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15090034I CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10110 PENINSULA AVE I CONTRACTOR: DOREEN ROVETTI PERMIT NO: 15090034 OWNER'S NAME: DOREEN ROVETTI 10110 PENINSULA AVE I DATE ISSUED: 09/04/2015 OWNER'S PHONE: 4089100807 CUPERTINO, CA 95014 1PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ REMOVAL OF FIRE DAMAGED PORTION OF RESIDENCE (SEE License Class Lic. # 15080024 FOR CONSTRUCTION). 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: 1. 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. 2. 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 permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. 1 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 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 with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. 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) 01 as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: 1. 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. 2. 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 thi 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 become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 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 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 with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Sq. Ft Floor Area: I Valuation: $800 APN Number: 32624028.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Date: -1 RE -ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintai n compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. te:�-�—i� CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408)777-3333- building aacupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION R ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS APN # _r L OWNERNAMEPH NE E-MAIL tD DTZ I MA 0 1--0 C C>LA - STREET ADDRESS_CITY, STATE, ZIP FAX -r1NC> L L C> AJi C r as(�04 — C NTACT NAME PHONE E-MAIL >v n.► -\s C- v \ s Z - S� A0,0014f U Am OVcc�ss STREET ADDRESS I o t l O PF M � VU sU t_ (kv c- CITY, STATE, ZIP Cv C1 -5 U l4AI FAX — ❑ OWNER ❑ OWNER -BUILDER WNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR 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;V COMPANY NAME E -NIHIL F.4X STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK , - / /C EXISTING USE PROPOSED USE CONSTR TYPE #STORIES 1 USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH I ❑ ATTACH I # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? ONO ADDITION' ❑ NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER IS THE BLDG AN ❑ YES EICHLER HOME" ❑ NO - RECEIVED BY:, e �j TOTAL VJdgWAT19N: 1W`f/,�� — By my signature below, I 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. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws Ing construction. I authorize re resentatives of Cupertino to enter the above -identified property for inspection purposes. OL Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK T]TE ROUTING SLIP "COVER -THF COUNTER BUILDING PLAN REQ IEw _ New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLICwORKS Form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FUZE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_201 1. doc revised 06/21/11 ,��,�� CITY OF CUPERTINO IY�//�I FEE ESTIMATOR - BUILDING DIVISION NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School Dictrirt ote )_ Thoco foot are ha.ced nn the nreliminary intnrmatinn available and are only an estimate Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 Efl, 7J /1I 13) ADDRESS: 10110 Peninsula Dr DATE: 09/04/2015 REVIEWED BY: Sean Mech. Permit free: APN: BP#: / 'VALUATION: $800 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: Pha ih' brsp. F'e", PENTAMATION 1 GENRES PERMIT TYPE: WORK Removal of fire damaged portion of residence See 15080024 for construction . SCOPE $0.00 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School Dictrirt ote )_ Thoco foot are ha.ced nn the nreliminary intnrmatinn available and are only an estimate Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 Efl, 7J /1I 13) ;ifech. Plan Check Phunb. Plan Check faec. PlanCheck Mech. Permit free: Plumb. Permit F"- F;lecPermit Fee Other A -tech. Insp.Li I )rher Plumb Insp-Lj )rtter L-lec. Insp. Li 11eech hrost,. Fire: Pha ih' brsp. F'e", _, l „, NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School Dictrirt ote )_ Thoco foot are ha.ced nn the nreliminary intnrmatinn available and are only an estimate Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 Efl, 7J /1I 13) FEE QTY/FEE I MISC ITEMS Plan Check Fee: Hourly Only? () Yes Q No $0.00 0 hours $0.001 Plan Check, Hourly 1 Suppl. PC Fee: (F) Reg. () OT0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? ()Yes Q No $0.00 Suppl. Insp. Fee -.0 Reg. Q OT0 0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: Administrative Fee: E) Work Without Permit? Yes (F) No $0.00 Advanced Plannin& Fee: $0.00 0 hours Inspections $143.00 ISTINSP Inspection, Hourly E) 0 7- cuvel Documenlalion Fees: Strong Motion Fee: IBSEISMICR $0.50 = hrs Admin./Clerical Fee $45.00 IADMIN Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $1.50 $188.00 TOTAL FEE: 0 $189.5ZJ Revised: 07/02/2015 E_ AK� inim CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - buildinoQ)CUQertino.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 ADDRES C N,ws� ��_J_APN-g - BPI l OWNER NAME OWNER ADDRESS - DESCRIPTION OF WORK: -ca O v c - rL r� a r�D j�- lL� ,C� ✓j(3 �!� %� �,� , ., ,......._ rp vf-L t vLw 14-vv0 L� LI/1- + ! -C Oe L We are providing you with an Owner-BuilderAckhowledgment 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.) (Y4. 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 infaries to workers on my property. 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. &3. 1 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 name instead of my own. VI understand Contractors are required by law to be licensed and bonded in California and to list their license ers on permits and contracts. f� 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. J-14 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. A -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 performed under contract with a licensed general building Contractor. OL8. 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. OwnerBuilderForrn 2010.doc revised 04/14/10 ,Ie g I understand I may obtain more information regarding my obligations as an "employer" from the Internal nue Service, the United States Small Business Administration, the California Department of Benefit Payments, P Y , 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 wvAv.cslb.ca.gov for more information about licensed contractors. . I 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. 4-4 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. JL2. I 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. It is also important for you -to understand that if an unlicensed Contractor or employee of that individual or irm is injured while working on your property, you maybe held liable for damages. If you'obtaih 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.) 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 verif the property owner's si naturp. Property Owner's Signature: Date: L --------------------------------------------------------------------------------------------------------------------------------------------- (NOTE: The follow✓ing 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. , %E S✓� o n �i 2 t) �� ilcvA4 �iqq,-r,;:�ti Scope of Construction Project (or Description of Work): V�,i-g o G -A ZYN:r„-. _') rc ma°, Project Location or Address: 10 ( t 0 PC_"i ,4 ,Lich Avg - C'J pc,�Zr wD GA C -j Vi z4 Name of Authorized Agent: —�� 1 L , r, Tel No '?211 `j Z4 Z8s8 Address of Authorized Agent: _i 1D x 1-0 ?C- IN i vJ S, U LA % y Eu:. I \J c�4.n-r �v�ro CCt��v�io CCtC 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:�/ J OwnerBuildel'Form 2010.doc revised 04/19/10