15120085-- --
CONSTRUCTION PERMIT APPLICA I IC
CcmjI IIUNITY DEVELOPMENT DEPART HENT BUILDING DIVISION
10300 TORRE AVENUE • CUPER T INC, CA 85014-3255 U (���
(408) 777-3228 • FAX (408) 777.3333 • buildinaCr�cuDeriino:ora
CUPERTR40
hrEW Co- -STRUCTIOAT ❑ ADDITi0I3 ElAL`I zp-kna I TI C❑ RI YI5I021' / DEj EpyL�D-1 O IGl?� AL PERMTI
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CITY, STATE,( (} r-�
STREti ADDRESS �i t t` 1 a )I-
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✓J OWI eR. OW �'R-BtTII Dry ❑ OVTcR AG= v't ❑ CO Q RACTOR ❑ COATiLhCTOR ACTT ❑ / RCfCT ❑ ENGn� yR ❑' D =I OPS ❑ iL1KAh?
LICsIEI�TUi„3ER
,c r I LICENSE 1 Y?B I BUS. LIC R
CONTRACiORXA� �n - I
MMW
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Co]✓:PA1vY NF�s
STREET ADDRESS
ARC'STECTrrlionzER 1xAmM
COMPANY I AIdG
STREET ADDRESS
DESCRIPTION OF WORK w ve"/1
X40A 5-A45
S'A
F ,TR4G USF_ PP.OPOSED U5E
EXLTG NE -w FLOOR DEMO
AREA I AREA I REA
RE dODEL AREA I REMODEL AREA
I, E-NkiL I FAX
CITY,STAin,ZIP I PHONE.
I BL's, LIC R
LICENSB IxUa7:'R
I FAX
I PHONE
CITY, sT: ZIP
asTRTY- , I r•STORTFS USE TYPE occ. I SQ -FT. I VALUATION(S)
?OT?S.
.\ AREA
1LE1,4QDEL AR~.A
A-JTAC:i
�DWELLINGU lis: I ISAst•_u�uu"L' u•..- -- ANO
BEING ADDED? ANO ADDITION? _
IS TAE BLDG AN ❑ YES 1=518,
C�Ifiew
� � �
PP-?�PLiCAI70N ❑YLS ff�S PROVIDE COPY OF ❑> O
TOTAL VALU4I�ON
PL A',^.3D.G?u'PLR ❑NO PLAN)\LGAPVP.LL.tTER EICHLERSOTiE?.. 'a-;,.,,�-°_ _.
r I have read this
rized a
By my signature beloNv, I cer+:iry to each of the follov ing: I zZve rept f lee Description of �or �� k nd erij it is zccur� e pI agree o -comply - ith all applicable local
application gad the infer -ration I hay e provided s correct. I
nz re : esentatives -of Cupertino to enter the abov; idem- `d prop-:-. ror inspection purposes.
orelnznces and state lay s r lzting to building : st, ctio. I p' 'V
Date:
SignztureofAppliczat/Agemt: _ { �
SUPPT Eh� NTAL 'tORTM TI011 REQUIRED
CEECK1�'EQUSZM1G LIE:
I] OAR fi1;�C0 ERS �. B JIIDL�GPL3Tr RniS�Fi
?yew SFD oz lvlul i*tinily dzv-ell n�s..4pply fOr d noh-10 1 per nit for
eaistiDgbL'llQlna(s�. De7i011ilOrlpermitlSreCluiredprier 01SSl1anCe0{build ng F�4�fi�P
peiP_".it for ne« bui:1_d ng. -
_mom
Com ercial Bldgs: Provide a completed d Hzardous Nate izls Dlsclesure 6 _� 1 > �� ac
r.
�� 4RGI c -�. - r
form ii any ,i?azaraous l.Qaterial s are beim used as part o� phis project. �` - z
AWY
DrP -
mug�RR s�Rni c
Copy of Plarlr_ing ,approval Letter cr _ I irg with Planing prior to
submittal ofBuildin.cr Permit application.
r
Bidglpp_?011.doc revised 06121/11
CITY OF CUPERTINO
- - - _7T1rl%T1''4 "TXT1rQ1fAN
NOTE: This estimate does not include fees due to other Departments (i.e. .1wand ) - -
in available and are of
District, etc... These ees are based on the reliminar
ormation
QTY/FEE
FEE ITEMS (Fee Resolution 11-0 3 E f 7ff 11113j
FEE
$0.00
Plan Check Fee:
Work Without Permit.
Suppl. PC Fee: Q Reg. 0 OT 0.0
hrs
$0.00 -
PME Plan Check:
$0.00
$5.74
$11290.00
Permit Fee:
Suppl. Insp. Fee -.Q) Reg. 0 OT 0.0
hrs
$0,00'
1BSEISMICR
$0.00
PME Unit Fee:
Bldg Stds Commission Fee:
IBCBSC
$0.00
PME Permit Feer
Sewer District, School
,o nvnt for addn'l info.
MISC ITEMS I
Select a Misc Bldg/Structure
or Element of a Building
rapt;°= C:l tiir t t -h;
Select allon-Residential Q
lIrrtttzi:/3 tit 1 ' £%.
Building or Structure 0
Work Without Permit.
Yes F No
$0.00
•
Select allon-Residential -�
Advanced Planning Fee:
I PLLONGR
$5.74
Building or Structure Q
fr`fdt rj £fli.,17$31£,'.7'iI£3 ion F",v s.'
Select an Administrative Item
Strong StroMotion Fee:
1BSEISMICR
$2.60
Bldg Stds Commission Fee:
IBCBSC
$1.00
TOTAL FEE: $1,299.34
SUB"�C►Tr�LS�:
$11299.34. $0.00
._
Revised: 10/01/2015
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS: Z2
SUBCONTRACTOR
t_M PERMIT # _ 12.(Mb
OWNER'S NAME:
PHONE # St7 2� 2
GENERAL CONTRACTOR:
BUSINESS LICENSE #
ADDRESS: `Z Z
M
V CITY/ZIPCODE: V ) 1 k" ^o I
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:19 II
,
gnature Date
Please check applicable subcontractors and complete the following information:
Owner / Contractor Signature
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner / Contractor Signature
Date
2
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(5cupertino.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 C J Q �R 1 U C �^f� I �.
APN '�
— O '�� (� –%
BP#
OWNER NA E
� `P rJ C � ►2V /40 �1..
OWNER ADDRESS�n
ztitid, ALM
w V( CvQC � i INoI C� g�
DESCRIPTION OF WORK:
j 1
00
Gi-,^VA O• Ar 1S c. IT, ♦ r,p---
We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make ou 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. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
uilder" 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.
2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
'qFe—construction and are not hiring a licensed Contractor to assume this responsibility.
OL -4 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.
A4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
umbers on permits and contracts.
5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
otal 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. I understand if I am considered an "employer" under state and federal law, I must register with the state and
deral 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.
I understand under California Contractors' State License Law, an Owner -Builder who builds single-family
sidential 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.
4(
6-inaln2ial derstand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
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
'L9. 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 www.csib.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
a�ii 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 abide
y 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
ormation l 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:
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 property owner's signature.
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 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, 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