15090079-Voided Dupt permitI CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 10362 JUDY AVE CONTRACTOR: BABY MARY E TRUSTEE PERMIT NO: 15090079
OWNER'S NAME: RABY MARY E TRUSTEE 10362 JUDY AVE DATE ISSUED: 09/11/2015
OWNER'S PHONE: 4086459451 CUPERTINO, CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION RESIDENTIAL E] COMMERCIAL ❑
REPLACE GAS LIN FROM METER TO WATER H�,E�A.TER.
License Class Lic. # -, ,.,
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 informe
correct. I agree to comply with all city and county ordinances and state
to building construction, and hereby authorize representatives of this cit,
upon the above mentioned property for inspection purposes. (We) agre
indemnify and keep harmless the City of Cupertino against liabilities,
costs, and expenses which may accrue against said City in conseque e
(relating
enter
save
of the
granting of this permit. Additionally, the applicant understands anill comply with
all non -point source regulations per the Cupertino Municipal Cod Section 9.18.
Signature
Date
Q OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contracto s License Law for one of
the following two reasons:
1. 1, as owner of the property, or my employees with ages as their sole
compensation, will do the work, and the structure s not intended or offered for
sale (Sec.7044, Business & Professions Code)
2. 1, as owner of the property, am exclusively co racting with licensed contractors to
construct the project (Sec.7044, Business & ofessions Code).
I hereby affirm under penalty of perjury o e of the following three declarations:
1. 1 have and will maintain a Certificate of onsent to self -insure for Worker's
Compensation, as provided f/ke
i n 3700 of the Labor Code, for the
performance of the work for permit is issued.
2. I have and will maintain Worpensation Insurance, as provided for by
Section 3700 of the Labor Coperformance of the work for which this
permit is issued.
3. I certify that in the performanork for which this permit is issued, I shall
not employ any person in anyo as to become subject to the Worker's
Compensation laws of Califofter 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.
Ve'&4 _fi
S�
Signature ate v
I 11
Sq. Floor Area: Valui-`$0
5
I A N Number: 37510006.00 `" I Occupancy Type: I
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Date: 4)_ f l 'l -5
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being insle If a roof is
installed without first obtaining an inspection, I agree to re ve all w materials for
inspection. `
Signature of Applicant: Date:
ALL ROOF COVERINGS 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.
Ow horize ge
e+te: Gll �J
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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
RECEIPT NUMBER: BS000028199
RECEIVED BY: SUEW PAYOR: MARY RABY
TODAY'S DATE: 09/22/15 REGISTER DATE: 09/22/15
TIME: 14:12/,, -�
4 /10,3 &a� �.�ul� � M 0—
ADDRESS CHANGE 15090079
BSA BLDG VALUATION 15090079
MECHANICAL ELEC PLUMBING 15090079
SMIP CATEGORY 1 15090079
TOTAL DUE:
CREDIT CARD: -$214.50 REF NUM: VISA
TENDERED
-$214.50
CITY OF CUPERTINO- BLD
10300 TORRE AVE
CUPERTINO, CA 95014
09/22/2015 14;01,20
MID; 000=417 TID, xxxxx180
CREDIT CARD
VISA REFUND
CARD # f0000D000000(7311
INVOICE 0007
SEQ #; 0006
Bath #; 000021
SERVER 0029
Approval Code;
Entry Method; Swiped
Mode; Offline
Oust Code, 029
REFUND AMOUNT $214,
I agree to pay above total amount
according to card issuer agreement,
(Merchant agreement if Credit Voucher)
M E. RABY
MERCHANT COPY
-$45.00
-$1.00
-$168.00
-$.50
----------------
-$214.50
CHANGE
$.00
All
N
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m
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i so �oio3 - fes` �,�°
I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 10362 JUDY AVE CONTRACTOR: RABY MARY E TRUSTEE PERMIT NO: 15090079
OWNER'S NAME: RABY MARY E TRUSTEE 10362 JUDY AVE DATE ISSUED: 09/11/2015
OWNER'S PHONE: 4086459451 CUPERTINO, CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
REPLACE GAS LINES FROM METER TO WATER HEATER.
License Class Lic.#
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.
Signature
Sq. Ft Floor Area: I Valuation: $0
APN Number: 37510006.00 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: 4-z y Date:
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
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
t. 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)
2. 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:
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.
a. 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
Sienature l/ l k? k-e-1//Date q/`l f J
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 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.
Ow��orize ge ed �j 1-11�G2.Gf/Lo te: t S
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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
GENERAL PERMIT APPLICATIONIRVA 01 E c Vzo 1 &
COMMUNITY DEVELOPMENT DEPARTMENT •BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 AMWL AML
la
CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • build inaCa)cuoertino.orcl M 15
PLUI4BING ❑MECHANICAL ❑ELECTRICAL 71,4ISCELLANEOUS
PROJECT ADDP.ESS s
APN
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STREET ADDRESS / I
CITY, STATE, ZIP � / FAX
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CONTACT N
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CITY, STATE, ZIP C� lZj�jFAX
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❑ CO?.TRACTOR ❑CON7RACTORAGENT ❑ ARCHITECT ❑ ENGA'EER ❑ DEVELOPER ❑ TMANT
CONTRACex' s
141
CENSE NUNIBER LICENSE TYPE
BUS. LIC
COMP.ANY N.
EMAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHO\S
ARCHITEMENGIINTER NAME
LICENSE NUMBER
BUS. LIC
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONTE
USE OF FD or DUPLEX ❑ MULTI-FAD11.Y
PROJECT IN WIT T)LAND ❑ YES PROJECT IN ❑ YES
IS THE BLDG AN ❑ YES
BtJJ ING: COMMERCIAL
URBAN P'TERFACE AREA NO FLOOD ZONE Q&L"0
EICHLERHOME7 NO
DESCRIPTION OF WORK
41
TOTAI VALUATION: �D '--
-C_I i ED Bi: i x7
By my signature below, I certify to each of the following: I am the property owner or authorized anent 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 relating to building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent:
Date:
SUPPLEMENTAL INFORMATION REQUIRED
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MEP1fiscl4pp_2011.doc revised 06121/11
%LL
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 10362 JUDY AVE
DATE: 09/11/2015
REVIEWED BY: SEAN
UNITS
APN:
BP#:
"VALUATION: 1$3,000
PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
#
PENTAMATION 1 RPGAS
PERMIT TYPE:
WORK
REPLACE GAS LINES FROM METER TO 1 WATER HEATER.
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
Plumb. Plan Check 0.0 hrs $0.00
QTY
UNITS
BP FEES
llec. Pernzit Fey:
Piping, Gas <=4 Outlets
1PGASRES
Omer 1 lec. Insp. EIF
1
#
$72
PME Unit Fee:
$72.00
PME Permit Fee:
$48.00
Construction Tax:
Administrative Fee: IADMIN
$45.00
Work Without Permit? 0 Yes 0 No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
$72.00
Strong Motion Fee: IBSEISMICR
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 preliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-033 EEf 7i1i13)
Lfech. Plan Check
Plumb. Plan Check 0.0 hrs $0.00
'aec. [Ilan Check
Alec/r t " I I I I
Plumb. Permit Fee: IPPERMIT
llec. Pernzit Fey:
Other Aferh. Insp
Other Plumb Insp. 0.0 hrs $48.00
Omer 1 lec. Insp. EIF
1, —h h7_Y!' Fc '
PME Plan Check:
i'..
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 preliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-033 EEf 7i1i13)
FEE
QTY/FEE
MISC ITEMS
PME Plan Check:
$0.00
PME Unit Fee:
$72.00
PME Permit Fee:
$48.00
Construction Tax:
Administrative Fee: IADMIN
$45.00
Work Without Permit? 0 Yes 0 No
$0.00
Travel Documentation Fee: ITRA VDOC
$48.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldp- Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
1 $214.50
$0.00 TOTAL FEE:
$214.50
Revised: 07/02/2015
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 • buildinoCa cuoertino.ora
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
/ de-- Ave__,
- •..-
It
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.)
y 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.
Z2.'[ 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.
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 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.
moo. 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.
V17. 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.
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.
OwnerBuilderForrn2010.doc revised 04/14/10
�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.cs[b.ca.gov for more information about licensed
contractors.
___Z/1 0. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
amt party 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
by all applicable laws and requirements that govern Owner -Builders as well as employers.
_Z12. 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. 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 perrriit 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 verifv the property owners sianature. n - / l
---
------------------------------------------------------------------------------------------------------------------------------------------
(NOTE: The following Authorization Form is required to be completed by the properly 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 owners 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 owners
signature.
Property Owner's Signature:
Date:
OwnerBuilderForm 2010.doc revised 04/14/10