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15090064CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 10406 AVENIDA LN I CONTR CTOR: GUTNIK YEVGENIY AND I PERMIT NO: 15090064 OWNER'S NAME: GUTNIK YEVGENIY AND LYUDMILA 110406 AVENIDA LN I DATE ISSUED: 09/10/2015 1 OWNER'S PHONE: 4083064403 CUPERTINO, CA 95014 1PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ REMODEL & RECONFIGURE (E) MASTER BATH (90 S.F.) & License Class Lic. # ADD 60 (N) RECESSED LIGHTS & 2 THROUGHOUT DWELLING. ADD 1 FAN TO (E) HALL BATH 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: t. 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. 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. Date P i 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) z. I, 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 this permit is issued. 3. 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. �� Date 679 /0 't DSS Sq. Ft Floor Area: I Valuation: $2000 APN Number: 34245034.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PE UANCE OR 180 DAYS F D INSPECTION. a e. 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: 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 maintain 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. Owner or authorized age t: �9 /0 0 �t Date: 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 CITY OF CUPERTINO wo FEE ESTIMATOR - BUILDING DIVISION kalADDRESS: 10406 AVENIDA LN DATE: 09/10/2015 REVIEWED BY: MELISSA Mech. Permit Fee: IMPERMIT APN: 342 45 034 BP#: 'VALUATION: 1$25,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY USE: SFD or Duplex Suppl. PC Fee: 0 Reg. 0 OT PENTAMATION PERMIT TYPE: 1 R3SFDRE A WORK REMODEL & RECONFIGURE E MASTER BATH 90 S.F. & ADD 60 N RECESSED LIGHTS & 2 SCOPE I THROUGHOUT DWELLING. ADD 1 FAN TO (E) HALL BATH 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 in ormation available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS (Fee Resolution 11-053 Ef : 71 11113) Mech. Plan Check0.0 hrs $0.00 QTY/FEE Elec. Plan Check 0.0 1 hrs $0.00 Mech. Permit Fee: IMPERMIT Plan Check Fee: Elec. Permit Fee: IEPERMIT Other Mech. Insp. 0.0 hrs $48.00 90 s.f. $645.00 Other Elea Insp. 0.0 hrs $48.00 Suppl. PC Fee: 0 Reg. 0 OT F0.0 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 in ormation available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS (Fee Resolution 11-053 Ef : 71 11113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 90 s.f. $645.00 Remodel, Bath (<=300 sf) 1REMRESBAT Suppl. PC Fee: 0 Reg. 0 OT F0.0 hrs $0.00 PME Plan Check: $0.00 60 $312.00 Electrical 1 1BREMFIXT Fixtures, Lighting Permit Fee: $0.00 Suppl. Insp. Fee:O Reg. 0 OT 0.0 hrs $0.00 # Mechanical $50.00 1BREMVENF I Ventilation Fan PME Unit Fee: $0.00 PME Permit Fee: $96.00 Administrative Fee: ]ADMIN $45.00 1 1 0 0 Work Without Permit? 0 Yes 0 No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure E) 0 i Travel Documentation Fee: ITRAVDOC $48.00 Strong; Motion Fee: IBSEISMICR $3.25 Select an Administrative Item 1 Bldw Stds Commission Fee: IBCBSC $1.001 SUBTOTALS: $193.251$1,007.001 TOTAL FEE: 1 $1,200.25 Revised: 07/02/2015 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTIN0 (408) 777-3228 • FAX (408) 777-3333 • building@cupertino.org ❑ NEW CONSTRUCTION ❑ADDITION ®ALTERATION; TI El REVISION / DEFERRED ORIGINAL PERM IT #"/ PROJECT ADDRESS l 0 ct o6 4 ve kt ` z a Zj^ -7 ' 1 APN # �'J s �- O 2 JBG�I OWNER NAME /, tf o6w l a a -v t�`� `k -SI PHONE � V O _ J O 6 _ -/ q OLI E-MAIL / _ STREET ADDRESS 10/ P6 4ve q t` /�j'Q 4 `A i ` I CITY, STATE, ZIP /�u /�11, 9Sa l'-yC l j jE-MAIL FAX CONTACT NAME 4 " u t 1'!?�r /<Q uf7/L t�L(K PHONE 1(. 5 © 6 ' oz 4 STREET ADDRESS (t �/ / A vee ! a% / m CITY, STATE, ZIP /�Pl­e'.A" / e A I Q S -D/ , I FAX 1-1OWNER ElOWNER-BUILDER El OWNER AGENT El CONTRACTOR 11 CONTRACTOR AGENT ElARCHfMCTJ ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME.4Ieoo/ �,��� [� LICENSE NUMBER03 3; 7 LICENSE TYPE �� BUS. L1C # 7 COMPANY NAME e L COQ f Z p �r ,,` D� /kc, E-MAIL FAX STREETADDRESS � 5-6 �VC C STATE, ZIP 11(4`D%� /YLL/T %6� V PHONE?G '-GZG-9JUY, oC ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE. DESCRIPTION OF WORK l7 e'A4O _O_ /' , �r a 60 zee"eflt5 g � p� 2 0l3 64 13k � Ive(es V EXISTING USE PROPOSED USE CONSTR. TYPE # STO IES USE TYPE occ. SQ.FI'. VALUATION ($I EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NETAREA BATHROOM(� KITCHEN OTHER REMODEL AREA ✓ O REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? []NO ADDITION? []NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES RECEIY TOTAL VALUATION: PLANNING APPL # []NO PLANNING APPROVAL LETTER EICHLER HOME? •C S 62 OD ^ J-5- By my signature below, I certify to each of the following: I am the rt ner or auth agent to act oeh 1a ad this n property ner's balf. application and the information 1 have provided is correct. I have re e Description of Work and verify it i ccurate. I ee to comply with all applicable local ordinances and state laws relating to building construction. I representatives of Cupertino to ente e abov - ' entified property for inspection purposes. ;UIlofize i 0-911 1 Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW _ 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 ❑ PUBLIC; WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE 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 Ldoc revised 06121111 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 • buildinpna cuoertino.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 ADDRESS p[lO6 �G{ .APN. 2 v� 03�G OWNER NAME :/. _ OWNER ADDRESS... DESCRIPTION OF WORK: ��� t "� n AteG We are providing you with an Ownef-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.) 4 ,i. 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 inj[rries to workers on my property. 4�_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. 44- 3. 1 understand as an "Owner -Builder" I am the responsible parry 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. ' 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. 46- 5. 1 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. 4e 6. 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. 4& 7. 1 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. 4(.r 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. OivnerBuilderForrn 2010.doc revised 04/14/10 4G 9. 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. 4,!� 10. 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. I( 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will aistde by all applicable laws and requirements that govern Owner -Builders as well as employers. 49 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information l have -provided on this form. License 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 may, be in civil court. Itis 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 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. 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 signature. Property Owner's Signature: Date: --------------------------------------------------------------------------------------------------------------------------------------------- (NOTE: The following Authorization Form is required to be completed by the property ov✓ne-r 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 1 40wci kr/ecc �PMEN ' PARTf�IENT ClIPERTINO ' to OpROVE� T�,,s set of play, ; cations fit' ST be kept at the ,CS site rj��ir'�n;]�' It is unla:vful make any change's or •_ it,, �t`ons on same, cc to deviate therefrom, v tnC", c+I'proval from the Building an and specifications SHALL NOT The Star"P[19 °I —isp roval of the violation be he'd fn "�, or State Law. PERh11T # O � W Q. D J � a- c)): � o N U U '3 o w m ._ p U cn 0 LL Q LJJ _w W o' /-, c u0"c: 161- Grk Ao4e)(. ioyd� Avera �ti , ul"ae i--F;tlo , eA, S Go�P vLu� ct°e,� Pit 69-Y y PQ /f( I vL's t{it leztw- A 7,Y-7 AT." AV 0 C %L,1�� Goffs O�ev� Q OFFICE COPY , r (I/V2 we't /Lt c.,,-fe,-y c,� t R& -*1 V r a PD e y F;J9P e y-Gi Yookll qe) g f *teve -ter r s- Ca cweA OFFICE COPY 0 ,Vrt-h -rcc,*-? P 6?( -rd o kvt CUPERTINO Building Deparnent �91 SEP 10 2015 REVIEWED FOR CODE COMPLIANCE Reviewed By: Wa tAi �f --- I upf 0 CUPERTINO n-iijimm Department SEP 10 2015 REVIEWED FOR CODE COMPLIANCE*`� Y: keviewed�� Y 6 D F COPY