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B-2016-1944CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10411 STERLING BLVD CUPERTINO, CA 95014-3831 (375 26 001) OWNER'S NAME: MAHMOOD SHAHBAZ OWNER'S PHONE: 408-205-5847 LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor HOMEOWNER BUILDER Date 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. 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. 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. 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 and state laws relating to building construction, and hereby 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 expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date 8/4/2016 OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons t. I, 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) I as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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 /y► performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by l Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 3. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of 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 be deemed revoked. 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 and state laws relating to building construction, and hereby 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 expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date 8/4/2016 CONTRACTOR: PERMIT NO: B-2016-1944 HOMEOWNER BUILDER DATE ISSUED: 05/13/2016 PHONE NO: PERMIT INFO: X BLDG X ELECT —PLUMB X MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: TO CLEAR CODE ENFORCEMENT CASE: KITCHEN REMODEL (164 SQ FT); REMODEL (4) BATHROOMS (136 SQ FT); (R) FURNACE. REVISION #I: ADD (2) SKYLIGHTS TO KITCHEN; ADD VENTS FOR CORRECT ATTIC VENTILATION; REPLACE (2) SLIDING DOORS AND (3) WINDOWS; ELECTRICAL PANEL UPGRADE (200 AMP). ISSUED 5/19/16. REVISION #2: REPLACE GAS PIPE FROM MAIN GAS METER TO WATER HEATER. ISSUE 8/4/16 Sq. Ft Floor Area: I Valuation: $70000.00 APN Number:. Occupancy Type: 375 26 001 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Abby Ayende Date: 05/13/2016 RE -ROOFS: 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 inspection. Signature of Applicant: Date: 8/4/2016. "An HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code; Chapter 9.12 and the Health & Safety Code, Section 25532(x) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous 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 the Health & Safety Code, Secti 5505, 25533, and 25534. Owner or.authorized agent: Date: 8/4/2016 CONSTRUCTION LENDING AGENCY hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLAR TION understand my plans shall be used as public records. CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO 1 (408) 777-3228 FAX (408) 777-3333 • building(a)cupertino org ElNEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI 9I�/ REVISION /DEFERRED ORIGINAL PERMIT #r `6 PROJECT ADDRESS io4o 2± b(%/d Cts ' � /0i4 APN# 2�'S -,Z(p —001 OWNER NAME S 11 �J pp �IIONFC1" MClyMD6f 4()%-2.5-�`%l E-MAIL�� STREET ADDRESS `�ly C, STATE, ZIP FAX C 9go 14 CONTACT NAME Sj fl���`ItiY16� PHONE p E� arlE-MAII-S:iIGs�'lmpcfi°7� � C.'m .fl � STREET ADDRESS 164 64 Qs CITY, STATE, ZIP FAX �+vd %.b14 OWNER ❑ OwNER-BuiLDER ❑ OwNERAGENT " ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK Wevj C--,ioa EXISTGI. NEw FLOOR DEMO AREA AREA I AREA BATHROOM - KITCHEN REMODEL AREA I REMODEL AREA TOTAL NET AREA OTHER REMODEL AREA lam, env t USE I TYPE I OCC.. I SQ.FT. VALUATION ($) # DWELLING UNITS: IS A SECOND UNIT - ❑ YES SECOND STORY DYES BEING ADDED? ❑NO ADDITION? []NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑YES REC; ED Y PLANNING APPL # E] No PLANNING APPROVAL LETTER EICHLER HOME? E] NO T AL VALUA� TTII-O,yN: By my signature below, I certify to each of.the following: I am the property owner or authorized agent to a t on th6 property owners behalf. I have read this application and the information I have is provided coli t. 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 cons 'on. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: �{ 5 SUPPLEMENTAL INFORMAT QUIRED _ New SFD or Multifamily dwellings: Apply for demolition for PLAN CHECK TYPE Ri3iiTING SLIP ' permit existing building(s). Demolition permit is required prior to issuance of building y ©v�R TH> COIINTE �J gi7LDdNG PL aN xEvrvv permit for new building. EXPRESS % . © TCommercial Bldgs: Provide a completed Hazardous Materials Disclosure PLANNIlaGPiANREVI> 15 �I STANDARD ❑ PIJxLiCtivvxzzs o—nn if any Hazardous Materials are being used as part of this project, s _ Copy of Planning Approval Letter or Meeting with Planning prior to I,ARGEy r-� ! � FiR);s DEPT � submittal of Building Permit application.'SE 'ERalsTuCx' BldgApp_2011.doe revised 06/21111 OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT •-BUILDING DIVISION 10300 T-ORRE AVENUE CUPERTINO, CA 95014-3255 CUPERTIPVGi (408) 777-3228 - FAX (408) 777-3333 • buildincupertino n— 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 W4 It �Pr/ y ` APN J -g IS' L�P_OC) BP# 51-&)-JOWNER NAMEv,�(�_a r ; ®I 7q OWNER ADDRESS ,Ga ��d I C;c O 95 1 DESCRIPTION OF WORK: KePLt_eA 01 i)ia I,t k r,, .n..., � 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.) 911. 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. 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. t2. I understand building permits are not required to be signed by property owners unless they are res onsib/e for the construction and are not hiring a licensed Contractor to assume this responsibility. p . 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. 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. 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 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. 017. 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.. 8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, 1 may be held liable for ny financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OWne7BuiiderFonn 2010.doc revised 04/14/10 . 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 tractors. 10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. V-1 1. I agree 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. 12. I 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 understandthat 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 theoitrr to verifv the aronerty nwnar,� .Qirrnnt„ro (, ay be required to be presented when the permit is issued 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: el 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 11 STEPdVG BLVD CUPERTINO, CA 95014-3831(375 26 001) PHONTE. 408-205-5847 Class Lic. # for MNEEUBUILDM Date hereby affirm that I am licensed under the provisions of Chapter 9 (commencing ith Section 7000) of Division 3 of the Business & Professions Code and that -Y cense is in full force and effect, hereby affirm under penalty gfpeyjury one of the following two declarations* L 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 hisurance, as provideii Section 3700 of the Labor Code, for the performance of the work far which this permit is issued. AP—PLI-CAN-1CENUEECAIM 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 and state laws relating to building construction, and hereby 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 expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date - CT0R-. JR NO: B-2016-1944 ISSUED: 0511312016 10B DFsCRIPTION: To CLEAR CODE ENFORCEMENT CASE: KITCHEN REMODEL (164 SQ FT); REMODEL (4) BATHROOMS (136 SQ FT); (R) FURNACE. vYVrTVM,AMVW�TS FOR FtFloor Area: !vahnition. 570000-00 API Number - 37526001 I hereby Affirm that I am exempt from the Contractor's License Law for one of the rellowing two reasons: 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) s. 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (See.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: 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 tile 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. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. if, after making this certificate of exemption, I b cc om e subject to the worker's Compensation PrOv isions Of the Labor Code, I must forthwith comply with such provisions Or this Permit shall be deemed revoked. AMP). # Fpril—In- # Scan Batch til �-Rf3ciFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, 1 agree to remove all new materials for inspection. AHUCANTLERTMLATM 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 and state laws relating to building construction, and hereby authorize representatives of this Illy 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 may acme against said City in consequence of the granting of this permit. Additionally, the applicant understands and vAll comply with all non -point urce regulations per the Cupertino Municipal Code. Section 9,18. of Applica - }IAZAFLDQUS MATERIALg.j)1.3CL I have read the hazardous materials requirements under Chapter 5.95 Of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 932 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally: should I use equipment or devices which emit hazardous air contaminants as defined by the Day Area Air Quality Management District I will maintain compliance with the Cupertino M icipal Code, Chapter 9.12 and Sectio o "'1 5"2 ;33'J,',,t, n Cupertino the Health & Safety Code, Seedo 5, 2 33, and 25534. owner or authorized agent: Date: A N V CDA&TR �TION.LE UCTIQZ I hereby affirm that there is a construction lending agency for the performance of worWs for which this permit is issued (Sec. 3097, Civ C.) Lender's Name andees Address ARCHLUCJIMCLARAIM understand my plans shall be used as public- records. Date JUrensed CONSTRUCTION PERMIT APPLI TIO COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE . CUPERTINO, CA 95014-3255 (4Q8) 777-3228 • FAX (408) 777-3333 * building _cupertino-orrt " 44/0 PROJECT ADDRESS 104 it APN ig O�vI:ERI�A�IE i irttitlPt excnIE — E.RIAI 1 k STREET hDDRES CITY STATE, ZIP FA )fit! €r�:iL CONTACT NAME �5- E-NIAILL---7-CF. ST El � -ANERAGE;gT 0 COMIAACTOR. 0 CO NTRACTORArENT 0 AR£}dR'ECT i �T�L+.`EEA ElIIEL ELOPER � TENANT OWNER 1 t?L'iN R-BUftoEIC i _ CONTICACTOA N Aia1E LICEI`SENiihSBER LICE -,"Sr TYPE BLS. LIC COMPANYNAME E NWL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCIIITECTXNGI --EFRNAN1C LICE?eSEl4't,` MER BUS. 11C COMPANYXIAME F -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESC'RUITION OF WORKg i t r t i Tt � [� t # -60 VI f 2Y`k .�,r' A a aSTIN" USE _.. CONSTR.T-yPE I #STORMS New S1FD or Multifamily dwellings: Apply for demolition pen -nit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure fonn if any Hazardous Materials are being used as part of this project. _ Copy of Planning Approval letter or Meeting With Planning prior to submittal of Building Permit application, BldgApp_Z01 Ldoe z ci=ised 03116111 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1944 10411 STERLING BLVD CUPERTINO, CA 95014-3831 (375 26 001) HOMEOWNER BUILDER OWNER'S NAME: MAHMOOD SHAHBAZ DATE ISSUED: 05/13/2016 I OWNER'S PHONE: 408-205-5847 I I PHONE NO: I LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor HOMEOWNER BUILDER Date 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. BUILDING PERMIT INFO: X BLDG —ELECT —PLUMB X MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: TO CLEAR CODE ENFORCEMENT CASE: KITCHEN REMODEL (164 I hereby affirm under penalty of perjury one of the following two declarations: SQ FT); REMODEL (4) BATHROOMS (136 SQ FT); (R) FURNACE t. 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. z. 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. 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 and state laws relating to building construction, and hereby 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 expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date 5/13/2016 OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: t. I, 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 /T y? sale (Sec.7044, Business & Professions Code) �. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: t. 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. z. I have and will maintain Worker's Compensation Insurance, as provided for by 40 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 3. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of 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 be deemed revoked. APPLICANT CERTIFICATION 1 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 and state laws relating to building construction, and hereby 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 expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Sq. Ft Floor Area: I Valuation: $60000.00 APN Number: Occupancy Type: 37526 001 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. by: Abby Avende RE -ROOFS: 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 inspection. Signature of Applicant: Date: 5/13/2016 ROOF COVERINGS TO BE CLASS "A" OR HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous 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 the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: Date: 5/13/2016 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Date 5/13/2016 Profession CONSTRUCTION PERMIT APPLICATION is COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - buildingP-cupertino.org CUPERTINO I ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/ Ti ❑ REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS.: f �„ i 1 S" . I v d APN # � 0-(k 00 I OWNER NAME Sbq Mqt mb�d PxoNE4o&-2DS-584 E-MAIL hat -S�nah>rn67`3CIn63aa. STREET ADDRESSl to f i I • b I y d CITY, STATE, ZIP C q' O L)5 ®I FAX CONTACT NAME �`1`Mahmood PHONEgQ8�-,LAS-S�y�` E-MAIL Smcihmaod`i3� o1[UlR•cD STREET ADDRESS 10411 0h11 S i 1vd CIT�O A 9,5014 FAX N o A OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT • ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE BldgApp_2011.doc revised 03116/11 ARCHITECTIENGINEER NAME JQse Feandic P E LICENSE NUMBER BUS. LIC # COMPANY NAME a F c�VSa&, E-MAIL Jfp1omsC ma -Lom FAX STREET ADDRESSSTATE, Uoi blvd �ulk,& ZIP CITY,cAmRbe PHONE /J�n W66flku 1. 1 9 cA 96009 T lT~ p 0 DESCRIPTION OF WORK • �em��iln�� E ( K,�hm� EXISTING USE PROPOSED USE CONSTR. TYPE # STORIES a , , -- OFFICE USE ONLY TYPE ""-DESGRIPTT' Y'. so' FT.. ` "� VALUATI N i EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA �,;,„ �c-' "m, BATHROOM KITCHEN OTHER REMODEL AREA REMODELAREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: ❑ DETACH °- ❑ ATTACH # DWELLING UNITS: 11 A SECOND UNIT ❑ YES SECOND STORY ❑ YES �� s: �. 'rN 71 BEING ADDED? ❑ NO ADDITION? ❑ NO .. VALUATION PRE -APPLICATION ❑ YES IF Y.".. ES, PROVIDE COPY OP PLANNER'S NAME: t vt E TOTAL PLANNING ADPL# ❑ NO PLANNING APPROVAL LETTER - 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 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 building constru ' . I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATIO REQUIRED $PLAN"eHECIZ rYPE RorrlNGsiiP , , _ New SFD or Multifamily dwellings: Apply for demolition permit for ❑ ovER THE COiINTER ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. J u ©= EXPRE5$ ❑ PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure r� Cl/ sxANriaRDu . '` ❑ PIBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑' LARGE 7 ❑ EIRE D>rpT''. _ Copy of Planning Approval Letter or Meeting with Planning prior to © '5e ❑ SEWER submittal of Building Permit application. 1VlAaoR SANITARY DISTRICT .< . ENVIRONMEIVTAI HEALTH BldgApp_2011.doc revised 03116/11 CUPIERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • C i PERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(a)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 ADDRESS 10411 Ste � CU fCVb APN `2'15 2uo0l P# X 4 q [ L K OWNER NAME �f IAi-4 L Q OWNER ADDRESS 10 Q4 it STIEQL.IN GI &V 0 LUQ�jINO Cid 9 DESCRIPTION OF WORK: Home Rconodcl {j� 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.) (r;? 1. I 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. 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. QtZ I 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. 49W4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. G 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 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. 1-0 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. 8. 1 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. OwnerBuilderForm 2010.doc revised 04/14/10 9*79. 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.cslb.ca.gov for more information about licensed contractors. 40710. 0710. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party.legally and financially responsible for proposed construction activity at the site address listed above. �&61 1 agree 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. 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: 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: OS —13�201� 1 --------------------------------------------------------------------------------------------------------------------------------------------- (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: OwneYBuilderForm 2010.doe revised 04/14/10 STATE OF CALIFORNIA ALTERATIONS - HVAC CEC-CFIR-ALT-03-E Revised 06/14 CALIFORNIA ENERGY COMMISSION CERTIFICATE OF COMPLIANCE CFIR-ALT-03-E Alterations - HVAC CZ 1, 3 to 7 and 16 (formerly CF -IR -ALT -HVAC) (Pagel of 1) Site Address: Enforcement Agency: Date Prepared: Permit#: 1 o'�j f STEIFIA bVV 6469 -TM Equipment Type Equipment Efficiency New: Ducting, Plenums, Lineset Conditioned Thermostat Required R -value Floor Area (sq ft) ❑ Packaged System ❑ Evaporator Coil AFUE COP ❑ R-6 (CZ 1,3-7) Ducts Served by system ❑ Setback ❑ Split System�KCondensin g Unit SEER ❑ R-8' (CZ 16) Ducts sq ft (If not already Furnace Lineset EER HSPF ❑ R-6 (all CZs) Plenums ❑ R-5 or R7.5 Lineseta ` present, must be installed) HERS VERIFICATION SUMMARY Installer determines work to be completed and matches to one of the options below. At permit application this form is allowed to be filled out by hand. For final inspection all forms are to be registered (no hand filled forms allowed) and a copy left on site. HVAC Changeout/Repair Required Compliance Documents to be left on site for Final: Can -include new ducting All Equipment, CFIR-ALT-02-E Condenser Unit, Evaporator Coil, CF2R: MECH-01, MECH-20-HERS Air Handler/Furnace CF3R: MECH-20-HERS Installer Requirement: Duct leakage (:5_15% or, L10% to outside, or seal all accessible leaks) Exempted from duct leakage testing if: ❑ 1. Duct system registered with HERS provider as previously sealed, or ❑ 2. There is less than 40 linear feet of duct in unconditioned space, or ❑ 3. Existing duct systems are constructed, insulated or sealed with asbestos (list manufacture date of building } mw�w HVAC System Required Compliance Documents to be left on site for Final: All new equipment and All New Ducts' CFIR-ALT-02-E CF2R-MECH-01, MECH-20-HERS, MECH-22-HERS, MECH-(23 or 24) -HERS CF3R-MECH-20-HERS, MECH-22-HERS, MECH-(23 or 24) -HERS' Installer Requirement: Duct leakage < 6%, Fan Efficacy (.58W/CFM'), Air Flow z 350 CFM/ton (or Standards Table 150.0-C / D alternative) ❑ 3. All New Ducts with Replacement Required Compliance Documents to be left on site for Final: Includes replacing or installing All New CF1R-ALT-02-E Ducts' and one or more of the following: CF2R-MECH-01, MECH-20-HERS, MECH-(23 or 24) -HERS Condenser Unit, Evaporator Coil, Furnace CF3R-MECH-20-HERS, MECH-(23 or 24) -HERS Installer Requirement: Duct leakage < 6%, Air Flow_ 350 CFM/ton (or Standards Table 150.0-C/ D alternative) ❑ Exempted from duct leakage testing I existing duct systems are constructed, insulated or sealed with asbestos. ❑ 4. New Ducting over 40 feet Required Compliance Documents to be left on site for Final: Adding or replacing ducts in unconditioned CFIR-ALT-02-E space but less than All New Ducts' CF2R: MECH-20-HERS CF3R: MECH-20-HERS Installer Required to: Duct leakage (:5_15% or, < 10% to outside, or seal all accessible leaks) ❑ Exempted from duct leakage testing I existing duct systems are constructed, insulated or sealed with asbestos. ' All new ducting R-8 required when more than 40 ft installed and R-6 when less than 40 ft installed. This includes in walls, between floors etc. ' A New Duct system is when the duct system is constructed of at least 75. percent new duct material, and up to 25 percent may consist of reused parts from the dwelling unit's existing duct system (e.g., registers, grilles, boots, air handler, plenums, duct material. 3 R-5 (1" thick insulation) for linesets 1" and less. R-7.5 (1.5" thick insulation) for linesets over 1 inch. Most mfg will require Suction line Diameter with insulation as the following 1.5-2T-2%", 2.5-3T-2yV, 3.5 to 4T-2%0, 5T-4%" Contractor (Documentation Author's /Responsible Designer's Declaration Statement) I certify the following under penalty of perjury, under the laws of the State of California: 1. The information provided on this Certificate of Compliance is true and correct. 2. 1 am eligible under Division 3.ofthe California Business and Professions Code to accept responsibility for the information on this document. 3. That the energy features and performance specifications for the design identified on this Certificate of Compliance conform to the requirements of Title 24, Parts 1 and 6 of the California Code of Regulations (CCR). 4. That the energy features and performance specifications, materials, components, and manufactured devices for the building design or system design identified on this Certificate of Compliance conform to the requirements of Title 24, Part 1 and Part 6 of the CCR. S. The building design features or system design features identified on this Certificate of Compliance are consistent with the information provided on other applicable compliance documents, worksheets, calculations, plans and specifications submitted to the enforcement agency for approval with this building permit application. Responsible Designer Name: Responsible Designer Signature: Date Signed: License: Iu Company: Address: City/State/Zip: Phone: For assistance or questions regarding the Energy Standards, contact the Energy Hotline at: 1-800-772-3300