B-2016-1353 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1353
7643 SHADOWIIILL LN CUPERTINO,CA 95014-5053(362 25 013)
OWNER'S NAME: SHADOWHILL IN TRUST 7-28-05 DATE ISSUED:02/11/2016
OWNER'S PHONE:4088738888 PHONE NO:
LICENSED–C-ONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor Date_ 2/11/2016 _X BLDG —ELECT -PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing
—MECH X RESIDENTIAL—COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
TO CLEAR CODE CASE:RETURN OPENING MADE IN GARAGE
I hereby affirm under penalty of perjury one of the following two declarations: WALL WITHOUT A PERMIT BACK TO ORIGINAL CONDITION
a. 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. 4
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 Sq.Ft Floor Area: Valuation:$245.00
APPLICANT CERTIFICATION
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 362 25 013
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.
Issued by:PAUL O'SULLIVAN
Signature Date 2/11/2016 Date:2/11/2016
OWNER-BUILDER DECLARATION
RE-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
FI 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(Sec.7044,Business&Professions Code) Signature of Applicant:
2. I,as owner of the property;am exclusively contracting with licensed Date:2/11/2016
contractors to construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. 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
z. I have and will maintain Worker's Compensation Insurance,as provided for California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
by Section 3700 of the 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
gA 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
i' shall not employ any person in any manner so as to become subject to the 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
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.
be deemed revoked. Date:2/11/2016.
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 Municipal Code,Section 9.18.
Licensed
Professional
Signature Date 2/11/2016 -
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE CUPERTINO,CA 95014-3255
� ,�, � (408) 777-3228 FAX(408)777-3333•buildinq(o1cupertino.org
❑NEW CONSTRUCTION ❑ ADDITION ❑ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT
PROJECT ADDRESS B i / f
wHl-L.l� l�!!11/1/v I APNco 01
-
OWNER NAMEC�!'t / 1 ljr
J -—- PHONE (t E-MAIL
j4 r �L' I Li i1 v G Gi
STREET ADDRESS / CITY, STATE,ZIPFAX
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CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE, ZIP FAX
OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑. ARCHITECT 11 ENGINEER ❑ DEVELOPER. ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER LICEATSE TYPE BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS L-IC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE;ZIP PHONE
DESCRIPTION OF WORK i
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LACARA
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EXISTING USE PROPOSED USE -- CONSTBLTYPE STORIES S E P C
USE TYPE OCC. SQ.FT. VALUATION(S)
E%ISTG NEW FLOOR. DEMO TOTAL - -
AREA AREA AREA NET AREA
-BATHROOM KITCHEN OTHER - -
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK(PORCH AREA GARAGE AREA: DETACH
❑ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES - -
BEING ADDED? No ADDITION? ❑NO
PRE-APPLICATION ❑.YES IF YES,PROVIDE COPY OF IS THE BLDG AN El YES C I D BY 'tap TOT VALUATION:
PLANNING APPL# ❑NO PLATTING APPROVAL LETTER EICHLER HOA'IE? ❑NO
By my signature below,I certify to each of the following: I am the property owner or authorized`agent to act on the property Owner's behalf. I Lve 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
New SFD or Multifamily dwellings: Apply for demolition permit for "A � '�` �£
O\'ER THE COU\TERBUILDI\GPL4\RE\'IE\
existing building(s). Demolition permit is required prior to issuance of buildings ,
permit for nein building. I], E�xEss £� � �" � �>PLAti
x a ;
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure L7 sT DAItD I� ruBLlci�olil.s
form if any Hazardous Materials are being used as part of this project.
_Copy of Planning Approval Letter or Meeting with Planning prior to *>
b ��NL�JOR � �.a�is � �� S�3ITAR]SEAERDtSTRICT�
submittal of Building Permit application. f {
Bldg 4yy_201 Ldoe revised 06121111
" OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT -BUILDING-DIVISION
,z— . 10300 TORRE AVENUE•CUPERTI.NO, CA 95014-3255
WEEN (408) .777-3228 - FAX(408)777-3333•buildina(a)cuaertino.org —
CUPERTI0
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 ICA : , ... .APhi. ej i IBP Oil
0 _R NAME a OWNER ADDRESS
DESCRIPTION of WORK: o".k6iN. 01266
�
L�
We are providing you with an Ownet-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.)
q; t-1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner-
Builder" building permitthat 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.
L 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
he construction and are not hiring a licensed Contractor to assume this responsibility.
j to L3. 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.
C'L4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
C �-5. 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.
1!�L6. 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.
( s`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.
I understand as an Owner-Builder if 1-!sell the property for which this permit is issued, l 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.
0-wnerBui1derForm 2010.doc revised 01/14/10
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 l 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.
CSL 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that l
am the party legally and financially responsible for proposed construction activity at the site address listed above.
Q11. 1agree 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.
iE
L,-12. l agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have on this form. Licensed contractors are regulated by-laws designed to protectthe..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
to verify the ro ert owner's signature.
Property Owner's Signature!,// '1-410 f
-------------------
(NOTE: The following Authorization Form is required to be completed by the property ov✓ner only Gvhen 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 ?010.doc revised 04,114110
CITY OF CUPERTINO Q
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 7643 Shadowhill Lane DATE: 02/11/2016 REVIEWED BY': PAUL
APN: 362 25 013 BP#c *VALUATION: $245
'P.ERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex PENTAMATION
USE: PERMIT TYPE:
WORK TO CLEAR CODE CASE: RETURN OPENING MADE IN GARAGE WALL WITHOUT A PERMIT BACK
SCOPE TO ORIGINAL CONDITION
1 oo'4, e bn e_k u,I..at
...,,ta. .l't e3b,! s Pe IF
ETCt wb I fat,n..b in,,qa 1'f£'., Znl*sll',
Plu nb I Vit).:Fee:
e:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District;etc. . These ees are based on the prelimina information available and are onl an estimate. Contact the Dept/or addn'l info.
FEE ITEMS (dee Kesolatiar7.1.1-053 Ff. 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Select a Mise Bldg/Structure
Suppl.PC Fee: (F) Reg. 0 OT 0.0 hrs $0.00 or Element of a Building
PME Plan Check: $0.00
Permit Fee: Hourly Only? C)Yes (j)No $0.00
Suppl,Insp.Fee.Q Reg. 0 OT Rflhrs $0.00
PME Unit Fee: $0.00
PME Permit Fee- T-T.;..- $0.00
.eldininistratim Fee:
Work Without Permit? 0 Yes (F) No $0.00
Advanced Planning Fee: $0,00 Select a Non-Residential G
Building or Structure 0
Strong Motion Fee: IBSEISMICR $0.50 3-0-1 hrs Inspections
Bldg Stds Commission Fee: IBCBSC $1.00 $429.00 ISTINSP Inspection,Hourly
SUI3TOT4L
$1.501 $429.00 TOTALEE $430.50
Revi 01/01/2016