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15100104CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1093 MILKY WAY CONTRACTOR: VICK SHARON A PERMIT NO: 15100104 OWNER'S NAME: VICK SHARON A ""j��c�--�� P.O.BOX 372 DATE ISSUED: 10/14/2015 OWNER'S PHONE: 6502799912 CUPERTINO, CA 95015-0372 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ REPLACE (E) SEWER LINE & BOTH FOUNDATION & PROPERTY LINE CLEANOUTS License Class Lic. # Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 � 7,71 .� r (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. Sq. Ft Floor Area: Valuation: $2800 I hereby affirm under penalty of perjury one of the following two declarations: 1. 1 have and will maintain a certificate of consent to self -insure for Worker's APN Number: 36219006.00 Occupancy Type: 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. PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS O SSUANCE OR APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is 180 D INSPECTION. 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 _ _ _ -- - U r upon the above mentioned property for inspection purposes. (We) agree to save Iss Date: 1( 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 ROOFS: all non -point source regulations per the Cupertino Municipal Code, Section 9.18. All roofs shall b spected prior to anyy roofing material being installed. If a roof is Signature Date installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE sale (Sec.7044, Business & Professions Code) I have read the hazardous materials requirements under Chapter 6.95 of the 2. I, as owner of the property, am exclusively contracting with licensed contractors to California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain construct the project (Sec.7044, Business & Professions Code). compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. I hereby affirm under penalty of perjury one of the following three declarations: Additionally, should I use equipment or devices which emit hazardous air 1. I have and will maintain a Certificate of Consent to self -insure for Worker's contaminants as defined by the Bay Area Air Quality Management District I will Compensation, as provided for by Section 3700 of the Labor Code, for the mainta' omplian with the Cupertino Municipal Code, Chapter 9.12 and the Hea Safety de, ions 25505, 25533, and 25534. performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance, as provided for by w or r' nt: / — Section 3700 of the Labor Code, for the performance of the work for which this Date: permit is issued. 3. 1 certify that in the performance of the work for which this permit is issued, I shall CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of work's become subject to the Worker's Compensation provisions of the Labor Code, I for which this permit is issued (Sec. 3097, Civ C.) Lender's Name must forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Address APPLICANT CERTIFICATION ARCHITECT'S DECLARATION I certify that I have read this application and state that the above information is I understand my plans shall be used as public records. 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 Licensed Professional 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 crue against said City in consequence of the granting of this pe dditio ally, a applicant understands and will comply with all non -point sour a re ulatio s p rtino Municipal Code, Section 9.18. Signature Date GENERAL PERMIT APPLICATION MEP COMMIUNI TY DEVELOPMi�ENT DEPARTMENT • BUILDING DIVISION 10300 TORP.E AVENUE • CUPERTINO, CA 95014-3255 (408) ?'r ?-3228 •FAX (408) 777-3333 • buildina(c-)cuDeriina.Orgy PL SING ❑IT�ECN_�1\ZC.�L ❑ELEC=C —L ❑A11-1SCELLA-N, EOUS PROJECT .aDr,PEss O / • `//' I AP?\ 00f OZ ITER NAME .0v s� Qh `�t/l- 2 79 (%P� 2— I E-I✓LL �Z STREET ADDP.ESS � .� / L 0oiax A ' � � �f i CIT' , S' AT ✓ � �l,Q L�i�►F.-"�X CONTACT 1\AIJE STREET ADDRESS I CITY, STATE, ZIP STREET a.DDRESSj�� I IS Ti -IE BLDG AN ❑ YEs � EM[JICI-MER. ROE? No F.gX ❑ Oti ?.fit >41AINER-BUII_DER ❑ 01; . 7ER .4Ga\? ❑ ,CO?\7R4CTOR ❑ coNTRACTOR AGENT ❑ .ARC:17-r-CT ❑ ENGWEER ❑ DE�ELOPER ❑ TEI-AITT CONTRACTOR YaJ,r ( LICENSE A'UASER I LICENSETYPE I BUS. LICiV COM2ANYNaJ�fiE I E -MAT. I F.gX STREET ADDRESS I CITY, STATE, ZIP PHONE fiRCInTECT/: NGL?T�F.R 1\.AT�E --- - LICENSE NUMBER i I BUS. LIC COI✓,P a NTY NAIviE E-I✓,AlL I FAY. --� — STREET ADDRESS I CITY, STATE, ZIP PHONE USE OF S� or DL'PLFX ❑ 14-LTI-FPJ'ULy I PROJECT ) rs l PROrCT N ❑ YES N1 BU=G: E]Col"=CI -T URB NL>`'Tr^R ' FACE AREA ❑ NN'� O FLOOD ZO❑ NO I IS Ti -IE BLDG AN ❑ YEs � EM[JICI-MER. ROE? No DESCRIPTIONOF 1T�'0. - - i� 40 27/ .I TOTAL VA.LUATIONT: /�Qq By my signature below, II certify to each of application and the information I have pr ordinances and state laws relating to it SignaLLre of Applicant/Agent: SU-PPLEIL 5,—,, ng: I am the op-- L or authorized anent prop��3,ner's behalf. I have read this I h reg T `� T -- - it is accurate. I agree to comply with all applicable local - rz. esentatives of Cupertino to enter the above-ideLtir d pr i �y� inspection purposes. Date: I'AL ENTORNIATION REQUIRED h'€PM'iscAP.P-2011.doc revised 06.i'1/11 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 1093 MILKY WAY DATE: 10/14/2015 REVIEWED BY: MELISSA jgjjMj APN: 362 19 006 BP#: I *VALUATION: 1$2,800 'PERMIT TYPE: Plumbing Permit FPLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1 RPSS USE: PERMIT TYPE: WORK REPLACE E SEWER LINE & BOTH FOUNDATION & PROPERTY LINE CLEANOUTS SCOPE APPLIANCE / EQUIP TYPE FEE ID Plumb. Plan Check 0.0 1 hrs $0.00 QTY UNITS BP FEES Elec. Permit Fe Sewer, Sanitary 1 PRSEWER )her Is1ec. Insp. 1 # $25 'ei-mil .l` ee: itt/�rJl. It2.S1? 1"ec PME Unit Fee: $25.00 PME Permit Fee: $48.00 ' iil,5`lJ'!-i('llt;Bt? Ta'%-.. F Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes No $0.00 TOTALS: Travel Documentation Fee: ITRA VDOC $25.00 Strong; Motion Fee: IBSEISMICR NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, hire, Sanitary Sewer District, School District_ ptG )_ Thpsp fops arp hated nn the nrpliminary infnrmatinn availahle and are only an estimate. Contact the Dent for addn7 info. FEE ITEMS (Fee Resolution 11-053 Ef . 7/1/13) I:Iech..Plccrc C —' Plumb. Plan Check 0.0 1 hrs $0.00 '';7ee. l'lcm Cheek 11ec'h. Permit Fee: Plumb. Permit Fee: 1 PPERMIT Elec. Permit Fe ¢ether .Hech..Insp. Other Plumb Insp. 0.0 hrs $48.00 )her Is1ec. Insp. PME Plan Check: $0.00 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, hire, Sanitary Sewer District, School District_ ptG )_ Thpsp fops arp hated nn the nrpliminary infnrmatinn availahle and are only an estimate. Contact the Dent for addn7 info. FEE ITEMS (Fee Resolution 11-053 Ef . 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check .Fire.' Sl.ivp[ 1'(*' F(:I", F PME Plan Check: $0.00 'ei-mil .l` ee: itt/�rJl. It2.S1? 1"ec PME Unit Fee: $25.00 PME Permit Fee: $48.00 ' iil,5`lJ'!-i('llt;Bt? Ta'%-.. F Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes No $0.00 Travel Documentation Fee: ITRA VDOC $48.00 Strong; Motion Fee: IBSEISMICR $0.50 Select an Administrative Item 7 Bldg Std s Commission Fee: 1BCBSC $1.00 SUBTOTALS: $167.50 $0.00 TOTAL FEE: $167.50 Revised: 10/01/2015 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 - b0ding(acuoertino.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 APIC BP# OWNER NAM O NER ADD. 3111-0144�7 Z41A----) DESCRIPTION OF WOR iCl 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.) 1. 1 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-Buiider, 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. G5i 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. 1 3. 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 name instead of my own. a �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. <F-5-1 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. (06. 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. (mak 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. <. 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. OwnerBuilderForm 2010.doc revised 04/14/10 `� 9c . 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.csib.ca.gov for more information about licensed contractors. 0. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that am the 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. 2. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the rmation 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. 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 be 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 owners si natur Property Owner's Signature: Date: ----------------------------------------------------------------------------------------------------------------------------------------------- (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 ap for, sign, and file the documents n essary to, btain 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 Ager Z 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 Signatur Date: `� S OwnerBuilderForm 2010.doc revised 04/14/10