B-2016-1563 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1563
1233 BELKNAP CT CUPERTINO,CA 95014-4904(362 10 023) GREGORY MILTON
AND JUDY TRUSTEE
1233 BELKNAP CT
CUPERTINO,CA
9501411904(362 10 023)
OWNER'S NAME: GREGORY MILTON AND JUDY TRUSTEE DATE ISSUED:03/17/2016
OWNER'S PHONE:4088922748 PHONE NO:4088922748
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor GREGORY MILTON AND JUDY TRUSTEE Date 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:
REMODEL 2 BATHROOMS ON 1ST STORY(120 S.F.)
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 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. Sq.Ft Floor Area: Valuation:$15000.00
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 ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 362 10 023
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 PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 3/17/2016 Issued by:PAUL O'SULLIVAN
Date:3/17/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Scc.7044,Business&Professions Code). Date:3/17/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. HAZARDOUS MATERIALS DISCLOSURE
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
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
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Munfcf al Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Vie,Sections 25 OS 5533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:3/17/2016
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Sectil8. 1 understand my plans shall be used as public records.
Licensed
Signature Date 3/17/2016
CONSTRUCTION PERMIT APPLICATION 13Wb
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255'
CLJPERT[NO (408) 777-3228 • FAX(408)777-3333 • building(cDcupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED
'� ORIGINAL PERMIT 9
PROTECT ADDRESS � -6 APN^ 26G� 1�I
1 1
0\dTTER NAME PHON �.E!-MA
STREET.4DDRESS t A� C CITY, STATE,ZIP FAX
CONTACT NAM i PHO � E-MAIL
L —
STREET kIgRESS � � CITY TATE, ZIP FAX
J
0—OWNER ❑ O\\'NER-BUILDER ❑ OWNTER AGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC n
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECTIENGLNEER NAME LICENSE NUMBER BUS.LIC n
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WOItK
2 6,"VrpLM e2 f 1 D S f
EXISTING USE 7-777SED USE CONSTR.TYPE n STORIES
USE TYPE OCC. SQ.FT. VALUATION(5)
EXISTGNEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECKTORCH AREA GARAGE AREA: DETACH
❑ATTACH
r D\VELLiNG UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES
BEING ADDED? E]NO .ADDITION? ON-0
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES ]ED.BY t TOT
VALUATION:
PLAI\'NING.APPLr ❑NO PLANNING APPROVAL LETTER EiCHLER HOME? ❑NO
By my signature below,I certify to each of the following: I in the property owner or authoriz d agent to act on the property owner's behalf. I he re
avad ibis
application and the information I have provided is correct. ave read the Description of\A7ork and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating t u'Id con tion authorize representatives of Cupertino to enter the above-identified property.for inspection purposes.
Signature of Applicant/Agent: k t Date:
SUPPLEMENTAL D\TFOR1\4ATION VIUIkED
I\Tew SFD or Multifamily d-,vellings: Apply for demel-ition peri-nit for c �
O�ER THE COU\TER3x y BUILDI\G PL4 RE\IER r �
existing building(s). Demolition permit is required prior to issuance of building r ; r FR.
permit for new building. RE
❑ EIRE
ua I 4 ❑ \L\G PL41\REQ IE�6 4
�sr
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ ST4\D4RD ❑ PU�LICVIORLS} _ ;
form if any Hazardous Materials are being used as part of this project.
L❑ LARGEt a 5: Lds FIRE DEPT c za k t
_Copy of Plalming Approval Letter or Meeting with Planning prior to
❑ M JOR ❑ S4\IT4R]SE1)ERDISTRICT
submittal of Building Permit application. e r
❑ H\\IRO\R1ENT.4L HEALTH
Bldg.4pp-2011..doc revised 06/21/11
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228 • FAX(408)777-3333 • buildin4 5cugertino.org —
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:
SITEADDRESS .......
. ... ..APN ® BP;i5�1� 66
i 3.
OWN Af �. . .. _..: .OWNER A D D.R.E.S '
,
DESCRIPTION OF WORK: 5 a+ �v-Gat
'J S
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.)
1. l 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
ersonally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
' n unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
rovide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
gi'fin urance 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
f h construction and are not hiring a licensed Contractor to assume this responsibility.
3. I understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may
rotect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
'n e instead of my own.
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
n mbers on permits and contracts.
�. 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
r o al value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
cc sidered an "employer" under state and federal law.
}'4
6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and
fe eral government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
T' unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family
o legally build them with the intent to offer them for sale unless all work is performed b
esidential structures cannot g y � p Y
F:1censed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
rformed under contract with a licensed general building Contractor.
r8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
an financial 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 04/14/10
- r
9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal
`' tDepartment Re; nue Service, the United Stales Small Business Administration, the Californiaaorn a ep t of Benefit Payments,
andsthe California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
Lic_ehse Board (CSLB) at 1-800-321-CSLB (2752) or ww\v.cslb.ca.gov for more information about licensed
mA
contractors.
� 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
ar� the 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, I will abde
y�by"all applicable laws and requirements that govern Owner-Builders as well as employers.
12. l 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. Itis 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 maybe 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 note
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the fbllowing 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
i returned to the agency responsible for issuing the permit. Note:A copy of the property owners drivers license,
form notarization, or other verification acceptable to e cit may be required to be resented when the permit is issued
p Y Y q p
to verify the property owners si t
Property Owner's Signature: 7 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 l 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.doc revised 04/14/10
A
P r",
\h Code: 2013 CR\./
COPy
CE Scope of ,Work:
Remode/Bathroom s
1toilet/shower area
a. install new tub
b. install low—flow toilet
C 01 M N I U T Ppl�r Remodel
0 c. install new vent
L'�_1_ARk1"'"i::r� fan/heater/light.
v
'1'BUILDLJL L ,qom Rern
"E' OPMIDNT,
G 13lvISjC,,\j - CU
APPROVED \"�tal area d. install new the flooring
.This sell of plan,, ar r S"t?dflcaticns i,111'_,`)T be kept at the
2. dressing area
cb Site dff' '
1�1�j c"IS',ruction. It is unla�.A.,fuj to make arfy
c'hanges or a ,tionson S_ me
r
or to deviate
therefrom, with( ut approval from thS�fijding Official, 7 a. install new vanity
'he Slarriping. rj�h'
I I
_J plan and specifflications SHALL NOT b. remove existing mirror
be, held to per it t or to be an approval
cfan rovision �orfany it, of the Violation
P,Y Cit Or�linance Or State Law. and new
- Lb
DAT po—n-6 16 -------------------- c. remove existing lighting
A
L
P E R
and install new
T
d. install GF1 outlet
e. install new the flooring
CUPERTINO
LU:hding Department
Occupancy group: R-3/U
7 2016 Construction type: VB
REVIEWED FOR CODE COMPLIANCE
Reviewed By: T��Oj
RECEWED
BY
Gregory, Residence
1233 Belknap Ct
Bwthroom Remodel
Locator 3-16-16
Y
Exiat(ng Walls
tollet/tub—shower dressing area
area 26 egft
26 sgft Ir
tollet/shower
J1
area dressing area
40 sqft 27 sgft
CUPERTINO
Building Department
7 201
REVIEWED FOR CODE COMPLIANCE
Reviewed By: Thu, +zl
Gregory Residence
1233 Belknap Ct
.Termite and Dry Rot Repair
Batroom Remodel
3-16-16