B-2016-1318 PERMIT, APP & OWNR-BLDRCITY OF CUPERTINO BUILDING PERMIT
PERMIT NO: B-2016-1318
10855 DRYDENAVE CUPERTINO, CA 95014 (356 14 013)
OWNER'S NAME: I (DATE ISSUED: 02/08/2016 1
'S PHONE: 408-203-5942
License Class Lie. #
Contractor OW NERIBUILDER Date
hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
Ith Section 7000) of Division 3 of the Business & Professions Code and that my
tense is in full force and effect.
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. 1 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
certify that I have read this application and state that the above
nformation is correct. I agree to comply with all city and county
xdinances and state laws relating to building construction, and hereby
authorize representatives of this city to enter upon the above mentioned
xoperty for inspection purposes. (We) agree to save Indemnify and keep
tarmless the City of Cupertino against liabilities, judgments, costs, and
;xpenses which may accrue against said City In consequence of the
Iranting of this permit. Additionally, the applicant understands and will
:omply with all non -point source regulations per the Cupertino Municipal
;ode, Section 9.I8.
Date
hereby affirm that I am exempt from the Contractor's License Law for one of the
iBawing 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)
2. 1, 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. 1 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
A,n this Permit's issued.
A_3. I certify that in the performance of the work for which this permit is issued, I
shall not employ any person in any mourner so as to become subject to the
Worker's Compensation laws of California. If, after snaking 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,
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.
Signatuo,, � Date alalr G
PHONE NO:
PERMIT INFO:
BLDG X ELECT _ PLUMB
MECH X RESIDENTIAL _ COMMERCIAL
B DESCRIPTION:
GARAGE, ADD 4 (N) LIGHT FIXTURES, I (N) DEDICATED
ICUIT& (N) 10 OUTLETS/SWITCHES
Ft Floor Area: I Valuation: $2325.00
"N Number: Occupancy Type:
356 14 013
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
by:
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.
of Applicant:
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 m- devices which emit hazardous
air comium ants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Cade, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25(5333,
)wner or authorjz it agent:
)ate: „Z C'r (//
O CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for the performance
if work's for which this permit is issued (Sec. 3097, Civ C.)
.ender's Name
Address
ARCHITECT'S DECLARATION
understand my plans shall be used as public records.
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
I - 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERT{NO (408) 777-3228 • FAX (408) 777-3333 • buildina( oupertino.ora
MISC
❑PLUMBING ❑MECHANICAL ELECTRICAL ❑MISCELLANEOUS
PROIECTADDRESS
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OIVNERNAME '�I IV`o�J A Cc P R1 E(? oG
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EMAIL y
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STREET ADDRESS CJ'�M
CITY, STATE, ZIP �[ i�%f'_ � � �(j � A C��r1
FAX
CONTACT NAME Ajq(ZA C-oIP(i'Ci
PHONE408 �aLd3`S-n�l[��nEMAIL
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FAX
❑ OWNER ❑ OWNER -BUDDER ❑ OWNERAOENT ❑ CONTRACTOR ❑ CONTIUCTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME T`I O. 1'� '
1 :i +/
LICENSE NIUM13ER
LICENSE TYPE
BUS. L1CN
COMPANY NAME
&MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEERNAME
LICENSE NUMBER
BUS. LIC N
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑SFD.,DUPLEX ❑ MULTI -FAMILY
B[HLDDJO: ❑COMMERCV.L
PROJECT IN WADLAND ❑YES
URBAN INTERFACE AREA ❑ NO
PROTECT IN ❑ YES
FLOOD ZONE ❑ NO
IS TH6 BLDG AN ❑YES
EICHLER HOMEY ❑ NO
DESCRIPTION OF WORK
fn;FcII .4. >1 t�Ct x�t�.rvs
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TOTAL VALUATION:-
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By my signature below, I certify to each of the following: I am die property owner or authorized ago D act on t7e property owner's behalf. I have read this
application and the information I have provided is correct I bave read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws mlaf urld g conshuction. I authorize represeDntativ�es of Cupertino to enter the above -'de i ed property for inspection purposes.
Sigrnalure of Applicant/Agent: n i'-Q'V'�--�f=='��'�•—�9--- Date: U ®�(0
SUPPLEMENTAL INFORMATION REQUIRED
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MEPMiscAyp2071.doc revised 06121111
CITY OF CUPERTINO
Irm FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 10855 DRYDEN AVE
DATE: 02108/2016
REVIEWED BY: MELISSA
APN: 356 14 013
BP#:
"VALUATION:
$2,325
xPERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
PEINTAMATION 1REAP11
PERMIT TYPE:
WORT{
IN GARAGE ADD 4 N LIGHT FIXTURES 1 N DEDICATED CIRCUIT &
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
QTY
UNITS
BP FEES
Fixtures, Lighting
1BREMFIXT
4
#
$72
Special Circuits
1BREMMISC
1
#
$143
Recep/Switch/Outlets
1BREMRECEP
10
#
$48
TOTALS:
$263.00
'
zA
: I4Wl. Plan ('Arzk
Plumb. Pi,o, Check
Mee, Plan Check
0.0
hrs
$0.00
tech' I o mit P'ee:
1'honh, Ai aid F"ec:
Elec. Permit Fee:
IEPERNIIT
Ozhe7 1-fec t. fiwp
tither Plumb fmn.
Other Elea Insp.
0.0
hrs
$48.00
AL(ech. &VI, fife-
Phu AU. Iresp, Fee'
Flr'c. 1 ?"r, heea
NOTE: This estimate does not include fees due to other Departments (i.e. Planninz, Public Works, Fire, Sanitary Sewer District, School
District, etc.. These fees are based on the preliminar information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053Eff. 7/1113)
FEE
QTY/FEE
MISC ITEMS
Plan Cfreck Fee:
d
S& )TV. PCJ'" e
PME Plan Check:
$0.00
U ypf)L fnij., Fee
PME Unit Fee:
$263.00
PME Permit Fee:
$48.00
f.. onslrurfion 7ay.
Administrative Fee: 111DMY
$45.00
Work Without Permit? 0 Yes (F) No
$0.00
Advanced ploxming Fee ;
d
Travel Documentation Fee: ITRAVDOC
$48.00
Stron�Motion Pee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IRCDSC
$1.00
'susTOTALs:
1 $405.50
$0.00
TOTAL FEE:
$405.50
Revised: 01/01/2016
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
GUPERTIN0 (408) 777-3228 • FAX (408) 777-3333 • build! ngCgcupertino.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 -- a�2y.���i
.. . — A_4� BP#
�lvExtts� ...:A:gcaNV-��s2-, i .__.
OWN Rt�p. ;. a ...
.E1 3�112f1 G®Rr2I1 YLo
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OWNER ADD ESS-
ro .!'SopS` yV ,4V_4ot/tl� eUP�rQTidlz) ..
DESCRIPTION OF WORK:'"
-
� T06A. 9—L—Wif-106
F xl&cca CtV_CVI r F �kJz,rCp¢/i aC'Ec�P77�cL
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.)
�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 injuries to workers on my property.
AC2. 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. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
K5, 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.
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.
�C-7. 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. 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.
0lvnerBui1derFbrm 2010.doc revised 04/14/10
I understand I may obtain more information regarding my obligations as an "employer" from the Internal
evenue 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.
�10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
he party legally and financially responsible for proposed construction activity at the site address listed above.
_11. I 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,
W-� . 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information 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. 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 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
Property Owner's Signature: `a,L&k Q? ea Date: �f2S/ �1�,
---------------------------------------------------------------------------------------------------- ---- ----- ------------------------
(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, 1 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, orother
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 04114110
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