15060076 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18986 TILSON AVE CONTRACTOR:MARIA NORINS PERMIT NO: 15060076
OWNER'S NAME: MARIA NORINS 18986 TILSON AVE DATE ISSUED:06/10/2015
OWNER'S PHONE: 4084807010 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
ELECTRICAL SERVICE UPGRADE(200 AMP).
License Class Lie.#
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:$380
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:37509010 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 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 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the �—
granting of this permit. Additionally,the applicant understands and will comply Issued by: , f' � Date: (� "l�'��
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.
❑ QQW-NERBUILDERJDEtLA,RA 110 4
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)
4`901 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,Sectio 25505 25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent l- !_(c.-�j /_ ✓� Date:
permit is issued.
if 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 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-pont source regulations per the Cupertino Municipal Code,Section Licensed Professional
9 18.
:a�?
Signalu ..,- - _ l ^Date 1
d -
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
CUPERfINCi' (408)777-3228 • FAX(408)777-3333•buildingCcDcupertino.org /� ell
7K,:-;)&0 �o M I
❑PLUMBING ❑MECHANICAL RELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS / 1/,S 0 h fi 1 yn APN R pfi J, Q�
OW1ERNAME lI/J77l T7 1\)01?-T PHONE D �8Dl1D%D E-MAIL M VAJD`'/l S Q X0490,
STREETADDRESS 1917S6
P 6 / /'19 D� V, CITY. STAT u E7�7- N0 nv 91D/l..FAX
CONTACT NAME MPR-7-19
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STREET ADDRESS n Ur, ^6 ir -,/(Z- CITY,STATE,ZIP T FAX
OWNIIER 11O"ANTER-BUILDER G('❑ OMIERRAGEN17 ❑ COI��TRACTOR ❑CONTRACTORAGENT ❑.ARCHITECT ❑ENGINEER ' ❑ DEVELOPER ❑ =AI\7
CONTRACTOR NA IM R n,) h U fr LICENSE NUI SER J n L LICENSE TYPE BUS.LIC f
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COPANTYNAME T.
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FAX
STREET ADDRESS CITY,STATE,ZIP
ARCMTECT/ENGINEER NAME LICENSE NUMBER BCl�1ULLS.LIC 4 V S
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF FD x DUPLEX ❑ MULTI-F:41`�.Y PROJECT LN WILDLAND ❑ YES PROTECT IN YES E THE BLDG AN El YES
BUIIALNG: COMTgItCL4L URBANlt\T=ACEAREA' '0 FLOOD 1\10 EICHLERHOME7 NO
DESCRIPTION OF WORK
El-e c-I/ ca/ Sel-vi,f-e- 0 1'0 e �O -00 Aj2-7 s
V D T^ bra vks',�Y• t v' ' S"xd a'v `K' r ''3'`x>�
TOTALVALUATIOT: RECEIVED..Bc125
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By my signature below,!certify to each of 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 information I have provided is correct 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 builrfil
structi thoriz�representatives of Cupertino to enter the above�-identified prope�rt(y�for`m pection purposes.
Signature ofApplicant/Agent: � "v Date: f/ I(2 Jr l/��J
SUPPLEMENTAL INFORMATION REQUIRED
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mgMEFl47sc4pp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
W'PERMT
DRESS: 18986 Tilson Ave DATE: 06/10/2015 REVIEWED BY: Sean
N: BP#: 15060076 "VALUATION: $380
PE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 REAP2
USE: PERMIT TYPE:
WORK Electrical Service Upgrade 200 amp).
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1ERT<200 200 Amps $48
TOTALS: $48.00
klech.Plan Check Plunib.Plan Check Elec.Plan Check 0.0 hrs $0.00
Mech. Permit Fee: Plumb.Permit Fee: Elec.Permit Fee: 1EPERMIT
Other Tech.Insp. Other Plumb hap. Ll Other Elec.Insp. 0.0 hrs $48.00
Adech.Insp.Fee: Plumb.Insp. Fee: Elec.Insp.Fee:
NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Worcs,Fire,Sanitary Sewer District,School
District,etc.). Thesefees are based on the prelintinar information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Supp/. PC Fee
PME Plan Check: $0.00
Permit Fee:
Suppl.Insp Fee
PME Unit Fee: $48.00
PME Permit Fee: $48.00
Construction Tax: T-T-
Administrative Fee: ]ADMIN $45.00
Work Without Permit? 0 Yes (E) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRAVDOC $48.00 A
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $190.50 $0.00 TOTAL FEE: $190.50
Revised: 05/07/2015
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTR40 (408)777-3228• FAX(408)777-3333•buildingaQcupertino.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:
E
SITADDRESS APIC:. BP#
. .._ 18986 �;F l�o.�. �-�'c� . -.:,.:.. ... � .
:OWNER NAME OW ER ADDRESS:
M R,P.T/9 I�/D/? /b'S : _. 6"7 . Svc ' , /9
DESCRIPTION OF WORK:
-221
We are providing you with an Owner-Builder Acknowl-edgment 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.)
/V/\/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.
/V/'-/2. I 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.
111W3. 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
nap /me instead of my own.
Al/y 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.
HA 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.
INbl6. 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.
N/'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 p�erfformed under contract with a licensed general building Contractor.
Ni"8. I 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
/J9. 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.cslb.ca.gov for more information about licensed
contractors.
J-L10. 1 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
Lallapplicable 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
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 maybe in civil court. If 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 maybe held liable for damages. If
you`obtain a perrhit 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.)
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 verific 'on acceptable to the city may be required to be presented when the permit is issued
to verify the property owner's siOn4targ.
Property Owner's Signature: - �- fz- Date: /J^
-
--
------------------------------------------------------------------------------------------------------------------------------------------
(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: 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 filled out the
above information and certify its accuracy. Note:A copy of the property owner's drivel'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
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: %g%g&, Ti 1 goi) lt✓e- PERMIT#
OWNER'S NAME: 09-R `-19- PHONE#
GENERAL CONTRACTOR: i,/ Z/? BUSINESS LICENSE#
ADDRESS: /9 Q alb %/5-0/9 "&-71 CITY/ZIPCODE: C J��/1� /-f`~iL`G? rh�-
*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: 0 l/�
•
Signature Date
Please check applicable subcontractors and complete the following information:
V 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/Contractor Signature Date