B-2016-1453 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1453
22465 PALM AVE CUPERTINO,CA 95014-2711(357 03 068) SANTOS ROBERT J
AND JANICE C
24465 PALM AVE
OWNER'S NAME: SANTOS ROBERT J AND JANICE C DATE ISSUED:03/01/2016
OWNER'S PHONE:408-725-8273 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor SANTOS ROBERT J AND JANICE C Date 03/01/2016 X BLDG X 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:
REPLACE(E)100 AMP PANEL AND UPGRADE TO(N)200 AMP MAIN
I hereby affirm under penalty of perjury one of the following two declarations: SERVICE PANEL
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.
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:$2000:00
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 357 03 068
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 INSP TION.
Code,Section 9.18.
Issued by:ALEX VALLELUNGA
Signature Date 03/01/2016 Date:03/01/2016
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
r. 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 ofApplicant:
. I,as owner of the property,am exclusively contracting with licensed Date:03/01/2016
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
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
2. 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 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
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
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 255 ,255 25534.
exemption,I become subject to the Worker's Compensation provisions of the 01
Labor Code,I must forthwith comply with such provisions or this permit shall
Owner or authorized agent:'."-
be
be deemed revoked. Date:03/01/2016
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
I understand my plans shall be used as public records.
understands and will comply with all non-point source regulations per the
Cupertino Municipal Code,Sect n 9.18.
Licensed
4' Cr J Professional
Signature Date 03/ /2016 01
GENERAL PERMIT APPLICATIONM E P
COMMUNITY DEVELOPMiiENT DEPARTMENT•BUILDING DIVISION
10300 TORP,E AVENUE•CUPERTINO, CA 95014-3255
UPERT[ C (408)777-3228• FAX(408)777-3333• buildina(a cuoertino:orgm Vj
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BUITDNG: ❑COI'0'=, .CNAL I URBAN N=_ ACE AREA ❑ NO FLOOD ZONS ❑ NO I mCF LER HOME? ❑NO
DESCP.IFTION OF WORK �y�yl 1 -Amp P^ha-
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TOTAL VALUATION: g'd-o` RECFI! Dn1� wM '
By Tay signatze below,I certify to each of the following; Ian the property owner or authorized aeent to act on the property owner's behalf. I have read this5 x
application and the iarfor ation I have provided is correct. I have read he Description of'Work and verify it is accurate. I agree to comply}viih all applicable Iocal
ordinances and st to lz;vs relit ng to IDIX,.a•,_constracaon. ae t o ' e representatives.of Cuuert no to enter`lue above-id=ntif d proper ty for insp=c ion purposes.
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Si�matL're of A.ppliCamt/:_gent: Date:
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3/El'?A/isc4Dp_20]1.doc revised 06121/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 22465 PALM AVE DATE: 03/01/2016 REVIEWED BY: ALEX V.
APN: 357 03 068 BP#: "VALUATION: 1$2,000
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 REAP2
USE: PERMIT TYPE:
WORK REPLACE E 100 AMP-PANEL AND UPGRADE TON 200 AMP MAIN SERVICE PANEL
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1 ERT<200 200 Amps $48
TOTALS: $48.00
.,, ? hm k'c Elec.Plan Check 0.0 hrs $0.00
Fvh, r t:z Is:e: ? :. '- hee Elec.Permit Fee: 1EPERMIT
Other Elec.Insp. 0.0 hrs $48.00
in""p, Fee",
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These ees are based on the prelimWina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS(Fee Resolution 11-053 E . 711113) FEE QTY/FEE MISC ITEMS
us:
PME Plan Check: $0.00
;e, 4= jt
§.,ti 3 {
PME Unit Fee: $48.00
{PME Permit Fee: $48.00
2.,Y(3P7 'fir. .fIP
TYF7
S.
Administrative Fee: IADMIN $45.00
Work Without Permit? 0 Yes 0 No $0.00
Travel Documentation Fee: ITRAVDOC $48.00
Strom Motion Fee: IBSEISMICR $0.50 Select an Adminis rve Item
Bldg Stds Commission Fee: IBCBSC $1,00
SITST(3TALS: $190.50 $0.00 TOTAL Fk E:: $190..50
Re-vi ed: 01/01/2016
ELIOWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPEIRTIINCy (408)777-3228•FAX(408)777-3333 building0-cupertino.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 gFg' �/' APN ^ BP#
R N ME OVJNERADDRESS
DESCRIPTION OF WORK:/ 1adi 10-4 1144/62 40�A
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.)
f
V1. 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.
f� 2. l understand building permits are not required to be signed by property owners unless they are responsible for
thonstruction and are not hiring a licensed Contractor to assume this responsibility.
ft3. 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
n7'A
instead of my own.
Q , . 1 understand Contractors are required by law to be licensed and bonded In California and to list their license
numbers on permits and contracts.
5. 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
con ldered an"employer" under state and federal law.
f 6. l 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
rn/e�o serious financial risk.
'" 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
/11iicensd subcontractors and the number of structures does not exceed four within any calendar year,or all of the work
rmed under contract with a licensed general building Contractor.
l 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.
OWneYBuildeYFonn 2010.doc revised 04/14/10
19. 1 understand I may obtain more information regarding m' obligations as an "employer"from the Internal
Y 9 9 Y g
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.csib.ca.gov for more information about licensed
jcop tractors.
°r A 0. I am aware of and consent to an Owner-Builder building permit applied for in my name,and understand that I
afhe party legally and financially responsible for proposed construction activity at the site address listed above.
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 I 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 may be 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: AILA 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 cit ay be re "re to be presented when the permit is issued
to verify the property owner's si atq e. _
Property Owner's Signature: Date:
----- ------------------------ ------------------------------------------------------------------------------------------- ------------------
(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, I hereby _authorize-the following 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 1 am the property owner for the address listed above and 1 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 owners
signature.
Property Owner's Signature: Date:
OwnerBuilderFonn 2010.doe revised 04/14/10