15120082CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS:
CONTRACTOR:
PERMIT NO: 15120082
22825 SAN JUAN RD CUPERTINO CA 95014 (342 22 109)
OWNER/BUILDER
OWNER'S NAME: (RAMONA BLVD INC)
DATE ISSUED: 03/07/2017
OWNER'S PHONE: (408) 973-0806
PHONE NO: 408-973-0806
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lic. #
Contractor OWNER/BUILDER Date
—BLDG —ELECT -PLUMB
MECH RESIDENTIAL COMMERCL4,L
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.
JOB DESCRIPTION:
VOLUNTARY RETROFIT OF (E) RETAINING WALL AT PARKING
I hereby affirm under penalty of perjury one of the following two declarations:
LOT WITH STAIRS TO LOWER LEVEL (360 L.F.)' CONVERT (E)
1. I have and will maintain a certificate of consent to self -insure for Worker's
WOOD DECK TO (I) CONCRETE DECK
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
Sq. Ft Floor Area:
Valuation: $250000.00
permit is issued.
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
342 22 109
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 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 FR LLED ECTION.
Signature Date 03/07/2017
Issued by: ANAME
Date: 03/07/2017
OWNER-BUII.DER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
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
compensation, will do the work; and the structure is not intended or offered for
inspection.
sale (Sce.7044, Business & Professions Code)
-I, as owner of the property, am exclusively contracting with licensed
Signature ofApplicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 03/07/2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. 1 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 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued..
Health & Safety Code, Section 25532(a) should I store or handle hazardous
3. -' 1 certify that in the performance of the work for which this permit is issued, I
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
willmaintain 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:,>�2L t
APPLICANT CERTIFICATION
Date: 03/07/2017 it
certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
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
of work's for which this permit is issued (See. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
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
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
ARC'HITECT'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 03/07/2017
Professional'
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(c�cupertino.org
v
NEW CONSTRUCTION . ❑ ADDITION !R` ALTERATION /T.I ❑
REVISION /DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS
APN_ ; .1 (w,l
A N AM ' A
OWNER NAME PHOY)#
,.
I=x 's CIES r
.E-MAIL
STREET ADDRESS
CITY, STA - , ZIP
FAX
9-2—R'—>.c; .1314ko J A
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CONTACT
PHONE
F-tMAAIL
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STREET ADDRESS
CITY, STATE, ZIP
-
FAX
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SANTA,
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OWNER ❑ OWNER -BUILDER :❑ OWNER AGENT ID CONTRACTOR ❑ CONTRACTOR AGENT , r`a't ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME -7
LICENSE NUMBER
LICENSE TYPE
BUS. LIC h!
COMPANYNAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECVRNGH-'BER NAME
LICENSE NUMBER
BUS, LIC 9
COMPANYNAMEpa�
E-MAIL
FAX
V Almr— C—A —LAS
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STREET ADDRESS
CI , STATE, ZIP
PHONE
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DESCRIPTION OF WORK
w
N �` 'fM 0 (31:-C� Rr--TAi LL N P R " i , `2 ` H
EXISTEJGUSE.
PROPOSED USE CONSTR.
TYPE
#.STORIES
USE
TYPE
OCC.
SQ.FT,
VALUATION (S)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA.
BATHROOM KITCHEN
OTHER.
REMODEL AREA. REMODELAREA..
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA DETACH
I
❑ ATTACH
# DWELLING UNITS:
IS A SECOND UNIT []YES
SECOND STORY E] YES
-
BEINGADDED? ❑NO
ADDITION? ❑NO
PRE=APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES
EIVED B TOTAL VALUATION:
PLANNING APPL # ❑ N0. PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO
3'6
250yf®
a .., ...,
By my signature below, I certify to each of the following: I am the property owner or author
zed 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 laws relating to building constructio I authorize representatives of Cupertino
to enter the above -id tti`fi property for inspection purposes.
Signature of Applicant/Agent: 1� %
Date: 7r'
SUPPLEMENTAL INFORMATION RE RED
Q
YLASti CHECK TXP�
_ New SFD or Multifamily dwellings: Apply for demolition permit for
❑ 'Oa rlll� cavNTEtt
BTIi7iIN{xPT ANRE4IEW
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
" ;EXPRESS-�.
rLArRYiNG PLANREVMW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
STANDARD
PuiILleonKs
rm if any Hazardous Materials are being used as part of this project.
fo—
U =LARGE _
b SI>2&DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to
sArITARaWERDISxiCT _
submittal of Building Permit application.Aaoi
- ,: .: --
❑-EI�`VIRONNiE}\''I'AL;HEALTH -.' ,�
B1dgApp_2011.doc revised 06121111
CITY OF CUPERTINO
pw FEE ESTIMATOR — RITILDING DIVT4ION
ADDRESS: 22825 San Juan Road
FEE
DATE: 12/08/2015
REVIEWED BY: PAUL
APN: 342 22 109
BP#:
*VALUATION: 1$250,000
"PERMIT TYPE: Building Permit
360 1 Lf.
$5,871.00
PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY Commercial Building
USE:
Civil Religious activities
in BO zone? 0 Yes 0 No
PENTAMATION 1CBCRW
PERMIT TYPE:
WORK
Voluntary Retrofit of E retaining
wall at parkinq lot with stairs to lower level 360 L.F. ; Convert E
SCOPE
wood deck to (N) concrete deck
NOTE. This estimate does not
t'..,3=#A r'lu { : °r
fees due to other Departments (i. e.
Sewer
District, etc,). Tbese ees are based on the prelimina information available and are only an estimate. Contact the Dept for addn'l info,
FEE ITEMS (Fee Resolution 1.1-0 3.E . 71.1/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
360 1 Lf.
$5,871.00
Retaining Wall
IRETSTN Standard Retaining Wall
Suppl, PC Fee: (E) Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Feer Reg. 0 OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax: IBCONSTAVC
$0.00
rt - x€gz.lss..m"; gee,
Work Without Permit? 0 Yes (F) No
$0.00
Advanced Planning -Fee.
$0.00
Select a Non -Residential
- Building or Structure
0
d z`{:.
Strong Motion Fee; IBSEISMICO
$70.00
Select an Administrative Item
Bldg Stds Commission F ee:.. IBCBSC
$10.00
SUBTOTALS
$80.001$5,871.00
TOTALFE .'
$5,951.00
ov
REQUEST FOR PERMIT EXTENSION
r Please e-mail thecompleted form to
Or ; building@cupertino.org
U PERT/00
0 Under Plan Review Process El Issued Permit
Building Address: 22825 San Juan Rd, Cupertino CA Permit Number: 15120082
Owner Name: Ramona Blvd. Inc
Owner Address:. 22825 San Juan Rd, Cupertino CA Phone: (408) 973-0806
Contact Name: Father Brian Shininger
E-mail Address: bshininger@legionaries.org Phone: (408) 768-8474
Reason(s) (Please be specific): I pulled the permit as Owner / Builder on March 7, 2017.
The vetting process to find and secure a general contractor has taken much longer
than expected, and I have.not secured a contractor yet. The permit expires
September 3, 2017.
August 31, 2017
Signature: ' ..?1/1/1,4--- Date:
A,- kortemic ad,
(CITY OF CUPERTINO USE ONLY)
Yes ' No
�'m
Approval: ! ❑ Expired Date: ` I Fee: $ U v
Revised 7/25/2017
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(o)cupertino.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 ADDRESS 22825 San Juan Road, Cupertino, CA
APN 342-22-109
BP# 15120082
OWNER NAME Ramona Blvd., Inc.
OWNER ADDRESS 22825 San Juan Road, Cupertino, CA
DESCRIPTION OF WORK: Site Improvements: voluntary retrofit of existing retaining wall, new stairs and convert existing
wood deck to new concrete deck.
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.)
r 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "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.
-7-
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. I 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.
r-�
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.
d��
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
7. 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 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.
2r�±8. I 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.
OwnerBuildeYForm 2010.doc revised 04/14/10
�9. 1 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,
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.cslb.ca.gov for more information about licensed
contractors.
r-
(? 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.
.' 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
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 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: Z
---------------------------------------------------------------------------------------------------------------------------------------------
(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): Voluntary retrofit of retaining wall, new stairs and convert
existing wood deck to new concrete deck.
Project Location or Address: 22825 San Juan Road, Cupertino, CA
Name of Authorized Agent: Brian Shinincier Tel No (408) 768 - 8474
Address of Authorized Agent 22895 San Juan Road. Cu Pn "rtino, CA
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: �1 Gt.t . �/t/IiL,��� Date: �O
OwnerBuilderForm 2010.doc revised 04/14/10
STATE OF ^ e��\c� )
\\ ss
COUNTY OF
On the � day of in the year before\ me, the undersigned,
a notary public in and for said state, personally appeared »1i J we w�la ,
personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s)
whose name(s) are/is subscribed to the within instrument and acknowledged to me that they executed the
same in their capacity and that by their signature on the instrument, the individual(s), or the person(s)
upon behalf of which the individual(s) acted, executed the instrument.
Notk Pub
l'
02
�� / �COMMERCENSERIVER'S
Dt_ NO. 060341568 Dos 04/19/1971
CLASS B EXP 04/19/2024
FRANK DAVID
FORNIOLO
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b816 FULHAM CT
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CUMMING, GA 30041-8037
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