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B-2016-3269CITY OF CUPERTINO BUILDING PERMIT it BUILDING ADDRESS: CONTRACTOR: , PERMIT NO: B-2016-3269 1160 SCOTLAND DR CUPERTINO, CA 95014-5026 (362 28 007) I, MONARCH BUILD RS INC FOSTER CITY, CA 94494 i OWNER'S NAME: HARDEE PETER G AND FRANCES J TRUSTEE Ij DATE ISSUED: 12/14/2016 OWNER'S PHONE: 408-881-1480 i PRONE NO: (877) 730-0190 LICENSED CONTRACTOR'S DECLARATION BUILDING PEM IIT INFO: License Class a Lie. #994013 Contractor MONARCH BUILDERS INC Date 06/30/2018 X BLDG _ ELE „T _PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing _ MECH X RES ENTLAL COMMERCIAL with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full farce and effect. JOB DESCRIPTION: 2ND FLR; CONVHRT (E) BEDROOM TO (N) FULL BATH & WALK-IN I hereby affirm under penalty of perjury one of the following two declarations: CLOSE i 1. I have and will maintain a certificate of consent to self -insure for Worker's REV # 1 - ADD 11100 AMP SUB PANEL TO GARAGE; RE -WIRE SFD Compensation, as provided for by Section 3700 of the Labor Code, for the -ISSUED 1/25/1' REV#1 NOT VALID performance of the work for which this permit is issued. REV #2 - UPG (E) PANEL TO 200 AMP BACK OF HOUSE - 2. I have and will maintain Worker's Compensation Insurance, as provided for by ISSUED 2/2017 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $40000.00 APPLICANT CERTIFICATION i I 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 362 28 007 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. WITHIN 186' DAYS 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 02/07/2017 Issued by: NIEL15I ANAMES Date: 12/14/2016 OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the ( RE -ROOFS: following two reasons: All roofs shall be iwI,�ected prior to any roofing material being installed. If a roof is 1. I, as owner of the property, or my employees with wages as their sole installed without first 'Ipbtaining an inspection, I agree to remove all new materials for compensation, will do the work, and the structure is not intended or offered for ; inspection. sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed Signature ofApplic contractors to construct the project (Sec.7044, Business & Professions Code). Date: 02/07/2017 i SII I hereby affirm under penalty of perjury one of the following three declarations: ALL ROO _ f COVERINGS TO BE CLASS "A" OR BETTER i. 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. H ARDQUS MATERIALS DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the hardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code, for the performance of the work for which this California Healt ''& Safety Code, Sections 25505, 25533, and 25534. I will permit is issued. maintain complian ' „' with the Cupertino Municipal Code, Chapter 9.12 and the 3. I certify that in the performance of the work for which this permit is issued, I Health & Safety material. Addition de, Section 25532(a) should I store or handle hazardous ly, 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 comp 4 nce with the Cupertino Municipal Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Healt Safety Cade, Sections 25505, 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authoriz d agent: APPLICANT CERTIFICATION Date: 02/07/2017 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 I hereby affirm that j here is a construction lending agency for the performance relating to building construction, and hereby authorize representatives of this city of work's for which ; his permit is issued (Sec. 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, Lender's Address'I 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 ARCHITECT'S DECLARATION Code, Section 9.18. 1 understand my plans shall be used as public records. Licensed Signature Date 02/07/2017 professional CONSTRUCTION PERMIT APPLICAI COMMUNITY DEVELOPMENT DEPARTMENT • BUILDIR 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TT A RRVTRTON / )N ION # I �TI (1RT(:TNAT PRRTRTT ff PROJECT ADDRESS ( ( APN # - -- - - --- OWNERmQ r�.L.tav PHO ��Y" P.4 STREETADDRESS-°'7,/ y- ' <•-" p CITY, STATE, ZIP it FAX CONTACT NAME PHONEp^ E-MAH. STREET ADDRESS GTS CITY, STATE, ZIP Q ❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT '11i CONTRACTOR ❑ CONTRACTOR AGENT ❑ I;CHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMl� LICE NSE TYPE BUS. LIC # COMPANYNAMEdy i b � E-MAIL FAX ✓ v�i'd+4t Y' � cam• 9 � � l� � it STREET ADDRESS�I Sj CITY, STATE, ZIP [ Y r PHONE 0 ARCHITECT/ENGINEER NAME LICENSE NUMBER " BUS. LIC # COMPANYNAME E-MAIL j �;I' FAX STREET ADDRESS CITY, STATE, ZIP i PHONE DESCRIPTION OF WORK AofelI A�— •. I' EXISTING USE PROPOSED USE CONSTR. T77 #STORIES USE 'ITYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: El DETACH ❑ ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? ❑ NO ADDITION? ❑ NO' PRE -APPLICATION []YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES R D Y: v TOTAL VALUATION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO By my signature below, I certify to each of the following: I am the property owner or authorized agent to act o the property owner's behalf. I have read this application and the information I have provided is correct. I have read the escription of Work and verify it is curate. I agree to comply with all applicable local ordinances and state law relating to building construction. I authorize r r entatives of Cupertino to enter the aborv�e 'dent. d\prro�perty for inspection purposes. Signature of Applicant/ Date y 1 i' SUP EMENTAL INFORMATION REQUIRED PLAN CHE: "{ TYPE ROUTING SLIP ❑ OVER-TILE-0'UNTER ❑ 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 ElSTANDARD ' i, ElPUBLIC WORKS rm if any Hazardous Materials are being used as part of this project. fo— El LARGE El FIRE WEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ! ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH i BldgApp 2011.doc revised 06/21/11 u I! CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-3269 1160 SCOTLAND DR CUPERTINO, CA 95014-5026 (362 28 007) MONARCH BUILDERS INC FOSTER CITY, CA 94494 OWNER'S NAME: HARDEE PETER G AND FRANCES J TRUSTEE OWNER'S PHONE: 415-260-5761 LICENSED CONTRACTOR'S DECLARATION License Class ]a Lic. #994013 Contractor MONARCH BUILDERS INC Date 06/30/2018 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: m. 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 CERTIFI ATION 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 ISSUED: 12/14/2016 PHONE NO: (877) 730-0190 BUILDING PERMIT INFO: BLDG —ELECT _ PLUMB MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: 2ND FLR; CONVERT (E) BEDROOM TO N FULL BATH & WALK-IN CLOSE 010h/Z"(57 REV # 1 - Y�4i✓E 100 AMP PANEL; RE -WIRE SFD - ISSUED 1/25/17 'jb Z.oO AMP Sq. Ft Floor Area: I Valuation: $40000.00 APN Number: Occupancy Type: 362 28 007 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Signature % Date 01/25/2017 Issued by: U Date:44-074 OWNER-BUII DER DECL RATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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: m. 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. a. 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 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 01/25/2017 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: 01/25/2017 COVERINGS 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: 01/25/2017 9 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 CONSTRUCTION PERMIT ,APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIV: O 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(@-cupertino.org �)4 ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI X REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS � { r O s � O kmk C`Ivlr�~JA OWNER NAME PHO JS 6<) _!& _4CE-MAH. STREET ADDRESS It�O CITY, STATE, ZIP FAX a c CONTACT NAME�i+� kw PHONE s E-MAIL A � L STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OwNER-BUILDER ❑ OwNERAGINT 1b. CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME A LICENSE NUMBER A ® 1 1 3 LICENSE TYPE BUS. LIC # COMPANY NAME t \ 1 ♦ 1 C E-MAIL MO ♦ C4 A'% FAX STREET ADDRESS�+ �� CITY, STATE, ZIP C PHONE O rOMa ARCHITECT/ENGHNEER NAME LICENSE NUMBER BUS. LIC # COMPANYNAME E-MAII - FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK /- R18t74� Q &^p <-YY`4e_ EXISTING USE PROPOSED USE CONSTR TYPE # STORIES USE TYPE OCC. SQYT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA 1 REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH E]ATTACH #DWELLING UNITS: ISA SECOND UNIT ❑YES SECONDSTORY ❑YES BEING ADDED? ❑ NO ADDITION? []NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES RECEIVED BY: TOTAL VALUATION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? []-NO 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 infonnation 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 au representatives of Cupertino to enter the abov -identified property for inspection purposes. Signature of Applicant/Agent: _ Date: I�'a , Or SUPPLEMENTAL •1N ORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP ❑ ovER-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 ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑- SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doe revised 06/21111 LETTER OF AUTHORIZATION TO TRANSFER PERMIT DATE: 1/25/17 To Whom It May Concern: 1, Dianna Kuo-, as the owner of the property listed as 1160 Scotland Dr, Cupertino, CA 95014 do _ authorize transfer of the building permit B-2016-3269 to the contractor Adam Yosef of Monarch Builders Inc (License #994013). - Dianna Kuo 1/25/17, Owner Date (408) 881-4802 Telephone Number diannaku,oa.cimail.com E -Mail Address CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR:. PERMIT NO: B-2016-3269 1160 SCOTLAND DR CUPERTINO, CA 95014-5026 (362 28 007) OWNER/BUILDER OWNER'S NAME: HARDEE PETER G AND FRANCES I TRUSTEE DATE ISSUED: 12/14/2016 OWNER'S PHONE: 408-881-4802 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic. # Contractor OWNER/BUILDER Date X BLDG _ ELE T _ PLUMB I hereby affirm that I am licensed under the provisions of Chapter 4 (commencing MECH X RESENTIAL a ;CPMIIIERCIAL with Section 7000) of Division 3 of the Business_ & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: 2ND FLR; CONVERT (E) BEDROOM TO (N) FULL BATH & WALK-IN I hereby affirm under penalty of perjury one of the following two declarations: CLOSET 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. Sq. Ft Floor Area: Valuation: $40000.00 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 "N Number: Occupancy Type: and state laws relating to building construction, and hereby authorize 362 28 007 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 E3T1RES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 1 0 DAYS 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 -1.211.41201.6 Issued by: MELISSA NAIVIF- Date: 12/14/2016 OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE -ROOFS: following two reasons: All roofs shall be, inspected prior to any roofing material being installed. If a roof is 1. 1, as owner of the property, or my employees with wages as their sole installed without irst 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 inspection. sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed Signature of Applican : contractors to construct the project (Sec:7044, Business & Professions Code). Date: 12/14/2016 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROO T COVERINGS TO BE CLASS "A" OR BETTER 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. ffIZARDOUS MATERIALS DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the ha rardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code; for the performance of the work for which this California Healt & Safety Code, Sections 25505, 25533, and 25534. I will permit is issued. maintain comptianc with the Cupertino Municipal Code, Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued I Health & Safety ode, Section 25532(x) should I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally, air contaminants as should I use equipment or devices which emit hazardous defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If, after making this certificate of will maintain compl lance 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, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agents APPLICANT CERTIFICATION Date: 12/14/2016 I certify that I have read this application and state that the above information is !,-ONSTRUCTION I hereby affirm that I LENDING AGENCY here is a construction tending agency for the performance 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 of works for which this permit is issued (Sec. 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 1 understand my plans AurHIT T° DECLARATION shall be used as public records. Code, Section 9.18. ;.1 ® Licensed Si nature t13`-.-- �` Date 12/14/2016 9 Professional CONSTRICTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 build ingP-cupertino.org fT n / / El NEW CONSTRUCTION 0 ADDITION N ALTERATION / TI 0 REVISION / DEF RRED ORIGINAL PERMIT # 7 PROJECT ADDRESS APN # ((4nC3 1SCC)-rL �� ��1z , N.2 28 --OCR >( OV✓NERNAME -D! afiV� bt Y -U ® �Q{ ke PHONE 0 01 7 r�tCt6'I�la kkG' cj!�t(Xt �o fi�/m'1 STREET ADDRESS r j onu 5co-0 �j D r CITY, STATE, P Al P CA � � @ FAX ck CONTACT NAME (t0 i PHO L E-MAIL STREET ADDRESS CITY, ST TE, ZIP FAX ❑ OWNER OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LIC NSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS r - — CITY, STATE, ZIP PHONE ARCHITECT(ENGINEER NAME tz�_ LICENSE NUMBER BUS. LIC # COMPANYNAME E-MAIL —1 _ i `("O )_°P S S t O � GZ 1 s-�E� S i � �\C� _ � t/ ►`) � 1'17G'i t ` , L"U FAX STREET ADDRESS CITY, STATE, ZIP PHONE (c�266 �ta cv,d(e t c 14 f_4og)9�6--79 8 DESCRIPTION 01"WORK i - vJ�tk._I�n� ^ s,r ,�. vg USE TYPE OCC. SQ.FT. VALUATION ($) EXISATG$ NEW FLOOR A i 2tl ��. AREA NETAREA3 Y lf�> .- 3 BATHROOM KITCHEN - OTHER S _._:.. REMODELAREA Iji[�) REMODEL AREA 1V REMODELAREA 1'7 S PORCH AREA DECK AREA TOTALDECKNORCH AREA GARAGEAREA: EIDETACH ❑ ATTACH # DWELLING UNITS: IS A SECOND UNIT SECOND STORY E] YES 6 DYES BEING ADDED? O ADDITION? 115<0 PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN❑YES TOTAL VALUATION: PLANNING APPL # _NO PLANNING APPROVAL LETTER. EICHLER HOME? T,<O .� ,� 4® 00D k r By my signature below, I certify to each of the following: I am the property owner or authorized agent to act o e 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 ccurate. I agree to comply with all applicable local, ordinances and state laws relatigg to building onstruction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: t% [ SUPPLEMENTAL INFORMATION REQUIRED „PLAN'UHE" k2Y�eR - ;• xouTINGSLII� .. " ❑� OVEZTHE-C IJNTER ❑ BEIILDINGPLAN1tEVI w New SkD 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 © PIANNINGPLANI?EVTEw Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑' STAR'AARD © PrmucwokK$ form if any Hazardous Materials are being used as part of this project. ❑_ "RGE = ❑ FIRE DEPT.= _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑NtTARX SEWERDSSTRICT SA submittal Of Building Permit application.IAdOR BIdgApp 2011.doc revised 06121111,, OWNER -BUILDER DISCLOSURE FOR COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING D 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CU6'EE%T11V i (408) 777-3228 • FAx (408) 777-3333 • building(a.cupertino.orc Dear Property Owner(s): An application for a building permit has been submitted in your name listing voi improvements specified at: SITE ADDRESS, M00 ScZ�iR�t� - C�, �r�, a APN 3�,2� soo B %Zo�6- 3Z6 OWNER NAME INAY1114OWNER ADDRESS is performed under contract with a licensed general building Contractor. DESCRIPTION OF WORK: %V,d Poor, r+.ywtrf- exmS \Vq M3*31 &&I''rrtz"I bVid WMA til dop- is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) tha 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 issue J 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 uno VkC.1. I understand a frequent practice of unlicensed persons is to have th Builder" building permit that erroneously implies that the property owner is I personally. I, as an Owner -Builder, may be held liable and subject to seriou an unlicensed person and his or her employees while working on my prope provide coverage for those injuries. I am willfully acting as an Owner-Builde insurance coverage for injuries to workers on my property. C 12. 1 understand building permits are not required to be signed by pr the construction and are not hiring a licensed Contractor to assume this or verify this information.) property owner obtain an "Owner- oviding his or her own labor and material financial risk for any injuries sustained by y. My homeowner's insurance may not and am aware of the limits of my ty owners unless they are responsible for onsibility. 'r 3. I understand as an "Owner -Builder" I am the responsible party of reord on the permit. I understand that I may protect myself from potential financial risk by hiring a Licensed Contractor a d having the permit filed in his or her name instead of my own. 4E,,' VtkA. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. e V-5. I understand if I employ or otherwise engage any persons, other tha i California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), includir g labor and materials, I may be considered an "employer" understate and federal law. 6. 1 understand if 1 am considered an "employer" under state and feder I law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation Jisability 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. W"4"7. 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. "8. 1 understand as an Owner -Builder if I sell the property for which this*mit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s) tha result from any latent construction defects in the workmanship or materials. �' OwnerBuilderForm 2010.doc revised 04114110 TV -9. I understand I may obtain -more information regarding my obligation 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 1-800-324-CSLB (2752) or www.cslb.ca.gov for rr ore information about licensed contractors. `0-10. I am aware of and consent to an Owner -Builder building permit ap lied for in my name, and understand that I am the party legally and financially responsible for proposed construction a tivity at the site address listed above. X11. 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. X12. I agree to notify the issuer of this form immediately of any addition information I have provided on this form. Licensed contractors are regulate) you contract with someone who does not have a license, the Contractors' assist you with any financial loss you may sustain as a result of a complain Contractors may be in civil court. It is also important for you to understand 1 employee of that individual or firm is injured while working on your property you obtain a permit as Owner -Builder and wish to hire Contractors, you will those Contractors are properly licensed and the status of their workers' con CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency deletions, or changes to any of the by laws designed to protect the public. If :ate License Board may be unable to Your only remedy against unlicensed iat if an unlicensed Contractor or you may be held liable for .damages. If )e responsible for verifying whether or not pensation insurance coverage. ' 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 he property owner's driver's license, form notarization, or other verification acceptable to the city may be required to e presented when the permit is issued to verify the propeq owner's si nature. Property Owner's Signature: 4 Date: C Y//G ------------------------------------------------------ --------------------------------- (NOTE. The following Authorization Form is required to be completed by the agent of the property owner to apply for a construction permit for the Owner -I Excluding the Notice to Property Owner, the execution of which i understand is authorize the following person(s) to act as my agent(s) to apply for, sign, and fil 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: ------------------------------------------------ )perty owner only when designating an IWNER'S BEHALF ry personal responsibility, I hereby the documents necessary to obtain an el No I declare under penalty of perjury that I am the property owner for the address li ted 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 pet mit is issued to verify the property owner's signature. Property Owner's Signature: OwnerBuilderFonn 2010.doc revised 04/14/10 CUPERTINO PURPOSE 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 • buildin P-cupertino.orq PERMIT CANNOT BE FINALED UNTIL THIS CERTIFICATE HAS BEEN COMPLETED, SIGNED AND RETURNED TO THE BUILDING DIVISION This affidavit is a self -certification for the installation of all required Smoke and Carbon Monoxide Alarms for compliance with 2013 CRC Section R314, 2013 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 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 X X the bedroom(s) On every evel of a dwelling unit including basements 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 has/have 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: { 1 �,Q_Scf 1a3qA Of Cxa in c, t CA Permit No. 6 Zo JC --S Specify Number of Alarms: _ # Smoke Alarms: FT, # Carbon Monoxide Detectors: T, 1 have read and aqree to comply with the terms and conditions of this statement ner (or Owner Agent's) Name: -------------- Signature ...... ....... �.......................................................Date: 7 i+6 J(� Co................................................................................................................................. Contractor Name: Signature.................................................................. Lic.# ......................................Date: Smoke and CO fO1717.doe revised 09127/16 CUPERTINO WATER -CONSERVING PLUMBING FIXTURES OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.org Owner Name _ K!.►yVn C IMAM Permit No. Address 1. Is your real property a registered historical site? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the forn and sign bottom of form. 2No 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 plumbing, 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. ZNo Go to Question 3. Is water service permanently disconnected for your building? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. VNo Go to Question 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. 12"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., Please check ONE of the following: J5 My 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 pluinbing 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 1101.1 through 110 1.8, the current California Plumbing Code and California Green Building Standards Code, and manufacturer's installation requirements, and that the water -conserving plumbing fixtures comply with the requirements as indicated in the table on the following nage. Owner or Owner Agent's Signature: ff _// Date: `I l/, 111 1 Upon completing and signing this Certificate, please return it to the Building Division in order to final your building permit. SB407 2015.doe revised 08/26/15