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B-2016-2626CITY OF CUPERTINO BUILDING PERMIT if BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2626 10850 E ESTATES DR CUPERTINO, CA 95014-4534 (369 22 005) OWNER BUILDER OWNER'S NAME: HOFLAND LYNN M AND ROSANNE I OWNER'S PHONE: 408-431-4376 LICENSED CONIRACTOR'S D I RATION License Class Lic. # Contractor OWNER 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. DATE ISSUED: 11/17/2016 PHONE NO: BUILDING PERMIT INFO: BLDG —ELECT —PLUMB MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: 1 ST FLR; REMOVE (E) FAMILY RM (568 SF); REBUILD (N) 1 ST FLR TO CREATE (N) 3 BEDROOMS, 1 (I) BATH (680 S.F. TOTAL); (N) 2ND FLR (N) BEDROOM (N) BATH (620 SF); 2ND FLOOR BALCONY (82 SF); (I) FURNACE; ATTIC DEF # 1 - TRUSS CALCS - ISSUED 2/15/17 I have and will maintain Worker's Compensation Insurance, as provided for by REV #1 - CHANGE 2ND FLOOR WINDOWS FROM 2 TO 1 AND ADD' Section 3700 of the Labor Code, for the performance of the work for which this 1 DOOR - ISSUED 4/25/2017 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 pf 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 04/25/2017 I hereby affirm that I, am exempt from the Contractor's License Law for one of the following two reasons: 1. 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 safe (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed t contractors to construct the project (Sec.7044, Business & Professions Code). Sq. Ft Floor Area: 732 1 Valuation: $275000.00 APN Number: Occupancy Type: 369 22 005 Deferred Submittal (R -3),R-3 (Custom) 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: 11/17/2016 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 foil inspection. Signature of Applicant: Date: 04/25/2017 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 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER ,,,,Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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. 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. �5� Signature Date 04/25/2017 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 the4 Health & Safety Code, Section 25532(a) should I store or handle hazardous -11 material. Additionally, should I use equipment or devices which emit hazardous' air contaminants as defined by the Bay Area Air Quality Management District II will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code ections 25505, 25533, and 25534. Owner or authorized agent: Date: 04/25/2017 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 Professional CCUPERTINO I F-1 NF.W CONSTRTTCTTOM CONSTRUCTION PERMIT APPLIRMSION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 •FAX (408) 777-3333 • building(cl)cupertino.or_q 0 TIT-WrMTT I I A T T, A -T 1 mr V( _ BldgApp_2011.doc revised 06/21/II PROJECT ADDRESS AP�N # �f K �7 �D OWNER NAME •f����s PHONE C1JLC y E-MAIL �g�j STREET ADDRESS j j� i CITY, STATE, ZIP 1 CONTACT NAME R �� #e' aa PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME / V 6� Z� A LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME t pipe LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK �%\�Qvt ��Y L� !4®� �1J� • G"6t�t. L �dEJ/� `4�' � 1(1 i�A.�QivJS �O • / ��s/` �rllPiJi�c� j Ner%iia,, hd,.5 c )u@e1 uer-Lal Oki EXISTING USE P OPOSED USE CONSTR TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA T-F BATHROOM KITCHEN OTHER , REMODELAREA REMODELAREA REMODELAREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH [3 ATTACH #DWELLING UNITS: IS A SECOND UNIT []YES SECONDSTORY E]YES BEING ADDED? []NO ADDITION? ❑ NO " PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF PLANNING ADPL# ❑ NO PLANNING APPROVAL LETTER IS THE BLDG AN ❑ YESRECEIVED EICHLER HOME? El NO BY:" _ _ - - - TOTAL VALUATION: By my signature below; I certify to each of the following: I am the property owner or authorized agent to hct 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 Iocal ordinances and state laws relating to, g construction. I authorize epresent tives of Cupertino to enter the above -identified property for inspection purposes. Signature ofApplicant/Agent: Date:120 , SUPPLEMENTAL FORMATION FtQUIRED PLAN CHECK TYPE: ROUTING SLIP ❑ 6 ER -THE -COUNTER ❑ BUILDING PLAN REVIEW New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure El STANDARD El- PuBLicWoRKs . To—nn if any Hazardous Materials are being used as part of this project. El LARGE ❑ FIRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to El RfAJOR ❑ SANITARY SEWER submittal of Building Permit application. DISTRICT ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06/21/II ;411 .♦ OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 - buildingAcupertino.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 CRESS �� APN �� �� pos OWNER A � � OW ERADDRESS,,_ DESCRIPTION OF WORK: i �T � 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.) - I understand a frequent practice of unlicensed persons is to have the property owner obtain an P"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. ,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. 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. I 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. 0 88. 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. OwneYBuildeYFonn 2010.doc revised 04/14/10 e9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal evenue 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 coactors. 10. 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. ` �11. 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. 0412. 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 verificatioA acceptable to the city may be required to be presented when the permit is issued to verify the pro ert owner's sin to e. 14-1 Property Owner's Signature: Date: Y _______________________________________________-_._.__-_________-_____________________-_____-_ (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.doe revised 04/14110 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2,626 10850 E ESTATES DR CUPERTINO, CA 95014-4534 (369 22 005) OWNER/BUILDER OWNER'S NAME: HOFLAND LYNN M AND ROSANNE I OWNER'S PHONE: 408-507-1914 LICENSED CONMACIDE'S DECLARATION License Class Lic. # Contractor OWN R/B I D R 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: 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. 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 92/15/2017 OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. 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 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. s: 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 02/15/2017 (DATE ISSUED: 11/17/2016 PHONE NO: BUILDING PERMIT INFO: X BLDG —ELECT _ PLUMB X MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: 1 ST FLR; REMOVE (E) FAMILY RM (568 SF); REBUILD (1) 1 ST FLR TO CREATE (N) 3 BEDROOMS, 1 (N) BATH (680 S.F. TOTAL); (N) 2ND FLR (N) BEDROOM, (I) BATH (620 SF); 2ND FLOOR BALCONY (82 SF); (N) FURNACE; ATTIC DEF # 1 - TRUSS CALCS - ISSUED 2/15/17 Sq. Ft Floor Area: 732 1 Valuation: $275000.00 APN Number: Occupancy Type: 369 22 005 Deferred Submittal (R -3),R-3 (Custom) PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Kms. 111le , � 5-- �a/-� 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 ofApplicant: Date: 02/15/2017 TO BE CLASS "A" OR BETTER 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: 02/15/2017 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 understand my plans shall be used as public records. Licensed CUPERTINO ❑ NEW CONSTRUCTION CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISIO 0 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building0cupertinno.orLg '&" —201 �(j { 17 ADDITION M AT.T.,,ATT..,Tr n r)M1TCT TJnIXn Dennnnyl ry—MITIT n Bl dgApp_2011. doc revisecd 0 612 1/11 M DDRESS/i PROLE AQa APN # OV4r AME PONS E-MAIL r STREE ADDRESS CITY, STATS, ZjP .-- Fp,X l !d iI NS� � �� M!—,e/ EMAIL S SEE ADDRESS CI Y, STATE Zt. FAX _ © OWNER D OWNER -BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AOHNT ❑ ARCHITECT ❑ ENUINBER ❑ DEVELOPER ❑ TENANT CON CTOR !� L1G pq f LICE E TYP f� Cf BUS. LIC # COnIPANYNAME E-MAIL FAX ST I, AADDRESS CI ,STAT ,Z L r ARCIRTECTIENGiNE R AMS LICENSENUMBER BUS. LIC$ C MPANYNAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP �� �'I30NE DESCRIPTION OF WORK EXISTINO USE PROPOSED USE CONSTR• TYPE MORES USE TYPE OCC. SQ.FT. VALUATION (�) EXISTG NEWFLOOK DEMO TOTAL AREA AREA AREA NETAREA BATHROOM KITCHEN OTHER - REMODSLAREA REMODELAREA REMODELAREA YDRCIiARBA DECKAREA TOTAL DECKIPORCHAREA GARAGEAREA: ❑DETACH " ❑ ATTACH I +❑YES It DWELLING UNITS: ISASECONDUNIT EJ YES SECONDSTORY BETNGADDED? ❑NO ADDITION? ❑NO PRE -APPLICATION ❑YHS IFYES,PROVIDE COPY OF ISTYWELDGAN [DYES RECEIVE TMALVALUATION: PLANNING APPL# ONO PLANNING APPROVAL LETTER EICHLER HOME? ❑ N Dy my signature below, I certify to each of lite following: I at e roperty owner or tth nized agent torr ropetty owner's behalf. I hav— eadtns—�- - ___ application and the inforimtion I have provided •s correct I e r ad th criptiop of V Or an verify it is accurate. I agree to couiply with all applicable local Ordinances and state laws relating to build' n nstnicti0rr: It rite epr n T .tino-to enter the above-identiJffed property for inspectionPurposes. Signature Applicant/Agent: - of Date:' SUPPLEMENTAL INFORMATION REQ PLAN CHECK TYPE ROUTING SLIP ❑ OWR-THE-COUNTER ❑ BUILDINGPLANREVIEW _ New SFD or Multifattlily dwellings; Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIE-vY _ Commercial Bldgs: Provide a completed IIazardous Materials Disclosure ❑ STANDARD ❑ PU13LIC-WORKS Form if any IIazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _ Copy of Planning Approval Tetter or Meeting with Planning prior to ❑ ❑ submittal of Building Pennit application. MAJOR SANITARY SEWER DISTRICT ❑ ENVTRONMENTALHEALT11 Bl dgApp_2011. doc revisecd 0 612 1/11 M t i� CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 10850 E ESTATES DR CUPERTINO, CA 95014-4534 (369 22 005) CONTRACTOR: OWNER -BUILDER PERMIT NO: E -2016-2626 OWNER'S NAME: HOFLAND LYNN M AND ROSANNE I DATE ISSUEDk 11/17/2016 OWNER'S PHONE: 408-507-1914 PHONE NO: LICMSED CMRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic. # Contractor OWNER -111-111-17117R Date 05/31/2017 X BLDG ELECT _PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing X MECH X RESIDENTIAL_ CONIIVIT RCLAL with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: I hereby affirm under penaltybf perjury:one of the following two declarations: IST FLR; REMOVE (E) FAMILY RM (568 SF); REBUILD (I) IST FLR 1. I have and will maintain a certificate of consent to self -insure for Worker's TO CREATE (N) 3 BEDROOMS, 1 2ND FLR (N) BEDROOM (N) BATH (620 BATH (680 S.F. TOTAL); (l) SF)' 2ND FLOOR BALCONY Compensation, as provided for by Section 3700 of the Labor Code, for the (82 SF); (1) FURNACE; ATTIC 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: 732 Valuation: $275000.00 APPLICANT CERTIFICATION 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 369 22 005 Deferred Subuuttt 1(R -3),R-3 (Custom) 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 City PERMIT EXPIRES IF W9 RK IS NOT STARTED may accrue against said this permit. in consequence the granting all Additionally, the applicant understands and willl comply with all non -point WITHIN 180 DAYS OF PERMIT ISSUANCE OR source regulations per the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 11717/2016 Issued by: Kim Dunbar Date: 11/17/2016 OWNER-BUH.DER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the ' following two reasons:. All roofs shall be inspected prior to any rooi ing material being installed. If a roof is s. 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 inspect on. J /_ sale (Sec.7044, Business & Professions Code) 7C(/ z.) I, as owner of the property, am exclusively contracting with licensed Signature ofApplicant: / contractors to construct the project (Sec.7044, Business & Professions Code). Date: 11/1712016 I hereby affirm under penalty of perjury one of the following three declarations:ALL 1. I have and will maintain a Certificate of Consent to self -insure for Worker's ROOF COVERINGS TO BE CLASS "A" OR BETTER 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. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the hazardous materials req ements 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, Sectimns 25505, 25533, and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the s. 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 shall not employ any person in any manner so as to become subject to the material. Additionally, should I use equipment air contaminants as defined by the Bay Area or devices which emit hazardous Air Quality Management District I Worker's Compensation laws of California. If, after making this certificate of will maintain compliance with the Cupert o 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, 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:'11/17/2016 ty apTRUe-TIONplication correct. that to .comply with all citio and county ordinances and state,laws is 9 comply city Y hereby affirm that is a of lending agency for the performance relating to building construction, and hereby authorize representatives of this city work's for which there is issued p ( ec. 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 Code, Section 9.18. ARCHITECT'S DECLARATION I understand my plans shall be used as public records. 4- Signatu a Date 11/17/2016 Licensed Professional CA 19 CUPERTINO M NPW CONCTRTTC`TTCN.T CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA -95014-3255 (408) 777-3228 • FAX (408) 777-.3333 • buildInnk_c., rtino.orq 13-0�� A -a C/o I JGI Ay iITTT[fYT.i I I A Y �rnn..a mr�wr i 1 1 �j _I - ---'-. ,—,. ..--•-�••••�••••• •• u PROJBCT ADDRESS y , i �. a y,.i. rg .,.: ,i+, a�i;•uiuv:u V1vV11YH4; CL'iC1V1113T AP1I N C9 %. OWNER NAME% lrf { fo.��TCNf'�D PHONE 4t✓� .567. l9 E-MAIL ' STREIITADDRESS 16850 �s E -6r e eS Vr'• CITY,. STA'PF r. P 1 y . �'i not CW FAX r CONTACT NAMII+ yon A ,� , t t - l oy)d PHONEA 6 I _dVe EMAIL Me ST REETADDRESS as aWqe. CITY, STATE, ZIP 4C r �� �AX IkOWNER ❑ OWNER -BUILDER 'la OWNER AGENT ❑ CONTRACTOR ' ❑courRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME�V i• S LICENSENUMEERR LICENSE TYPE US.LICB COMPANYNAME r _ f�il1 �LJ1Pi GI^� E-MAIL jtAx STREET ADDRESS IZp 0+ CITY, STATE, ZIP V" Jasp GAF [1Z PHO E o9"205- lir ARCHITECTIENGINEER NAME NAME L1CFNSE NUMBER j3US. LIC -ft COMPANY NAME � �y E. p f y� iAf 6Y 1 i e4 {1` i eJ Atli !s �T 14•� E-MAIL o � � � } p lry �, V" 4 1 7 AX STREET ADDRESS. 1� IMVS"I'f CITY, STAu a'�. p p y d V pg r -5-5 ppSCRIPTION-OF WORK - 1ePnov.�}a G x'67. - amtii r`,te _r �rl{.c-I tt Iu1se= �G i l itil t '� 0 e -t tl 2- "Won 1 lee 6j141t1&n Wilt i n el l/A � A CJS room's G -,-,� b, -L4 EXISTING USE �PRjOPOyRE USE CONSTR.TYPE �-^ B STORIES USE TYPE OCC. SQ.PT. VALUATION{$) EXISTG p� AR17A +211 NEW FLOOR AREA -754.p- DEMO AREA 5G7, 4 TOTAL ,} NET AREA 30.07-.4' 11 �� 1CX2P1GC - -Z - BATHROOM REMODELAREA NA KITCHEN REMODEL AREA OA OTHER - REMODEL AREA �A A - PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH © ATTACH #DWELLING UNITS; } IS ASECOND UNIT E] YES BEING ADDED? J�{(NO SECOND STORY YES ADDITIONP NO PR I–APPLICATIONYES 1PYES,PRovmF cGPY OF PLANNING APPLB [I to PLANNING APPROVAL LETTER IS THE BLDGAN YES EICIILERIIOMEP RNO REC D BY- TOTAL VALUATION: - Ai By my signature below, l certify to each of the following; I am the property owner or authorized agent to act on the property owner's bi half. 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 compply with all applicable local ordinances and state laws relating build' construction- [ authorize re es ntatives f Cupertino to enter the above -identified properth for ins ection purposes. Signature of ApplicanttAgent: Date: SUPPLEMENTAL INFORMATION RE D PLANCRRCICTYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for � OVER-THE-COUNTER D�IILDING PLAN R1iVIE,SV existing building(s). Demolition permit. is required prior to issuance of building _ permit for new building. ❑ EXPRESS -9-5 'ANNING PLAN REViEW021 n Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PJELIC WORKS form if any Hazardous Materials are being used as pari of taus project ❑ ❑ V Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. LARGE 11 MAJOR FIIRE DEPT El S TARY SEWER DISTRICT ❑ ENVIRONM.PsNTAL HEALTH Bldglppl 2011.doc revisedO6121111 Cahn �f OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 408 777-3228 777-3228 - FAX (408) 777-3333 - buildinaCalcupertino.org Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the bu improvements specified at: of the property SITE ADDRESS APN " OWNER NAME L r, oFX z 1/tf� OWNER ADDRESS f� �� J l ( -P11 DESCRIPTION OF WORK: c e''m o ai We are providing you with an Owner -Builder Acknowledgment and Information Verification Fornj 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 untilyou 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. I understand a frequent practice of unlicensed persons is to have the property ovine obtain an "Owner - Builder" building permit that erroneously implies that the property owner is providing his or er 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 homeoA ner's insurance may not provide coverage for those injuries. I am willfully acting as anOwner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. *2. l 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. , . 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 instead of my own. r��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. 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 ma erials, 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, 1 must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insura ice, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these Jaws may subject me to serious financial risk. a7. 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 /I 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. k:& I understand as an Owner -Builder if I sell the property for which this permit is issue I, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from an latent construction defects in the workmanship or materials. OwnerBuilder, onn 2010.doc revised 04/14/10 pry. I understand I may obtain more information regarding my obligations as an "employ I r" from the Internal Revenue Service, the United States Small Business Administration, the California Departm lnt 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. �60. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that am 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 by all applicable laws and requirements that govern Owner -Builders as well as employers. 2. 1 agree to notify the issuer of this form immediately of any additions, deletions, or c anges to any of the information I have provided on this form. Licensed contractors are regulated by laws design ad to protect the public. If you contract with someone who does not have a license, the Contractors' State License Bo?rd 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 heldliable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible fppr 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 Nhich 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 ow ers 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 s nature. 4 11 Property Owner's Signature:Date: �� f/ ------------------------------------------------------------------------------------------- ------------1----------------------------- (NOTE: The following Authorization Form is required to be completed by the property owner ony when designating an agent of the property owner to apply for a construction permit for the Owner -Builder). TION OF AGENT TO ACT ON BEHA Excluding the Notice to Property Owner, the execution of which I understand is my personal res onsibility, 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 personally filled out the above information and certify its accuracy. Note: A copy of the property owner's driver's license,J form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to erify'the property owner's signature. Property Owner's Signature: Date: 2010. doe revised 04/14/10 CUPERTINO SMOKE / CARBON MONOXIDE ALARMS OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building aQcupertino.org PERMIT CANNOT BE FINALED UNTIL THIS CERTIFICATE HAS BEEN COMPLETED, SIGNED.'AND RETURNED TO THE` BUILDING DIVISION PURPOSE This affidavit is a self -certification for the installation of all required Smoke and Carbon Monoxide Alarms for compliance with 2016 CRC Section R314, R315, 2016 CBC Sections 420.6 and 907.2.11.2 where no interior access for inspections are required. GENERAL INFORMATION Existing single-family and multi -family dwellings shall be provided with Smoke Alarms and Carbon Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds $1000.00, CRC Section R314, R315, and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon Monoxide Alarms be installed in the following locations: AREA SMOKE ALARM CO ALARM Outside of each separate sleeping area in the immediate vicinity of the bedroom(s) — (Smoke alarms shall not be located within 3 feet of bathroom door) X X On every level of a dwelling unit including basements and habitable attics X X Within each sleeping room X Carbon Monoxide alarms are not required in dwellings which do not contain fuel -burning appliances and that do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal. Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated. In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do not result in the removal of wall and ceiling finishes or there is no access by means of attic, basement or crawl space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for alarms which must be connected to the building wiring. As owner of the above -referenced property, I hereby certify that the alarm(s) referenced above hasihave been installed in accordance with the manufacturer's instructions and in compliance with the California Building and California Residential Codes. The alarms specified below have been tested and are operational, as of the date signed below. Address: �STTS%Z� Permit No. Specify Number of Alarms: /!? # Smoke Alarms: I /lr � # Carbon Monoxide Detectors:.= er (or Owner Agent's) Name: 4 Contractor Name: 1 have read and agree to comply with the terms and conditions of this statement Lic.#-471zl ✓t........... Date,6�'vr� •,7•` ��%`7 Smoke and COform.doe revised 01/10./2017 WATER -CONSERVING PLUMBING FIXTURES OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION CUPERTIN4 10300 TORRE AVENUE • CUPER'TINO, CA 95014-3255 /^ (408) 777-3228 •FAX (408) 777-3333 • building(akupertino.org Owner Name !' "�� {�-r�'��/2� Permit No.���� Address le g��2 1. Is your real property a registered historical site? ❑ Y Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. D -No Go to Question 2. 2. Does your real property have a licensed plumber certifying that, due to the age or configuration of the property or its pluip.bing, installation of water -conserving plumbing fixtures is not technically feasible? Yes Civil Code Sections 1101.1 through 1101.8 do not apply. ❑ The licensed plumber's certification has been provided to the Building Division. Skip the rest of the form and sign bottom of form. ❑ No Go to Question 3. Is water se ' e permanently disconnected for your building? ❑ Y Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. o Go to Question 4. 4. Is your real property built and available for use or occupancy on or before January 1, 1994? ❑ No My real property is built and available for use or occupancy after January 1, 1994. Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. Yes My real property is built and available for use or occupancy on or before January 1, 1994. Civil Code Sections 1101.1 through 1101.8 apply. Check one of the three following statements and sign bottom of form.. Ple, e check ONE of the following: tMy property is a single-family residential real property. See Civil Code Section 1101.4. On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures throughout the building. On or before January 1, 2017, all non- compliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless of whether property undergoes alterations or improvements). ❑ My property is a multifamily residential real property. See Civil Code Section 1101.5. On and after January 1, 2014, specified building alterations or improvements shall require non- compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures. On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water - conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). ❑ My property is a commercial real property. See Civil Code Section 1101.5. On and after January 1, 2014, specified building alterations or improvements shall require non- compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures. On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). I, as the owner or owner's agent of this property, certify under penalty of perjury that non-compliant plumbing fixtures will be replaced prior to date specified above with water -conserving plumbing fixtures in accordance with Civil Code Sections 110 1. 1 through 1101.8, the current California Plumbing Code d California Green Building Standards Code, and manufacturer's installation requirements, and that the water-conseivgfplumbing fixtures comply with the requirements as indicated in the table on the following pate. e _ 'In -� Owner or Owner Agent's Signature: Date: ,h Upon completing and signing this Certificate, please returryft Vthe Building Division in order to final your building permit. SB4072015.doc remised 01/05/17 CUPERTINO J 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: 112p PERMIT BUSINESS NAME OWNER'S NAME: PHONE Cabinets & Millwork GENERAL CONTRACT BUSINESS LICENSE # q-0/ 2 -op" ADDRESS:,!�' 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 Please check applicable subcontractors and complete the following information: Date 6/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation ,/�/ ��,�� 7j Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal T S ®� ,��riz-G� 6 - /` 7 Sheet Rock Tile Owner / CdVactor Signature Date 0 ell