B-2016-1291 Permit, App, Fee Est, Owner Builder Cupertino Sanitary ApprovalCITY OF CUPERTINO BUILDING PERMIT
CONTRACTOR:
B-2016-1291
10321 MARYAVE UNIT 10321 CUPERTINO, CA 95014-1338 (326 52 999)
I OWNER'S NAME: PATIL ANAND AND GEETA I I DATE ISSUED: 02/02/2016 1
PHONE: 408-249-4799
LICENSED CONTRACTOR'S DECLARATION
License Class Lie. #
Contractor Date 2 2120 6
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:
r. I have and will maintani 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 20 6
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
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
L for sale (Sec.7044, Business & Professions Code)
1. I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (See.7044, Business & Professions Code).
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
performance of the work for which this permit is issued.
z. 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.
I certify that in the performance of the work for which this permit is issued, I
/ -shall not employ any person in any mammer 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
ertify that I have read this application and state that the above information is
mact. I agree to comply with all city and county ordinances and state laws
sting to building construction, and hereby authorize representatives of this city
enter upon the above mentioned property for inspection purposes. (We) agree
save indemnify and keep harmless the City of Cupertino against liabilities,
Igments, costs, and expenses which may accrue against said City in
nsequence of the granting of this permit. Additionally, the applicant
derstands an will comply with all non -point source regulations per the
ipertino Muni i al Cpde, Section 9.18.
BUILDING PERMIT INFO:
BLDG —ELECT _PLUMB
MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
Convert (E) bathroom into 2 Bathrooms (96 St)
Sq. Ft Floor Area: Valuation: $5000.00
AP 52 umber: Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
by:1981
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: 2/2/2016
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 e, Sectius 25505, 25533, and 25534.
Owner or authorized agent:
Date: /22 /2016
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.
2/212016
Licensed
Professional
!2974 -
CUPERTINO'
❑ Ntw CONS-j-.?'uC;,oN
PROJECT ADDRESS 10 3 21
CONSTRUCTION PERMIT APPLICATION B,Q%,
COMM,UNI T f DEVELOPMENT DEPARTMiiEN T m BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014..-3255 ts
(408) 777-3228 • FAX (408) 777-3333 + building0guDei'ino.oro
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STREET ADDPESS jo321 Mavyf4t, I cr., M,7R,Z?Cu?e-mi V'O e I. I:Ax
COYfACT NAM]s A v\a K d f ck7' PHONE Tit ADDRESS ld�2l *lczv /'ve CCr!TY, STATE, Zr3 �C.�1iC N''ll� I CE 1'�✓:.<.Il9.
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COh?J.CTOA NAME
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FAX —
STREET ADDRESS
4'1Y, STATE, ZIP
PHONE
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DESCRI 7101E OF WORK COnvQafi^ob}haHg,,�Y�rt�
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EMSTiG USE PROPOSED USE CONSTR TIDE .'STORIES
li0.) h Y•• w . r,aRa✓� wt . I USE TYPE 0M SQ.FT. I VALUATION IS)
EEOSTGIAA FLOOR. AREA TOTAL
A96 N0 > FAREA I I I I I —
BAT1500. KIICi'rrQ Oir'=R
R71=7Lx
AREA96 fP7':ODEL AREA (REMODEL A_'�--_A 7-t /}
BEING ADD"^-D+ ffI.0
iDDIT10N° Ova
PRZAoonCtu04 ZIES 17 = PROVIDE COPY Or
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IS,KE BLDG AN ❑1S
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100
By aty sEnatue below, I certify to each or the following: I an the prop;..}' os;-Ter or authoriled
agent to act on the propery otiner's behal_`. I have reed this
application and the inkimation I have provided is correct. I have read the Description of f%,'ork and vcri`y it is accu te. I agree to comply t', th all=Pplicable local
ordGaes and state laws relating to building onstp! t�n, I authorize represenstives of cupendno to enter th
xe above -id en_ti_;Ied Proper y for inspection purposes.
S;mahcx oi:;pplicant/"- nt J ��_
Date G!!= 0�/ rl6l6
SUPPLE14EhTAL T'POR-biATION ILQUTRED
Net+' SFD or -amily dwell;,us.:.Daly 'or dznohtlo- oe.-at:or
Luile.ae(s). Demolition -eeu::ec
ni a ram. coD�.r
e.spcg p ; i;t Is ar+or to 'Ma_n.ce 01 Dnile,
� roe -Tit for new bWldirg.
Comm-m:al3ldES'PrOvide
acomDletcd`-1P>&00-s Mterial>DICC1CCL
=--• oaf ;`-,y f._�e .�.ous h!a.srals =_e ce,-g ,used as.„-. e -4.s a, e}ect.
Copy of Planning AppiDval Lefter or Meeu = Y,:h I'iano�_-,e Dner to
_
;=e
I Sl_rl. sue- r
snb 'ual of Br;1d �g Permit cPDllC iiG1,
-3'F 10.2 ' •'zve >``
r - Y c __` c=n�rC-ry
?Ica An_2011. do revised 06121/11
--- CITY OF CUPERTINO P>-a°l6 - Iaq I
FEE ESTIMATOR - BUILDING DIVISION
J&DDD7RE7SS:
10321 Mary Ave
DATE: 02102/2016
REVIEWED BY: PAUL
PN: 326 52 999
BP#:
"VALUATION:
$5,000
"PERMITTYPE: Building Permit
PLAN CHECK TYPE; Alteration / Repair
PRIMARY SFD or Duplex
USE: p
PENTAMATION
PERMIT TYPE: 1R3SFDRE e
WORK
Convert E bathroom into 2 Bathrooms 96 S.f.
SCOPE
11eCIr. PJon C'iaecfi Fi�uNfi. I'!cm (:Yk•ck flee. l'l,rr CGeeb
r'm- f'ee_ l' � rrl. }' mii I'M, r Ir:-. Vernm 1".
C3iker .17et1,. hw'1>. 0kv Plendr!r_<p_ 0iLer"'I" Insp,
;iiecH. I,��P. ,`•,.,: Phvwn Insp. Prd: h7ec. lrc�r. kre'
N07T. This estimate does not include fees rlite to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
Dietrirt. etc 1. These feat are. based an the nreliminary information available and mx anly an eefimate. Cnrrtact the I)en! fia• addrx'L info.
FEE ITEMS (Fee_ Resolution 11.05.3 _F_,�:_ 7_11113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
96 s.f. Remodel, Bath (<=300 so
$645.00 limmjRESBA7'
Suppl. PC Fee: 0 Reg. 0 OT
1 0.0
Ins
$0.00
PME Plan Clieck:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. 0 OT
p•0
hrs
$0.00
PME Unit Fee:
$0,00
PME Permit Fee:
$0.00
Construction 74':
'Wiriirtim,wive Fee;
Work Without Permit? ® Yes 0 No
$0.00
AdvancedTianning Fee:
$0.00
Select a Non -Residential
Building or Structure 0
A
YFa,zfl>o, m�razafiore,t'eEs_
StiwE Motion Fete: IBSEISMICR
$0.65
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:-1
$1.651
$645.00
TOTAL F E
E:rt-- $646.65
Revised: 1/01/2016
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO. CA 95014-3255
(408) 777-3228 • FAX (408) 777.3333 • building(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 ' U2,Z I... �'P�
I J-.
/1lt. (tt p7 1y+WL0-
.; AP N. 39 1
Ejf"_I _I9
'"Ih
CJ��
OWNER NAME
,. �_
o
..:.OWNER
ADDRESS_i1J�Ko
mayy lKc Cei r/'iiW C/1 w S_b )
-DESCRIPTION OF WORK:
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.)
c0-1. 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 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.
. 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.
,N '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.
u4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
mbersnon permits and contracts.
. 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,
446. 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." 1 also understand my failure to abide by these laws may subject
me to serious financial risk.
r� 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.
qI understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
anfiBnanclal 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 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 w,nnv.cslb:ca.gov for more information about licensed
contractors.
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.
l agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
b all applicable laws and requirements that govern Owner -Builders as well as employers.
I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
in��ormation-I 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 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 acce table to the city may be required to be presented when the permit is issued
to verifythe rp opert owner's signature
111
Property Owner's Signature; ZZ Date: O : o 20l
----------- - --- ----------- ----- ----- ----------------------- - ------- ------------------------- ------Agna- -----
(NOTE: The following Authorization Form is required to be completed by the property ov✓ner 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: Tel No
Address of Authorized Agent:
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.dec revised 04114/10
DISTRICT MANAGER -ENGINEER
MARK THOMAS & COMPANY, INC.
RICHARD K. TANAKA
DISTRICT COUNSEL
ATKINSON • FARASYN, LLP.
MARC HYNES
February 1, 2016
City of Cupertino
Building Department
10300 Torre Ave.
Cupertino, CA 95014-3202
4Q~1�p SANI iggyo'IP
f9
��rAg(ISNEO 1°'�6
20863 STEVENS CREEK BOULEVARD, SUITE 100
CUPERTINO, CALIFORNIA 95014,2154
(408) 253-7863 PHONE • (408) 2S3�5173 FAX
www. rupertinosonitarydistrirt. org
Subject: Bathroom Remodel — APPROVED
Name: Patil Residence
Address: 10321 Mary Avenue, Cupertino
APN: 326-52-004
Permit No. NA - Over The Counter
BOARD OF DIRECTORS
ANGELA S. CHEN
JOHN M. GATTO
STEVE C. ANDREWS
WILLIAM A. BOSWORTH
PATRICK S. KWOK
File: CSD — MOP #16-021
Building Dept. — Cupertino
The Cupertino Sanitary District has reviewed the plans for the subject project:
• Sanitary sewer is available and the existing building is connected to sanitary sewer, see
conditions/requirements listed below.
The following Conditions/Requirements are made:
Install new property line, cleanout to District's standards or locate and raise to grade
an existing property line cleanout. Property line cleanout must be within 5 feet of the
property line. Cleanout shall be the same diameter as the street portion of the service
lateral. Gravity lateral is 411 diameter minimum. (O.C. 4101)
• Closed-circuit video of the existing/new property line cleanout, point of connection
and District lateral is required prior to clearance for City of Cupertino Final
Inspection. Owner to call District at least 48 hours prior to video inspection to
schedule a District Inspector. District to provide Building Department with written
notification upon completion of inspection. (O.C. 5104)
Page 2
Subject: Bathroom Remodel — APPROVED
Name: Patil Residence
Address: 10321 Mary Avenue, Cupertino
APN: 326-52-004
Permit No. NA - Over The Counter
All conditions, requirements and recommendations are to be completed at the
(owner/developer)'s expense.
Storm water from surface or roof drains, other general surface runoff water or condensate from
any residential HVAC equipment shall not be discharged to the sanitary sewer.
Yours very truly,
MARK THOMAS & COMPANY, INC.
District Manager -Engineer
f RicTanaka
If you have any questions or need additional information, please call Ivy To at
408-253-7071.
U:\Administration\Correspondence - General\Letters\2016\Letter #16-021 Cupertino Building Department_NA Over
The Counter —Bathroom Remodel_10321 Mary Ave_Approved_2-1-16.doc
SUPPLYING SANITARY SEWERAGE SERVICES FOR: CITY OF CUPERTINO, PORTIONS OF THE CITIES OF SARATOGA, SUNNYVALE, Los ALTOS AND SURROUNDING UNINCORPORATED AREAS