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B-2016-1327 1 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1327 642 MILLER AVE CUPERTINO,CA 95014-4640(375 42 014) OWNER'S NAME: BELL SEAN AND PEREZ-BELLADRIANA DATE ISSUED 02/09/2016 OWNER'S PHONE:408-568-4468 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: 1 License Class Lic.# X BLDG X ELECT _PLUMB Contractor Date 2/9/2016 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; UPGRADE(E) 100 AMP PANEL TO(N)200 AMP PANEL I 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 3700of the Labor Code,for the performance of the work for which this permit is issued. 2. Thave 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:$1200.00 APPLICANT CERTIFICATION_ I certify that I have read this application and state that the above APN Number: Occupancy Type: information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby 37542014 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 912016. Date:2/9/2016.. .. . 1 _ r I OWNER BUILDER DECLARATION RE-ROOFS: I herebyaffirm 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 installed without first obtaining an inspection,I agree to remove all new materials for following two reasons: inspection, i. 1,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) Signature of Applicant: `z. I,as owner of the property,am exclusively contracting with licensed Date:2/9/2016 J` contractors to construct the project(Sce.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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 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. I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the by Section 3700 of the Labor Code,for the performance of the work for which m Health&Safety Code,Section 25532(a)should I store or handle hazardous this permit is issued. material. Additionally,should I use equipment or devices which emit hazardous ? ,3. I certify that in the performance of the work for which this permit is issued,I 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 Co e,Sections 25505,25533,and 25534. exemption,I become subject to the Worker's Compensation provisions of the f' Labor Code,I must forthwith comply with such provisions or this permit shall Owner or authorized'agent: be deemed revoked. Date:2/9/2016 CONSTRUCT ON LENDING AGE NCI' APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance I certify that.I have read this application and state that the above nformation,is of work's for which this.permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws Lender's Name relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Address to save indemnify and keep harmless the City of Cupertino against liabilities, judgments,costs,and expenses which may accrue against said'City in ARCHITECT'S DECLARATION consequence of the granting of this permit. Additionally,the applicant I understand my plans shall be used as public records. understands and will comply with all non-point source regulations per the Cupertino Mu 'cipal Code,Section 9.18. �� Licensed Professional Signature Date 2/9/2016 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUO ERTINO (408)777-3228•FAX(408)777-3333•building(a)cupertino.org misc ❑PLUMBING ❑MECHANICAL , ELECTRICAL (� []MISCELLANEOUS � PROJECT ADDRESS -.. .. APN# ►' f ` [� . - -. - OWNERNAME ! , PHONE E-MAIL Coy, e I are STREET ADDRESS Jry i CITY, STATE,ZIP FAX CONTACT NAME rPHONE_C q®g go_ _`1 & E MA1'�Gl"l L 4 '( �.).0 � � ` STREET ADDRESSi CITY,STATE,ZIP q�,O FAX IL OWNER ❑ OWNER-BuILDE R `❑ OWNERAGENT ❑ CONTRACTOR O CONTRACTOR.AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT p CONTRACTORNAME r `13A LICENSE NUMBER qq� LICENSE TYPI BUS.LIC# Y J Lt "(° COMPANY NAME M ' tJ\ E-MAIL vJ. V "° FAX STREET ADDRESS � � F3 I & CITY,STATE,ZIPIYwt ��, r PHONE Lf Dg_Lj 7b_Aj�( Y� I "( ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS:.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE _ 1 t� _ FD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND El YES USE OF PROJECT IN YES IS THE BLDG AN YES USEOFBUILDING: El COMMERCIAL URBAN INTERFACE AREA �.NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO (((lll DESCRIPTION OF WORK `/jA � Db q0 �el RELEl-C ED BY: TOTAL VALUATION: By my signature below,I certify to each of the following: I ain the property owner or authorized 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 buildconstruction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Date: Signature ofApplicant/Agent. SUPPLE EN AL INFORMATION REQUIREDor, ;l = ' �Fzcli�ISI7 orrLY- . —777 + ©; STfXNDARD MAJOR,; MEPMiscApp 2011.doc revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 642 Miller Ave DATE: 02/0912016 REVIEWED BY: PAUL APN: 375 42 014 BP#: VALUATION: $1,200 PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair 1 PRIMARY SFD or Duplex PENTAMATION 1 REAP2 USE: p PERMIT TYPE: WORK UPGRADE E 100 AMP PANEL TON 200 AMP PANEL _ SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Services 1 ERT<200 100 Amps $48 m TOTALS: $48 00 Pf -= Elec.Plan Check 0.0 hrs $0,00 f.e"h,Perr PerPei u,i Fee: Elec.Permit Fee: IEPERMIT olhe; Other Elec.Insp. 0.0 hrs $48.00 NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . These fees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS(Fee Resolution 11-053 Eff. Z/1/13) FEE QTY/FEE MISC ITEMS sl x? 1 t rz PME Plan Check: $0.00' Permit 1 ,, PME Unit Fee: $48.00 PME Permit Fee: $48.00 Administrative Fee: ]ADMIN $45.00 Work Without Permit? C) Yes (j) No $0.00 Travel Documentation Fee: 1TRAVD0C $48.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTTrLS: $777777- 777 190.50 $0.00 TOTALFE:: $190.50 _ Revise 1/ �z OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION 10300 TORRE AVENUE-CUPERTiNO, CA 95014-3255 (408)777-3228 FAX(408)777-3333 •buildina(a cuaertino.ora — CUPERTINO 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 1 �1I APN OWNER NAME M- QWNER ADDRESS-_442— k rp �� .. DESCRIPTION OF WORK: 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. Y�'e 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.) 1661. 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. 1, 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. 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. 06. 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. 6. 1 understand if I am considered an"employer" under state and federal law, I must register with the state and federal govemment, 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. 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 Conwith a licensed general building Contractor. is performed under c 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. OxaserBulderForm 2OIO.doc revised 04/14/10 19. 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 wvnv.cslb.ca.gov for more information about licensed contractors. 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I 4 am the party legally and financially responsible for proposed construction activity at the site address listed above. 64 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, 1 will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the -information-1 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. 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 held liable for damages. if you will be responsible for verifying whether or note you obtain a perrriit as Owner-Builder and wish to hire Contractors,y � p fy' g 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 buiiding 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 owner's signature. Property Owner's Signature: Date: o --------------------- ------- --- - - --- - -- - --------- --- - ------ -------- ------------------------ --------"---------------- (NOTE: ---- ----- - -------- -------------- -------- ---------------- (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 drivers 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.doc revised 0?/I4/10