJECT ADDRESS TLi S�S �t �e V i APN 9 OWNS Au PHONE�a� �60� E-MAIL/1A �w i rr r b II 11 h I !�� & /� ��t'l STREET ADDRESS �J S1 Iver I N,* CI Y, ST/crc,zip I \ FAX 1C 'C �Y f CONTACT NAME: Of� C PHOtI ((. * 6 6� r 1 1 1 C Iv IT•�E, / E DVal �� c) .5, (rt 6 AA STREET ADDRESS �I 2-6 — �� CITY, ZIP ` C FAX qc._ v e rec/o ! (A rv� D 75ZD-F70 OWNER ❑.: OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT j CONTRACTOR N?�i n / �� LICENSENUI,SER LICEBTYPE 1- to BUS.LIC 4 ✓�f�/� COMPANYNAA�IUex)A � AA( n. `+Y �7 ��`� FAX c(`� > �7L OIO STREET ADDRESS /! C CITY, STATE, ZIP __- CA q5J HONE'f6g5/S ?� L 1 ( d o ARCHITBCT/ENGINEERNA.ME TU\ LI CENSE NUMBER BUS. LIC COMPANY NAMEI, DA E-MAIL 00 l' / o FAX - STREET ADDRESS 516L4Lo r en oq CIT ATE, ZIP � R P DESCRIiIONOF WORK Ek3STINGUSE PROPOSED USE CONSTR TYPE ISTORIES USE TYPE OCC. SQ.FT. VALUATION (S) E)CSTG NEW FLOOR DEMO TOTAL AREA AREA AREA - NET AREA -- BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA . DECKAREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ATTACH DWELLING UVi r$: IS A SECOND UNIT El YES SECOND STORY ❑ YES BEING ADDED? ❑ NO ADDITION? ❑ NO PRE -APPLICATION ❑ YES T YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES R$CEI Y '^ To'�kL VALUATION: PLANN[NGAPPL4 ONO PLANNIRIG APPROVAL LETTER EICHLERHONIE? 1-71 NO By my signature below, I certify to each of the follon ng: I am the property owne or authorized agent on the pro ow-ners b al£ I have read this application and the information I gide is c ee . have read the Description of Work and verify it isac gree to co iy with allapplicable local ordinances and state laws la in t 1 i C on a thorize representatives of Cupertino to enter t nod > ed�op #O ection purposes. Signature of ApplicanUAgent: Date: l I/ SUPPLEMENTAL INTFORMATION REQUIRED New SFD or Multifamily d o,,ellinos: Apply for demolition permit for 0 OVERTECOUhTER BIJILDLi.GPL4NREVSEFiT '' -.-- existing building(s). Demolition permit is required prior to issuance of building permit for new building. C7 EXP$ESS ❑'PI aNAGPLA�v uEylEw Commercial Bldgs: Provide a completed Hazardous Materials Disclosure Cl srAntiARD r G D PUBLTcwoRx _ form if any Hazardous Materials are being used as part of this project. 7,F>D A of Planning Approval Letter or Meeting with Planning prior to _Copy submittal of Building Permit application. ,MA7OR -� a ��'SATTTARYSER'EitDISTRIGT .���- �r .- -X-s �. � - � ��EATYLROIt'MENT4L'HEALTAr BldgApp_201 ].doe revised 06/21/11 WV CITY OF CUPERTINO F M—N FEE ESTIMATOR - BUILDING DIVISION OCCUPANCY TYPE: ADDRESS: 20455 SILVERADO AVE DATE: 07/23/2015 REVIEWED BY: MELISSA PC FEE ID APN: 369 39 016 BP#: *VALUATION: 1$18,000 xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: 1BTIPLNCK PENTAMATION 1B TI PERMIT TYPE: WORK CHAMBER OF COMMERCE - T.I. TO RECOFIGLIRE AND REMODEL E 1379 S.F. & ADD SCOPE COVERED PORCH AREA (160 S.F.) OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA (s.f.) PC FEES PC FEE ID BP FEES BP FEE ID B (Tenant Improvements) II-B,III-B,IV,V-B 1,539 $2,175.46 1BTIPLNCK $1,489.31 1BTIINSP je, PME Plan Check: $0.00 i $1,489.31 Suppl. Insp. Fee:Q Reg. Q OT 0,0 hrs $0.00 i PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 1,539 $2,175.46 $1,489.31 MECH, HOURLY Y 0 Yes 0 No PLUMB, HOURLY Q Yes Q No ELEC, HOURLY © Yes Q No MISC ITEMS Plan Check Fee: F-777 . _ ., ; c ... .,, ft .. El Suppl. PC Fee: (F)Reg. © OT 0.0 hrs je, 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 preliminary information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEW (Fee Resolution 11-053 Eff 7/1'13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,175.46 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: (F)Reg. © OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $1,489.31 Suppl. Insp. Fee:Q Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Work Without Permit? C) Yes E) No $0.00 Advanced Pianning_Fee: $0.00 Select a Non -Residential Building or Structure i 1)o-0 turw0"'1,_'i Strong Motion Fee: IBSEISMICO $5.04 Select an Administrative Item Bldg* Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $3,670.81 $0.00 TOTAL FEE: $3,670.81 Revised: 07/02/2015 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: >-0 4/--S1- S;'/✓ o .61-0— PERMIT # 7 CQ i OWNER'S NAME: PHONE # GENERAL CONTRACTOR: 2 yrn Znc BUSINESS LICENSE # / O ADDRESS: -70/ CITY/ZIPCODE:-�„ (?� 9_�Y/2 *Our municinal code renuiffes all husinesses working in the city to have a Citv of Cunertino husiness licence_ 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. �go— I am not using any subcontractors: Signature Date Please check applicable subcontractors and 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 Sheet Rock Tile Date OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(E)cuoertino.orq Dear Property Owner(s): An applicatlion for a building permit has been submitted in your name listing yourself as the builder of the property improvemehts specified at: SITE ADDRESS.�/� _........ Gil l S J, / API. QI — 8P# �, �J ER NAME �, ..._ . OWNER ADDRESS- DESCRIPTIO OF WORK: We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your resposibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not is' ue 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, i OWNER'SIACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Cwner- Builde�" 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 icjuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injQries to workers on my property. _V2 41 understand building permits are not required to be signed by property owners unless they are responsible for the cor struction and are not hiring a licensed Contractor to assume this responsibility. �ct3J 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 b hiring a licensed Contractor and having the permit filed in his or her P Y P Y 9 9 name unstead of my own. l4 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 total lue 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. I understand if I am considered an "employer" under state and federal law, I must register with the state and government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to oyment compensation for each "employee." I also understand my failure to abide by these laws may subject erious financial risk. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family tial structures cannot legally build them with the intent to offer them for sale, unless all work is performed by I subcontractors and the number of structures does not exceed four within any calendar year, or all of the work rmed under contract with a licensed general building Contractor. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for tncial or personal injuries sustained by any subsequent owner(s) that result from any latent construction in the workmanship or materials. OwnerBuilderForm 2010. doe revised 04/14/10 9.',1 understand I may obtain more information regarding my obligations as an "employer" from the Internal Re entre 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 contractors. &Z0. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am 4 ;party legally and financially responsible for proposed construction activity at the site address listed above. 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by allapplicable laws and requirements that govern Owner -Builders as well as employers. OI agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the iinorm�Oiion l 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 maybe in civil court. Itis 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 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. (DIRECTO NS: Please complete the following construction lending agency in 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 Lender Address: Before a bluilding permit can be issued, this form must be completed and signed by the property owner and returned tp the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarikation, or other verification accepvle�Tcim ay be required to be presented when the pe mit is�sued to verifv the oroperty owners signature.y// Property Owner's Signature: -1-"" - -4 - Date: a/ a L-1-- ------- - - - - -- ------------------------------------------------------------------------------------------------------------------------------ (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 t1ke 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: l Address of Authorized Agent: Tel No I declare um: der 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 pen -nit is issued to verify the property ov✓ner's signature, !, Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revised 04/14/10