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B-2016-1201 Permit, App, Fee Est, Owner BuilderCITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1201 18800 LOREE AVE CUPERTINO, CA 95014-3635 (375 15 022) OWNER'S NAME: DATE ISSUED: 01/15/2016 OWNER'S PHONE: PHONE NO: LICENSEDICIDNTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic. # c Contractor Date X_ BLDG —ELECT —PLUMB MECH X RESIDENTIAL COMMERCIAL 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. JOB DESCRIPTION: Remodel kitchen (90 S.f); Remodel master and hall bathrooms (70 S.E) I hereby affirm under penalty of perjury one of the following two declarations: r. 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. ]. 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 Sq. Ft Floor Area: Valuation: $75000.00 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 APN Number: Occupancy Type: ordinances and state laws relating to building construction, and hereby 375 15 022 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 PERMIT EXPIRES IF WORK IS NOT STARTED expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal 180 DAYS FROM LAST CALLED INSPECTION. Code, Section 9.18. Ise clUw low Signature Date Datate: OWNER -BUILDER DECLARATION RF-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed. If a roof is following two reasons: installed without first obtaining an inspection, I agree to remove all new materials for i. I, as owner of the property, or my employees with wages as their sole inspection. compensation, will do the work, and the structure is not intended or offered for sale (Sce.7044, Business & Professions Code) Signature of Applicant 2. I, as owner of the property, am exclusively contracting with licensed Date: contractors to construct the project (Sec.7044, Business & Professions Cade). ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: r. 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 HAZARDOUS MATERIALS DISCLOSURE performance of the work for which this permit is issued, I have read the hazardous materials requirements under Chapter 6.95 of the ]. I have and will maintain Worker's Compensation Insurance, as provided for California Health & Safety Code, Sections 25505, 25533, and 25534. I will by Section 3700 of time Labor Code, for the performance of the work for which maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the this permit is issued. Health & Safety Code, Section 25532(a) should I store or handle hazardous �i Ip s. I certify that in the performance of the work for which this permit is issued, I material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I shall not employ any person in any manner so as to become subject to the will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and Worker's Compensation laws of California. If, after making this certificate of the Health & Safety Code, Sections 25505, 25533, and 25534. 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 Owner or authorized agent: S/ �6 be deemed revoked. Data: APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there Is a construction lending agency for the performance correct. I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued (Sec. 3097, Civ C.) relating to building construction, and hereby authorize representatives of this city Lender's Name to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant ARCHITECT'S DECLARATION understands and will comply with all non -point source regulations per the I understand my plans shall be used as public records. Cupertino Municip ode, Section 9.18. Licensed Signatur Date Professional CUPERTINO CONSTRUCTION PERMIT APPLICATION 16 )X) COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(I cupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS I APN # OWNER NAME /! 1/�/'V`G. PHOaIyap r'P� / 'l/' 4J'06 E-MAIL ^ M STAE�f�J]j SSU' Lar I W CITYB,}�S_ TAT!/ r /J\ �'r\.LOWE FAX G r CONTA 6-9, f�1Ay" B� O.JO� _raV�V�K� EML-,�-V1-tId-Z4A 'A Imo'` -ei- STREET ADDRES CITY, STATE ZIP FAX Z 22 1-- � ti� _ Q OWNER OWNER -BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORNAME LICENSE NUMBER LICENSE TYPE BUS. LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC 4 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK W-7CObvs) ( q6) EXISTING USE PROPOSEDUSE CONSTR. TYPE #STORIES USE TYPE OCC, SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODELARE/If6 `DEC REMODELARF.A fi^ REMODEL AREA PORCH AREA AREA TOTAL DECKTORCH AREA GARAGE AREA: LJDETACH Q ATTACH ADWELLINGUNITS: IS A SECOND UNIT ❑YES SECONDSTORY [:]YESBEINGADDED? ❑NO ADDITION? ❑NO PRE -APPLICATION []YES IF YES, PROVIDE COPY OF 1S THE BLDG AN ❑YES �/ED BY 1 TOTI VALUATION: PLANNINGAPPL# []NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO By my signature below, I certify to each of the following: I am the property owner or authorizcb 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 relating to buiIdi onshuction. I authorize representatives of Cupertino to enter the above-'dcut ifed property for inspection purposes. Signahu'e of Applicant/Agent: — Dale: i SUPPLEME ORMATION REQUIRED PLTN CHEcx TYrE = `aau'rinc sue =- New SFD or Multifamily dwellings: Apply for demolition permit for _ existing building(s). Demolition permit is required prior to issuance of bung ovER-TxE coosrEa _ BtnLDnsPi,.nN RE\ IEw permit for new building. ❑ �REss - ❑- PLA�xINc rtnN REVIEW= - Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ sTA�•nwxn ❑ PUBLIC woRLS, - _ for'm if any Hazardous Materials are being used as pall of this project, ❑ '❑_ ' LAIicE rH1E DEeT _ Copy ofPlalming Approval Letter or Meeting with Planning prior to ❑ Maioe. ❑ sEnveR submittal of Building Permit application. sa_vITARr msTRicT- ❑ ENVIRONMENTAL DEALTH Bld App_2011.doc revised 06121111 8016 010) -- CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 18800 Loree Avenue DATE: 01/15/2016 REVIEWED BY: PAUL APN: 37515 022 BP#: `VALUATION: $75,000 VERMITTYPE: Building Permit PLANCBECKTYPE: Addition PRIMARY SFD or Duplex PENTAMATION 1 R3SFDRE e USE: PERMIT TYPE: WORIc Remodel kitchen 90 S.f. ; Remodel master and hall bathrooms 70 S.f. SCOPE ;1.1$eh. Purl Check Pl±surh. Plfr! to < Nor, C'hrak 1F eH. lYrt,xit Fee: Phonb_ Perm d Fee: t tec. k'ernait /"v C}et ��r Aicri?. Ins{. t)t3rCr Phrrd>7+zu;. Othe? E'I<,; Imp. ;El werh. Irsr,. 1-e": phvgn. Lasv. I a.: Zitec. hl r� I ee: NOTL: This estimate does not include fees tlite to other Departments (i.e. Planning, Public Works, Tire, Sanitary Server District, School nhi-W os.• 1 Tha.•o fone mv. hncod nn fhn nrnlirninnry in fmmm/inn nvni/nhle and rme nnly nn eclimnte. Contact the Dent for addn'l into. FEE ITEMS LFee Resolution, 11-053 b — 1 1 FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 F-7707 s.f. $645.00 Remodel, Bath (<=300 sf) IREjURESBAT Suppl. PC Fee: .® Reg. C)OT 0.0 hrS $0.00 PME Plan Check: $0.00 90 s.f. $645.00 Remodel, Kitchen (<=300 sfl IRENIRESKIT Permit Fee: $0.00 Suppl. Insp. Fee: Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Conslrrtciion ??ac: Aebniwt ir<s4ne Fec: 0 Work Without Permit? 0 Yes (2) No $0.00 Advanced I'lannina Fee: $0.00 Select a Non -Residential Building or Structure E) 0 Lirare' Iiocznraarttcxlil�ra,ersr Strong Motion Fee: IBSEISMICR $9.75 Select an Administrative Iten Bldg Stds Commission Fee: IBCBSC $3.00 SUBTOTALS: $12.75 $1,290.00 TOTAL FEE: $1,302.75 Revise . 1/01/20 OWNER -BUILDER DISCLOSURE FORM JWQ COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • building(a),cucertino.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 ADD SS .,.- .. .. ... iA l/d �• ..APN. ���2 8P �f! ''�if'1l. f7 (2C\J N OWNER ADDR DESCRIPTION OF WORK:-'-' f% .... ... ... A - quo 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. 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 -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 homeowners 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. A/ 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. 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. 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. vr�5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the otal 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. 6. I understand if I am considered an "employer" under state and federal law, I must register with the state and ederal 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. 17. 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 artwork 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. 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. 0ivr7erRui1derForm 2010,doc revised 04114110 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. &L10. 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. 4-11. 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, /fifA 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the VIInnfoorrmation 1-have provided on this form. Licensed contractors are regulated bylaws 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 firm 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 theirworkers' 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 Div.) 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 Property Owner's Signature: Date: - 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: 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 owner's signature. Property Owner's Signature: Date: OwneYBuilderForm 2010.doc revised 04114110