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13110160 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10116 ADRIANA AVE CONTRAC PERMIT NO:131/0160 OWNER'S NAME: MEGA TREASURE LAND LLC �t _ DATE ISSUED:1283/2013 OWNER'S PHONE: 4088573787 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION .JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL E] MODIFY EXISTING STAIRS AND HOUSE/GARAGE License Class Lic.# SEPARATION TO BRING UP TO CODE,REMOVE AND REPLACE(2) Contractor Date WINDOWS IN BEDROOMS,TO MEET EGRESS. 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: 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 whieh this permit is issued. Sq.Ft Floor Area: Valuation:$12000 1 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 APN Number:32620010.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save X80 - T LED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I Z3 r'3 granting of this permit. Additionally,the applicant understands and will comp ued by: ate: with all non-point source regulations per the Cupertino Municipal Code, n 9.18. RE-ROOFS: Signature Date 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. d OWNER-BUILDER DECLARATION Signatnre of Applicant: Date; I hereby affirm(hat I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,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) 1,as owner ofthe property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE -construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will 1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous 1 have and will 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 ofthe Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance ofthe work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and 1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,See' 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agen 7 Date. 3 permit is issued, 7,+ 1 certify that in the performance ofthe 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,l 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 1 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 1 understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point so a regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. J Signature Date / ,z CONSTRUCTION PERMIT APPLICATION U0 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION d, 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(406)777-3333•building(d)cupertino.org ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROTECT ADDRESS �� APN A(>116 Main& ha OWNERNAMEV E-MgfL STREET ADDRESS ' FAX 1,00-11 AA CA CONTACT NAME PHONE O` E-MAIL aI t 1 gpl All M CC Yn STREET ADD 5 CITY,STATE, ZIPFAX 14 tj �u ❑ OWNER ❑ OWNERBuILDER D OWNERAGENT ❑ CONTRACTOR ❑CONIRACTORAGENT ❑ ARc=ECT ❑ENorNEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSENUMBER LICENSE TYPE BUS,LAC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE. ARCHITECTIENGPIEERNAME LJCENSE NLNMER HUS.LIC# 1'11 COMPANY NAME E-MAIL FAX r STREET ADDRESS CITY,STATE,ZIP n 1 PHONE • � y, V DESCRIPTION OF WORK t G� rd Wil EXISTING USE PROPOSED USE CONSM TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION(5) EX TG NEW FLOOR DEMO TOTAL AREA C O AREA /)n� BATHROOM) p fKITCHEN OTHER AREA NET AREA r� OTHER 3 REMODELAREA REMODEL AREA REMODELAREA PORCH AREA DECK ARBA TOTAL DECKIPORCH AREA I GARAGE AREA: DETACH Ar TACH #DWELLING UNTES: IS A SECOND UNrr ❑YES SECOND STORY ❑YES BEINGADDED? []NO ADDITION? ©NO PRE-APPLICATION []YES IF YES,PROVIDE COPY OF 15 THEBLDGAN ❑YES RECEIy, $Y -� TOTAL VALUATION: PLANNNG ADPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? E]NO } By my signature below,I certify to each of the following: I am the pro owner or authoriz ag to act on the property owner's behalf. I have read this application and the information I ha rFo ed is correct. I have rea a Des tion of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating t build' g struction. I authori a repres tatives of Cupertino to enter the above-identified property for inspection purposes. Signature ofApplicanti.0.- : Date: SUPPLEMENtAL INFORMATION REQUt ED q-T '11ECK•TIPE�_,.,,� S.uoUT1N0,SLiP _ _New SFD Or Multifamily dwellings: Apply for demolition permit forV ❑`O�ER7H13COUt [ER D1IwGPLARREVII?N < existing building(s). Demolition permit is required prior to issuance of building "° x ` � z permit for new building. ��MDARD, ❑ Pi Alyi,rlaGp xI AN xEvl�ty _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure Ct rtrsLlc R()RT< _ form if any Hazardous Materials are being used as part of this project. ; , t CI.9�LARGE': ss ^?v � ❑i FIRE AEP7` ❑ _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ srr�xYs��liz r>tT �T; h1,pJOIt t r submittal of Building Permit application. 'INII.IR"OM�IEhTAI,IIEp1,TH.:.. Bldgflpp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10116 adriana ave DATE: 11/22/2013 REVIEWED BY: Mendez APN: BP#: 511al(o `VALUATION: 1$12,000 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Repair ENTAMATION 1GENRES PRIMARY Sf=D or Duplex P USE: PERMIT TYPE: wORK modi existing stairs to-bring up to code remove and replace 2 windows in bedrooms to,meet SCOPE egress Mech.Plan Check Phrnrb.Plan Check Elea Plan Check Mecb.Perwit Fee. Plumb.Permit Fee: 6lec. Permit Fee: Other l9ec:fr,Insp. Uthc Plumb Insp. Other Flee.Insp. LJ Plech.Insp. Fee: Plumb.Insp.Fee: Flee.Insp,Fee: NOTE. This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District eta). Thesefees are based on the relindna information available and are only an estimate. Contact the De t or addn'1 info, FEE ITEMS (Fee RQsoludon 11-053 Eff. 7/1113) FEE QTY/FEE NIISC ITEMS Plan Check-Fee: Hourly Only? ()Yes No $0.00 2 hours Plan Check,Hourly Suppl..PC Fee: Q Reg. Q OT Q,Q hrs $0.00 $278.00 ISTPLNCK PME Plan Check: $0.00 2 # Window 1 Sliding Glass Door Permit Fee: $0.00 $418.00 IWINREP "Replacement Suppl. Insp.Fee-.0 Reg. Q OT 0,0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax.- -F-T Administrative Fee: Q Work Without Permit? © Yes (F) No $0.00 0 Advanced Planning Fee: $0.00 Select a Non-Residential Tral,el Documentation Fees: Building or Structure A Strong Motion Fee: 1BSEISA9CR $1.20 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SVOTOTALS: 1 $2.201 $696.00 TOTAL VEE: $698.20 Revised: 10101/2013 f ' Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 C O P E RT I N O Telephone: 408-777-3228 Fax: 408-777-3333 CONTRACTOR/SUBCONTRACTOR LIST JOB ADDRESS: a( [6 V {A O ua PERMIT# 1 -? / 10/ 60 OWNER'S NAME: A&y G PHONE# GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL 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: ✓ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring/Carpeting Linoleum/Wood Glass/Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile VpGfer/dedtractor Signature Dat OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE- CUPERTINO,CA 950143255 CUPERTINO (408)777-3228• FAX(408)777-3333• buildine dl cuoertho.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: SETEADDRESS AVQ APN 3a/ , J BP# l2 + f !60 OWNER NAME q I�C(.Q OWNER ADDRESS SA{e G S ��j.� 7 I f [ DESCRIPTION OF WORK: CD rr a c-r e k r.01 c u o f Cs w h��Lys Q-(a Q Wct(I If y 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 oficial address indicated. An agent of the owner cannot execute this notice unless you, the properly 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.) X1. 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. 1, as' n 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. 4-C 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. l 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. 5. 1 understand if 1 employ or othen�vise 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"understate and federal law. I 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. rV `� 7. 1 understand under California Contractors' State License Law,an Owner-Builderwho builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless al[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. 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 resultfrom any latent construction defects in the workmanship or materials. OS+merBieilderFor-nr 2010.doc revisedO4114110 t' k 9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal r 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) orwww.cslb.ca,gov for more information about licensed contractors. 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that �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, l will abide all applicable laws and requirements that govern Owner-Builders as well as employers. G 12. 1 agree to notify the-issuer of this form immediately of any additions, deletions, or changes to any of the infor ation 1 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 s1 natu e. Property Owner's Signature: 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). 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: Tel No Address of Authorized Agent: 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: Date: Owi?erBuildel'Fon?? 2010.doc revised 04/14/10