B-2017-0067 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0067
10406 S S FOOTHILL BLVD CUPERTINO,CA 95014-2604(357 03 078) LEE KENNETH M AND
DAISY W C TRUSTEE
7995 PUMPKIN CT
CUPERTINO,CA
95014-4902
OWNER'S NAME: LEE KENNETH MAND DAISY W C TRUSTEE DATE ISSUED:01/12/2017
OWNER'S PHONE:408-832-3073 PHONE NO:None
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class !Lic.#
Contractor LEE iKENNETH M AND DAISY W C TRUSTEE Date X BLDG X ELECT X PLUMB
MECH X RESIDENTIAL_COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing
with Section 700;..0)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
PER PG&E THE GAS AND ELECTRIC METERS SHALL BE LOCATED
I hereby affirm 'under penalty of perjury.one of the following two declarations: AT MAIN RESIDENCE(10414 S FOOTHILL). PERMIT TO RUN GAS
1. I have;'and will maintain a certificate of consent to self-insure for Worker's AND ELECTRIC FROM METERS AT MAIN HOUSE TO SECOND
Compensation,as provided for by Section 3700 of the Labor Code,for the UNIT.
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:$5000.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 357 03 078
representativesi 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 180 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 1.12.17 Issued by:SEAN HATCH
Date:01/12/2017
OWNJER-BUELbER DECLARATION
RE ROOFS:
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 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 obtaining an inspection,I agree to remove all new materials for
rinspection.
compensation,will do the work,and the structure is not intended or offered for
sale(S�0044,Business&Professions Code)
�. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:1.12.17
I hereby affirm i under penalty of perjury one of the following three declarations: ALL ROOF 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. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections Municipal
25533,and ter 9.1 I will
permit)is issued. maintain compliance 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 Code,Section 25532(a)should I store or handle hazardous
material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. owner or authorized agent:
Date:1.12.17
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance
correct.I agree,'to comply with all city and county ordinances and state laws
relating to building construction,and hereby authorize representatives of this city of work's 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 indemriify 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 ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal
I understand my plans shall be used as public records.
Code,Section;9.18.
Licensed
Signature Date 1.12.17
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPF-ITINO (408)777-3228•FAX(408)777-3333•buildingR-cupertino.ong � � I S C
CUP1�F��Tt�a ,
i. PLUMBING ❑MECHANICAL Tj5ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS ! N#
OWNER NAME' `S�f B� �a� PHONE/66 A' ,}fJ�- � E-MAIL
STREET ADDRESS �. 'f�LiI `{ �� CITY,STATE,ZIP C ✓ FAX
CONTACT NAME PHONE ' `� MAID G �J
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STREET ADD ESS r 9 6�/, ) d i ICY,STATE, ,'%-'� j/`^ FAX
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OWNER-BUER ❑ OWNER AGENT 11CONTRACTOR ElCONTRACTOR AGENT ElARCHITECT ElENGINEER ElDEVELOPER ElTENANT
CONTRACTOR NAME("f t( 7LI
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COMPANY
NAME A FAX
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ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC
COMPANY NAME I E-MAIL FAX
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STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD m DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLANTD �- n YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: i� COMMERCLSL URBAN INTERFACE AREA "'.NO FLOOD PONE 51go EICHLER HOME? ANO
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DESCRIPTION OF WORK t t e
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TOTAL VALUATION: RECEIVED BY:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state lawsrelating toZbding c structio I authorize representatives of Cupertino to enter the above-identified propertyfor inspection-purposes.
Signature ofApplicandAgent: A- Date: � C
SUPPLEMEN AL INFORMATION REQUIRED
OFFICE IIsiIVLx
OVER-THE�;CoUNTER `
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OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
(408)777-3228-FAX(408)777-3333-buildincIO-cuperrino.org
CUQPER�, INO
Dear Pr6 erty Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improve ents specified at:
SITE ADD ESS 16 �o 05 t7
AP
OWN ERN�
�ME OWNER ADDRESS
We are p Iroviding you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your resiionsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We
will not i�ssue 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 roperty owner,obtain the prior approval of the permitting authority.
JS ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
OWNER
(DIRECTIIONS:Please read and initial each statement below to signify you understand or verify this information.)
11. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner-
hat
--_— building permit~that~'~~~�yimplies property owner is providing his or her own labor and material
personally. 1, as,an Owner-Builder, may be-held liable-and-subject to serious financial risk for any injuries sustained by
an q licensed person and his or her employees while working on my property. My homeowner's insurance may not
pro d6 coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
insuvi'ance coverage for injuries to workers on my property.
&__11112. 1 understand building permits are not required to be signed by property owners unless they are responsible for
--7-onstruction and are not hiring a licensed Contractor to assume this responsibility.
q(�3..I understand as an"Owner-Buildee'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
nuM ers on permits and contracts.
5. 1 understand if I employ or otherwise engage any persons, other than Cali mia licensed Contractors, and the
total value of my construction is at least five hundred dollars($500), including labor and materials, I may be
conl'�idered an "employer"under state and federal law.
-6`I understand if I am considered an"employee'under state and federal law, I must register with the state and
fed6ral government,withhold payroll taxes, provide workers'compensation disability insurance, and contribute to
une�nployment compensation for each"employee." I also understand my failure to,abide by these laws may subject
mejo serious financial risk.
7. 1 understand under California Contractors' State License Law, an Owner�Builder who builds single-family
re i9ential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
lice 01sed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is p, ormed 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, | o�aybehe� Uab�hx
� financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects inthe workmanship ormaterials.
ownucom&yerforv_20/0.°o,revised o4114Du
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9. 1 understand I may obtain more information regarding my obligations as an"employe"from the Internal
Revenue Service,the United States Small Business Administration,the California Department of Benefit Payments,
and(the California Division of Industrial Accidents. I also understand I may contact the California Contractors'State
License Board (CSLB)at 1-800-321-CSLB (2752)or www.csib.ca.gov for more information about licensed
contractors.
tlL-''10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am�he party legally and financially responsible for proposed construction activity at the site address listed above.
L1` 1 I. 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.
r 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
youi;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.)
hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
i
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 owrner's driver's license,
form notarization, or other verification acceptable to they- jtbe equired to be presented when the permit is issued
to veri ;:the property owner's signature. -,
Property Owner's Signature: �a`
�..'"' Date:
] -------------------------------------------------------------------------------------------------------------------------------
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of.'the property owner to apply for a construction permit for the Owner-Builder).
i. 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:
I
Name of Authorized Agent: Tel No
Address of Authorized Agent:
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 Owners Signature: Date:
OwnerBuilderForm 20I0.doc revised 04/14110
I
Building Department
City Of Cupertino
10300 Torre Avenue
j Cupertino, CA 95014-3255
Telephone: 408-777-3228
C O P E RT I N O Fax: 408-777-3333
CONTRACTOR/SUBCONTRACTOR LIST
e f
JOB ADDRESS: a ' �t t 6hIC( C,- PERMIT# ; J 0 f 0 0 C
OWNER'S NAME: r -tSy ,g�' -- PHONE# J 7.,3
GENERAL CONTRACTORS 13-JA; t BUSINESS L�CENSE#
ADDREss: Ic <- ' CITY/ZIPCo E:
*Our mumcipal'coie requires all businesses working.in the-city.to have.a City oCupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WIL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: `
Signature Date
Please check applicable subcontractors and complete the following information:
V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE`#
Cabinets &Millwork
s.
Cement Finishing ^f.
Electrical
Excavation 1 ) ;I r� �
f �
Fencing r'
Flooring/Carpeting
Linoleum/Wood
r
j Glass/Glazing
t Keating j
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving j
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
f
11 211
Owner/Contractor Signature If- Date '�