B-2017-0363CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
19479 ROSEMARIE PL APT 1 CUPERTINO, CA 95014-3452 375 Ol007 CONTRACTOR: PERMIT NO: B-2017-0363
(
) HOMEOWNER
BUILDER
OWNER'S NAME: COHEN DAVID N AND WEISS CONSTANCE U ET AL
DATE ISSUED: 03/06/2017
OWNER'S PHONE: 650-766-9160
PHONE NO:
N T T' D I
BUILDING PERMIT INFO:
License Class Lic. #
Contractor HOMEOWNER BUILDER Date X BLDG —ELECT — PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing — ME' CH X RESIDENTIAL — COMMERCIAL
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 penalty of perjury one of the following two declarations: UNIT 1 - KITCHEN REMODEL (200 S.F.); BATHROOM (50 S.F.)
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.
APPLICANT CERTIFICATION Sq. Ft Floor Area: Valuation: $15000.00
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 37501 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
may accrue against said City in consequence of the granting of this permit. PERMIT EXPIRES IF WORK IS NOT STARTED
Additionally, the applicant understands and will 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 17 Issued by: Abby nde
Date: 03/06/2017
OWNER-11MDER 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
i. 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 inspection.
-'ale (See.7044, Business & Professions Code)
2. 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: 3/612017
I hereby affirm under penalty of perjury one of the following three declarations:
i. 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. 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
�f Section 3700 of the Labor Code, for the California
performance of the work for which this Health & Safety Code, Sections 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 or devices which emit hazardous
Worker's Compensation laws of California. If, after making this certificate of air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the C rd Municipal. Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the the Health &Safety Co 25505,
ections 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
=Owner or authorized agent•
I
APPLICANT CERMCATION Date: 17
certify that I have read this application and state that the above information is roNSTR rr.TIONLENDINGAGENCY
correct.
relating
I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
to building construction, hereby
to
and authorize representatives of this city of work's for which this permit is issued (Sec. 3097, Civ C.)
enter upon the above mentioned property for inspection Lender's Name
to
purposes. (We) agree
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 gr ting of this permit. Additionally, the applicant understands
and
will comply with on -point source regulations per the Cupertino Municipal ARCHITECT'S nFCLARATION
Code,
Section 9.1 1 understand my plans shall be used as public records.
Signature
V
Date / 17 Licensed
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
CUPERTINO(408) 777-3228 • FAX (408) 777-3333 - building(cr7cupertino orq
El NEW CONSTRUCTION ❑ ADDITION Q ALTERATION / TI ❑ REVISION / DEFERRED
PROJECTADDRESS 19479 Rosemarie Pl, # "- Cu- ertino, CA
� p APN# 375-01-007
' P ON6
PERMIT #
OWNER NAME
COhen David N et al PHONE
650-766-9160 E-MAILdc94086@comcast.net
STREETADDRESS460 Fairfax Ave. CITY, STATE, ZIP
San Mateo, CA 944. 02 FAx
CONTACT NAME Robert Moore PHONE
408-824-1116 E-MAIL robert@losnessgroup.com
STREET ADDRESS3131 S Bascom Ave., #230 CITY, STATE, ZIP
Campbell, CA 95008 FAX
❑ OWNER ❑ OWNER -BUILDER IN OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAMETim Heath LICENSE NUMBER 863821
LICENSE TYPE Elect BUS. LIC #
COMPANY NAME Star Lighting & Electric E-MAILheath833 mail.com
@9 FAX
STREET ADDRESS 3860 Oakes Dr. CITY, STATE, ZIP
Hayward, CA 94542 PHONE (650) 787-7250
ARCHITECT/ENGINEER NAME LICENSE NUMBER
BUS. LIC #
COMPANY NAME E-MAIL
FAX
STREET ADDRESS CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
Bathrooms & Kitchens: Remove and replace existing cabinets, plumbing and electrical fixtures, and tile, like -for -like.
Under Contractor Star Lighting & Electric: Upgrade kitchen electrical to current code.
EXISTING USE PROPOSED USE CONSTR. TYPE I #STORIES
USE TYPE 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: DETACH
❑ ATTACH
# DWELLING UNI'T'S: 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 EIVEI�r _
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO . ; - _ TO l ALL
. t iG�.
By my signature below, I certify to each of the f§J ing: I am the property owner or authorized agent td act on the property owner's behalf. I have read this
application and the information I have provid 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 buildin construction. I authorize representatives of Cupertino to enter the ab a -Vee of ^d� property for inspection purposes.
Signature of Applicant/Agent: Date: � / 4'7 Cf i� f `Z
SUPPLEI\JU-INTAL INFORMATION UIRED
_ 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.
—Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
form if any Hazardous Materials are being used as part of this project.
_ Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application.
PLAN CAECK,TYPE
RCiI7'iINGSLIP
171'U4EIt'1HE CFIUNTEIt
BUILDINGPLAN,"VIEtY
ijXPRI ss
PLANNING PLAN REVIEW '
l� STANDARD
PUBLIC IVQRii3 - '
b LARGE
iiiEDEPT
SANITARY SEWER DISTRICT,
EA VIRQNMIENTAI,'i3EAI TN
BldgApp_2011.doe revised 06/21/11
OWNER -BUILDER DISCLOSURE FORM
CC1fv1'fvtUN1TY DEVELOPINIENT DEPARTMENT - BUILDING
10300 TORRE AVENUE - CuPERTIN,0, CA 95014_3�,,55
(408) M-32,28 -,FAX (tWq 7-,7
CupoiTmo
Dear'Property Owner(s)-
An application for a building permit has be
en Submitte 41 I if Your name listing YOUrsell'As the builder of the property
Improvements specified at:
stege renovations renovations and efectriGal panel uPgrades on all 4 units or, 0_-_
ur -plex"
W4 O are providing Y06 wide an OwnerBuildoe Aclulowledgment and Infon-natiOn Verification Form to make you aware of
your responsibilities and Possible risk you may in I cur 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 PrQvision, signed, and
returned this form to us at our -official address indicated. An agent of the owner cannot ex
you, the property owner, obtain the prior approval of the permitting authorRy. execrate this notice unless
UHLUTIONS, Pleas -6 read, arrd,_initial e
statement below to slgjqify younderstar, d � or verify tins informatio,
U
I understand a frequent practice of unlicensed persofl� is to have the ProPeftY owner obtain an twirier-
Suilder" building pen -nit that erroneously implies that the Property owner Is Providing his car her own labor And material
personally. 1, as an Owner -Builder, may be held liable and subject to serious financial risk for ally injuries sustained by
an unlicensed Person and his or her employees while working on my property. My homeowner*s insurance may
ay hot
provide coverage for those injuries..t am Willfully acting as an Owner -Builder and am aware of
insurance wverage for injuries to workers, on my property,
the limits of my
2-1, b 'f understand building permits are not required to be signed by property owners unless they are responsible for
the oonstruction and are not hiring a licensed Contractor to assume this responsibility_
s'Yxw, 3 1 understand as an "Owner -Builder I am the responsible party of record an the permit. 1 understand that 1 may
P6fect myself from Potential financial risk by hiring a licensed Contractor, and having the permit filed in his or her
name instead of, my o},stn.
4z-1 understand Contractors are required by law to be licensed and bonded in Calkornia and to list their -license
numbers on permits and contracts,
tzt& -1 understand if I employ or oWerwis'a engage any Persons, other fir Calif6rnia licensed Contractors, and the
ran
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
G
considered an "employer" under state and federal law.
A Understand if I am considered an "employer, under state and federal faw, 1 must register with the state and
federal government,
unemployment compensation withhold payroll taxes, provide, workers' compensation disability insurance, area contribute to
, pensation for each `employee-" 1 also understand my failure to abide by these laws rpsubject
me to serious financial risk,
1, understand.under California Contractors' State License Law, an Own&w8uifder who builds single-family
fial structures cannot legallV build them with the intent to offer them for sale-, unless a// 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.
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 inateriak.
9
I understand I may obtain more informal ion regarding my obligations as an "employer" from the Intemai
Revenue Service, the United States Sinali Business Administration, the California lPartMant of Benefit Paymerts,
and the California Division of Industrial Accidents. I also understand I m8Y contact. the California, Gontraclors' state
License, Board (CSL8) at I �80o-321-13SI_13 (27 52) orwww.',b.ca.gofor or mote in
'c,Qntractors. csformation about licensed
A
am aware of and comment to all Owner -Builder building perish applied for in MY name, and understand that I
am the party legally and financially responsible for PrOposedconstruction activity at the
site ddress -listed above.
a
411-1-1 , I agree that, as the party legally and financiallY responsible for this proposed construction activity, I will abide
by 611 applicable laws and requirements that govern Owner -Builders as Well as etnployers.
Z*a-dree to notify the issuer of this form immediately of any additions, deletions, oes r changto
any Of the
Information I have provided on this form. Licensed contractors are regulated by IaWS 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 compi int Your 0111YT&Medy against unli
Contractors maybe in civil court. Itis "I eased
8 a ISO-IMportant for you to Understand that if an Unlicensed Contractor or
employee of that inOlvidual or firm is injured while working an your property, you may be held liable for damages. if
you obtain a permit as Owner-Buildof 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
iii byt R
L�EDING �AGEN�CY
(DIRECTIONS? Please con"Plete falba wing construction lending agency trillon-natio.,-k-)
I hereby affirm that there is 8 COristt-0000 lending -Igency for the performance of the
(Sec 3097 Civ.) work for which this Permit is issued
Lender Name,
lander Address:
retur _u"Ving permit can be'ssuodfthis form m 0 COMPleted and signed by the-, property
d to the -agency responsible for ass uing the pormit. Note; A ropy of the -owner and
form notarization. or other v_erifka tio , n arcProperty owner's driver's license,
yptablep M7�ary may be required to be presented when the permit is issued
Az6
Property Ownees Signature.,
Date.
agent of the property owner to appl-y 41 not plvpit�fiy owner omy wnen designating an
y foi a construction Permit for the Owner -Builder).
A ;ENT TO ACT ON PROPERTY 0 LE BEHALF
ExIcluding the Notice to Property Owner, the execution,of which I understand is my Personal responsibility,
authorize the foltowing person(s) to act as m I hereby
Y agen0) 1`0 apply for� sign, and file the documents necessary to obtain an
Owner -Builder Permit for my project, renovations -and electrical
Scope of Construction Prbiect (or Description of Work): kitchenpanel upgrades.
19479 Rosemarie Pl, Cupertino, CA 95011
Pf"PleCtLecation or Address, V
Name of Authorized Agent, Robert V Moore
7.1 No -408-824-1116
Address of Authorized Agent 3 131 Basicom Ave.,. #230, Campbell, CA 95008
I declare Odder penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above inforinat'10 n and certify its accu
racy Note.- A copy of theprop&i-ty owner's driver` license, -form notadzetion, or other
Verification acceptable to #ie cit'
ay be moyired
signature. Presented whetn the et ret is issued to veruthe property oml&rs
Property Owri&s Signature,
Date,
_2010. &bc rerisvd 04.44110