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13050065-CANCELLEDa CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10171 VICKSBURG DR CONTRACTOR: AHMED SALLAM PERMIT NO: 13050065 OWNER'S NAME: AHMED SALLAM 10171 VICKSBURG DR DATE ISSUED: 10/28/2013 OWNER'S PHONE: 4086446338 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL❑ License Class Lic. # ADD 1141 SQ FT TO INCLUDE KITCHEN, FAMILY ROOM, (2) BATHROOMS, BEDROOM, ST ENLARGE Contractor Date LIVING I hereby affirm that I am licensed under the provisions of Chapter 9 ROOM, REM E XISTI G O CLUD 1,545 SQ FT, (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: 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 Sq. Ft Flior A Valuation: $230000 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for b y �ea: / Z Section 3700 of the Labor Code, for the performance of the work for which this permit is issued: APN Nu ber: 6907006.0 Occupancy Type: 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 re ng PE ��EXPIRES IF WORK ISNOT ARTED to building construction, and hereby authorize representatives of this city to en - WI 1 DAYS OF PERMIT is CE OR upon the above mentioned property for inspection purposes. (We) agree to sav 8 AYS M LAST CALLED SPECTION. indemnify and keep harmless the City of Cupertino against liabilities judgments costs, and expenses which may accrue against said City in conseque e of the O �� granting of this permit. Additionally, the applicant understands and It comply rI sued by: Date: with all non -point source regulations per the Cupertino Municip ►od ,Section 9.18. _. Signature Da � RE OOI All roofs shall be inspected prior to an. roofing material being installed. If a roof is ' installed without first obtaining an ' sspection, I agree to remove all new materials for inspection. ❑ OWNER -BUILDER D CLARATIO J I hereby affirm that I am exempt from a Contractor s I en a Law for one of Signature of Applicant: Date: the following two reasons: ALL ROO ' COVERINGS TO BE CLASS "A" OR BETTER I, as owner of the property, or my employee with wages th sole compensation, will do the work, and the structure is not inten , ed or off ed for sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contra ith licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have r ad the hazardous materials requirements under Chapter 6.95 of the Califo nia Health & Safety Code, Sections 25505, 25533, and 25534. 1 will I hereby affirm under penalty of perjury one of the following three ma' tain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: alth & Safety Code, Section 25532(a) should I store or handle hazardous I have and wilt maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for b the Health &Safety Code, Sections 25505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which is permit is issued. / Owner...or-authorized agent: Date: t ® 23 I'.1��, F:t..t-fil� u 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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; ARCHITECT'S DECLARATION - costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature lyDate— CONSTRUCTION PERMIT APPLICATION U0 COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION JU 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 „( �V.� A B CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • buildingc&-cupertino.org ❑ NEW CONSTRUCTION JJ;;iADDITION n AI,TF,RATTON / TT n RFVTCTnN / nFFFRRFri ()RT(-TNAT PRPIIAT`T PROJECT ADDRESSy Q g ¢5 5 m p4 f �.Vl�`JCi�lC APN#/ 9 0 N -"" /ai-Ar\4Ep S I—LA1,11 STREET ADDRES�(D ! \ / CITY, STATE, ZIP _. i FAX A - IGONTACT-NAME-\ �_A A PHO _ ,_ F.:, .- � � _ 'YAC -COM STREET ADDRESS CITY, STATE, ZIPFJ A 1 OWNER ElOWNER-BUILDER❑ OWNER AGENT 11 CONTRACTOR El CONTRACTOR AGENT E3AR1ik T ❑ V/EvOPER RJ ❑ TENANT CONTRACTOR N 1�s� LICENSE NUMBER LICENST E COMPANY NAME _J E-MAIL `I / Y FAX STREET ADDRESS CITY, STATE, ZIP ' PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER W / 1 V BUS. LIC # COMPANY NAME a I -MAIL _ f F - STREETADDRESS 11TY,STAT ZIP - PHONE a DESCRIPTION OF WORK � 1141 �-_ - 9 1 4 1 i P91C 6 l�ylsG e v r EXISTING USE - `� PROPOSED USE _ •ONSTR TYPE - # STORIES USE TYPE OCC. SQ.FT. VALUATION ($) t J EXIISA T�G NEW FL ( Olt- AREA 11 DEMO AREA TOTAL NET AREA - y, BATHROOM KITCHEN OTHER - - OF REMODEL AREA REMODEL AREA REMODEL AREA PP�Ei t1R�j.A - �`• / DECK AREA TOTAL DECK/PORCH AREA GARtJtG�E A$EA: �C_H (� � CH - [f l01 (/ # DWELLING UNITS: IS A SECOND UNIT ❑ YES BEINGADDED? []NO SECOND STORY • ADDITION? [JNO 41 - 1 -PRE-APPLICATION ❑ YES IF YES, PROVIDE COPY OF PLANNING APPL# ❑NO SPI.. LETTER IS THE BLD. ❑ YES EICHLER HOME? ❑NO RECEIV $ `TOTAL VALUATION.-,, 6CWPROVAL a By, my signature below, I certify to each of the following: I am the property owner or authorized age 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 b '1 ' onstruction I thonz epresentatives of Cupertino to enter the above -identified property for inspection purposes. �SigliatiiieofApplicant/AgenY "'- +�' ._ f_Date / "'�1-,-��+�'�•; SUPPLEMENTAL INFORMATION REQUIRED PLAN CI3ECK TYPE ROUTING SLIP ❑ OVER-THE-COUNTER BUILDING PLAN _ 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 - LANNING:PLAN REVIEW . _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STANDARD PUBLIC wORics form if any Hazardous Materials are being used as part of this project. El LARGE PYRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to MAJOR SANITARY SEWER DISTRICT submittal of Building Permit application. ENVIRONMENTAL HEALTH BIdgApp_2011.doc revised 06121111 CITY OF CUPERTINO Fv�Ams rar, r, rcmrnR A rVn1D RTTTT .T1TN(i' 71TV1ginN OCCUPANCY TYPE: R-3 (custom) TYPE OF CONSTR. FLR AREA s.f. ADDRESS: 10171 vicksburg dr DATE: 05/08/2013 REVIEWED BY: Mendez ia ,e BP#: . 0300 � *VALUATION: $230,000 APN: 36PLNCK — - I,Jech. fnsp. f'ee: 686.6 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Duplex 2nd Unit? , Yes •' No�PEN OTC? Yes No 1 R3SFDADDUSE: FEE ITEMS (Fee Resolution 11-153 E ff 711112 I Plan Check Fee: WORK RE -BUILD- ADD 1141 SQ FT TO INCLUDE KITCHEN FAMILY ROOM 2 BATHROOMS SCOPE BEDROOM, STUDY AND ENLARGE LIVING ROOM, REMODEL EXISTING TO INCLUDE 1,545 SQ p OCCUPANCY TYPE: R-3 (custom) TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID Other 1 II-B,111-B,IV,V-B 1,141$2;506 36PLNCK — - I,Jech. fnsp. f'ee: 686.6 IR3INSP District, etc). Theseees are based :n the prelimina FEE ITEMS (Fee Resolution 11-153 E ff 711112 I Plan Check Fee: Suppl. PC Fee: Q Reg. ® OT 0.0 hrs PME Plan Check: Permit Fee: Suppl. Insp. Fee: Reg. OT 0,0 his PME Unit Fee: TOTALS: 1,141 $2,506 6' 4 $1,686.4Epi L I 'l CF k ( \ Ph...b. Plan Check, w u ' Elec..Plan (;heck Plumt Cmait, cze: EW. Perini 'e: Iras�r. \ Cfiherllec.Inap. LFee: Elec. Inap. Ca Pkartifient i.e. Planning, Public Works, Fire Sanitary Sewer District, School Fo maln available and are onl an estimatt Contact the Dept for addn'l info. t QTY/FEE MISC ITEMS $2,506.36T$4, 45 s.£ w�gRemodel, Other $0.00 545.00 nEES2 $1,686.4642 — Work Without Permit? Yes No $0.00 Advanced Planning Fee: IPLLONGR $148.33 Travel Documentation Tees: Strong Motion Fee IBSEISMICR $23.00 Bld�mmission Fee: IBCBSC $10.00 �T $4,374.15 $4,545.00 c. Select a Non -Residential —� Building or Structure 0 Select an Administrative Item Revised: 04/29/2013 can ce lech..l'errarat Fee: Other 1 Other :!3ec>h. lisp. I,Jech. fnsp. f'ee: P/urnlr. NOTE: This estimate does not inch a fees due to ot) District, etc). Theseees are based :n the prelimina FEE ITEMS (Fee Resolution 11-153 E ff 711112 Plan Check Fee: Suppl. PC Fee: Q Reg. ® OT 0.0 hrs PME Plan Check: Permit Fee: Suppl. Insp. Fee: Reg. OT 0,0 his PME Unit Fee: PME Permit Fee: Construction Tit::; 17L 'Idtntni tt ative .F'ee: Plumt Cmait, cze: EW. Perini 'e: Iras�r. \ Cfiherllec.Inap. LFee: Elec. Inap. Ca Pkartifient i.e. Planning, Public Works, Fire Sanitary Sewer District, School Fo maln available and are onl an estimatt Contact the Dept for addn'l info. t QTY/FEE MISC ITEMS $2,506.36T$4, 45 s.£ w�gRemodel, Other $0.00 545.00 nEES2 $1,686.4642 — Work Without Permit? Yes No $0.00 Advanced Planning Fee: IPLLONGR $148.33 Travel Documentation Tees: Strong Motion Fee IBSEISMICR $23.00 Bld�mmission Fee: IBCBSC $10.00 �T $4,374.15 $4,545.00 c. Select a Non -Residential —� Building or Structure 0 Select an Administrative Item Revised: 04/29/2013 EE=W\T1• DISCLOSURE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(LDcupertino.org CUPERTINO Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS 10M V' C K5os� 4 p & h o • APN j, �� j tG r 6;9 BP# OWNER NAME A A A L� / e �p H LL,^i OWNER ADDRESS /017tVIcrs 14 ��k i DESCRIPTION OF WORK: IUAV We are providing you with an Owner -Builder Acknowledgment and Informat n I tion Form to make you aware of your responsibilities and possible risk you may incur by having this permit is-ued i y. r ame as the Owner -Builder. We will not issue a. building permit until you have read, initialed yourrider to i of each provision, signed, and returned this form to us at our official address indicated. An age t •f the e cannot execute this . otice unless you, the property owner, obtain the prior approval of the permitting au I o�ity. IONS: Please read and initial each statement Belo to nify ynderstand or verif=y this information.) 1. 1 understand a frequent ractio of unlicensed -sons I to ave the prope owner obtain an "Owner - ler" building permit that er oneous implies that t e � ro • e F owner is prove$• ing his or her own labor and material onally. 1, as an Owner -Bu der, ma be he d liable - n • subject to serious, �financial risk for any injuries sustained by nlicensed person and his or her employe - while or in g on my propeTyy. My homeowner's insurance may not ide coverage for those in ries. I am willfu acting as n Owner-Bu'Aer and am aware of the limits of my -ance coverage for injuries to workers on prop . Y. 2. 1 understand building ermits are not =q i • to be signed by property owners unless they are responsible for :onstruction and are not h ing a license o tractor to axs -enme this responsibility. 3. 1 understand as an "O er-Builder" I -the respo s' ible party of record' on the permit. I understand that I may Y :ct myself from potential fin - ncial risk b hiring a lensed Contractor and having the permit filed in his or her instead of my own. 4. l understand Contractors a e - ired by law to be licensed and bonded in California and to list their license )ers on permits and contracts. 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the value of my construction is at least five hundred dollars ($500), including labor and materials, I may be idered 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 feral government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to employment compensation for each "employee." I also understand my failure to abide by these laws may subject to serious financial risk. _7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family dentias structures cannot legally build them with the intent to offer them for sale, unless all work is performed by nsed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work erformed 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 financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction cts in the workmanship or materials. Owne7BuilderFon72 2010.doc revised 04/14110 M-9- I 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, arndthe 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.cs[b.ca.gov for more information about licensed conttractors. " 110. 1 am aware of and consent to an Owner -Builder building permit app led i• r i y a and understand that I am the paty legally and financially responsible for proposed construction ac i vitt' = t t e i e a dress listed above. 11. I agree that, as the party legally and financially responsible for is p opo- ed uction activity, I will abide by al,l applicable Laws and requirements that govern Owner -Builders a w-il a - e plo ers �12. I agree to notify the issuer of this form immediately of any adds -'o s, d'e. ons or changes to any of the information I have provided on this form. Licensed contractors are regul -t by aws 'esigned to protect the public. If you contract with someone who does not have a license, the Co ctor tat- License Board may be unable to assist you with any financial loss you may sustain as a resulffof a c• mplai our only remedy against unlicensed Contractors may be in civil court. It is also important for youlo un • e�stan that if an unlicensed Contractor or employee of that individual or firm is injured_while working otrha your •Pope y, you may be held liable :or damages. If you obtain a permit as Owner -Builder and wish to hire 'ntr ctors, y• ill be responsible for veiling whether or not those Contractors are properly licensed and the stags the r work= rs' compensation insuran -9 coverage. CONSTRUCTION LENDING AG (DIRECTIONS: Please complete(7e—fo\l.ing con uctics I ding agency information.) I hereby affirm that there is a cotion lendin , ag - c for the performance of the ork for which this permit is issued (Sec 3097 Civ.) Lender Name: e der Address: Before a building permit can be issued, this f I rm must be completed�= nd signed by the property owner and returned to the agency responsele for issulr g the permit. Note: A a0py of the property owner's driver's license, form notarization, or other verificati • acceptable to the city may be re • uired to be presented when the permit is issued to verifythe property owner's si nat Property Owner's Signature: i Date: /.V LAO A ------------------------------------------------------------------------------------------------------------------------------------------ (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: t _ Date: i Owne7BuilderForm 2010.doc revised 04114110