B-2016-2462CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-2462
10345 MORETTI DR CUPERTINO, CA 95014-3638 (375 14 009)
HOMEOWNER
BUILDER
OWNER'S NAME: SU WALLACE AND AMY
DATE ISSUED: 08/04/2016
OWNER'S PHONE: 408-410-7535
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lic. #
Contractor HOMEOWNER BUILDER Date
X BLDG X ELECT _PLUMB
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:
(N) TEMPORARY POWER POLE (100 AMP); POLE
I hereby affirm under penalty of perjury one of the following two 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
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
Sq. Ft Floor Area:
Valuation: $470.00
permit is issued.
APPLICANT CERTIFICATION
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 authorize
375
375 14 009
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.
WITHIN180DAYS 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 8/4/2016
Issued by: Abby Avende
Date: 08/04/2016
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
1. 1, 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
will do the work, and the structure is not intended or offered for
inspection,
/,,compensation,
sale (See.7044, Business & Professions Code)
contracting with licensed
Signature of Applicant:
I, as owner of the property, am exclusively
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 8/4/2016
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
performance of the work for which this permit is issued.
HAZARDOUS MATERIALS DISCLOSURE
I 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
t
maintaincompliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
a. 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
Worker's Compensation laws of California. If, after making this certificate of
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sections 25505, 25533 did 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
owner or authorized agent:
APPLICANT CERTIFICATION
Date: 8/4/2016
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
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,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
ARCHITECT'S DECLARATION
and will comply with all non -point source regulations per the Cupertino Municipal
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
/.Signaur�p ate /
Professional
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.org
,2qMISC
PROJECT ADDRESS f o 3 q r�/�,r k 7 ),- APN # 37Y
I Y---0 0 Y
OWNER NAME / v d �s� 9J / PHONE /i Q j� `% / E-MAIL Volt.. � C �%% Ll �i �
fwd 11 of L �� W v�9 0L. -P
STREET ADDRESS #g ^2 �g /, S L � a" CITY, STATE, ZIP ? , ,� � % 1 j /+� II Ir) y FAX l J09 �I 1 � � Yi'
CONTACT NAME fi j f4 PHONE ,�I 9! C EE-MAfL Q e O
STREET ADDRESS CITY, STATE, ZIP FAX
WNER ❑ OWNER-BUHDER ❑ 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
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF SFD or Duplex ❑ Multi -Family
STRUCTURE: E]Commercial
PROJECT IN WILDLAND
URBAN INTERFACE AREA
❑ Yes El NO
PROJECT IN
FLOOD ZONE El Yes
El NO .
DESCRIPTION OF WORK
ym.e4w
yde,�ij e-
P6V_
TOTAL VALUATION:
REC`Eii�EDBY.
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 construction. I authorize representatives of Cupertino to enter the above -identified properly fo spection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED QFFIt E us>} ONLY
MEPMiscApp_201 1. doc revised 03116111
A
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OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.ora
CUPERTIN
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 oVrZ� >
APN e % —L 0 �
BP# 'Q)-Z0t(o " 2,q(p 2
OWNER NAME /
OWNER ADDRESS
DESCRIPTION OF WORK:
A 5,fti/ I Z&2!22
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.
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 -
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: I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on, permits and contracts.
I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
alue 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
fed ral 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,
resi&ential 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. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
any pinancial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
OwnerBuildefForm 2010.doc revised 04/14/10
RUg. I understand I may obtain more information regarding my obligations as an "employer" from the Internal
4enue 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.
aW10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
rh the party legally and financially responsible for proposed construction activity at the site address listed above.
_ /W^ 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
b 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 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 owners signature. — - -
Property Owner's Signature: r Date:
--------------------- ----------------
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the propertyowner 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 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
COMMUNITY DEVELOPMENT DEPARTMENT . BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL
&a10300 TORRE AVENUE • CUPERTINO, CA 95014-3255UPER„�„
(408) 777-3228 • FAX (408) 777-3333 • buildin cu ertino.or
PURPOSE
For residential single family or duplex construction, there are cases where gas and electric utilities are ,
requested to be released prior to the issuance of the certificate of occupancy. Upon approval from the
building inspector, the City of Cupertino is allowing both utilities to be released prior to the final sign -off of
the building.
INSTRUCTIONS
1. Download this form at: http:/./xAw�Ni.,cupertino.org/index.aspx?pa�e=297.
2. Complete the form and obtain signatures from both the owner of the property and the primary contractor.
3. Fax, E -Mail, Mail or hand deliver the original signed form to:
City of Cupertino
Building Division
Attn: Utility Release Request -564 408-777-3228 office
10300 Torre Ave. 408-777-3333 fax
Cupertino, CA 95014 building(cu ertino.or
4. Schedule a Gas Meter Release inspection (#403) and/or Electric Meter Release inspection (#404). Please
note, a Gas Test inspection (#506) is required prior to or at the same time of the Gas Meter Release
inspection.
BUILDING INFORMATION (Please complete the following information):
APN
BLpG PERMIT #: t
DATE:
SITE"Y.
ADDRESS: 0�
C 44? - A
l tb 7
OWNER'S NAME:
�UJ
04 ll -�
FAX #:
MAILING ADDRESSif different from site address) �� Z : r�
ADDRESS(if h
z ,
l' j20s'e- ciY
CONTRACTOR:
PHONE #:
FAX #:
CONTACT:
PHONE #:
FAX #:
I request the City to release my utilities prior to obtaining a final inspection approval for the building. I fully understand the occupants of
the building cannot move into the residence until they receive all of the required final sign -offs and the City has issued a certificate of
occunancv for the building.
nl AinPr- ..... Print: V D1 �Cy� Chi 'S/ . ........................ Date ......... I
Contractor: ......... .......................................... Print:......................................................................... uate:.............................
UtilityReleaseForm 2011.docrevised 08109111
Building Department -
City Of Cupertino
.10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ -SUBCONTRACTOR LIST
JOB ADDRESS: 10(jye6q 0Y=
PERMIT # t- t(Q- 2q
OWNER' S NAIVIE:. Jtt
_
PHONE #
GENERAL CONTRACTOR: CVnj+MC `W -t _ ?
BUSINESS LICENSE #
ADDRESS: `4/v�.'CITY/ZIPCODE:
*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:
Signature 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
Pav,ing
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock,
Tile
Owner /'Contractor Signature
_ _ Date