B-2017-1399i
CITY OF CUPERTINO BUILDING PERMIT-
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1399
10641 STOKES AVE CUPERTINO, CA 95014-1236 (326 49 014)
HOMEOWNER
BUILDER
OWNER'S NAME: HARVEL ROBERT W IH AND SHAWNA J TRUSTEE &
DATE ISSUED: 08/22/2017
OWNER'S PHONE: 408-375-9021PHONE
NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lic. #.
Contractor HOMEOWNER BUILDER Date
X BLDG _ ELECT _ PLUMB
IAL COMMERCIAL
MECH X RESIDENT
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:
1ST FLOOR BATHROOM REMODEL (16 S.F.)
I hereby affirm under penalty of perjury one of the following two declarations:
1. Ihave and willmaintain 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
Sq. Ft Floor Area:
Valuation: $10000.00
permit is issued.
APPLICANT CERTIFICATION
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
APN Number:
Occupancy Type:
, s relating to building construction, and hereby authorize
state law
and state
326 49 014.
repand
es of this city to enter upon the above mentioned'property for
inspection purposes., (We) agree to save indemnify and keep harmless the
City of Cupertinoiagainst liabilities, judgments, costs, and expenses which
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrueiagainst said City in consequence of the granting of this, permit.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,1ahe applicant understands and :will comply with all non-point
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAY. S, LAST CALLED INSPECTION.
Signature Date 8122/2017
Issued by: Abby eL' nde
i
Date: 08/22/2017
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: I
All roofs shall be inspected prior to any roofing material being installed. If a roof is .
1. I, as owner of theproperty; or my employees with wages as their sole
installed without first obtaining an inspection, I agree to remove all new materials for
ompensation, will do the work, and the structure is not intended or offered for
inspection.
Qf ale (Sce 7044, 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: 8/22/2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
t. 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
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
Secti6n'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
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. I certify that in the`perforniance 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 manner so as to become subject to the
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Woiher 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 it forthwith comply with such provisions or this permit shall
be deemed
ener `
revoked
or authorized agent:
APPLICANT CERTIFICATION
Date: 8/22/2017
I certify 'thatIf Have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
correct. 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
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 upor 6:above mentioned property for inspection purposes. (we) agree
Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities;
judg' ments, 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 ail non point source regulations per the Cupertino Municipal
ARCHITECT'S DECLARATION
Code, Secti6n'9.18.
I understand my plans shall be used as public records.
ignature //�t"'– — Date 8/22/2017
Licensed
Professional
CUPERTINO SANITARY DISTRICT
20863 Stevens Creek Blvd #100, Cupertino, CA 95014
Tel (408) 253-7071 - Fax (408) 253-5173
\tea SAKI IgRYd
y .rr
Frlget tsnF.r '`'� CUPERTINO
SANITARY DISTRICT PERMIT LEER
Cupertino Sanitary District has adopted Resolution No. 1263.
Building Permit Request
(Over -the -Counter)
Single Family Project 0 Multi -Family Project ❑ Commercial Project
Project Address
1 oGq S�o k&V1 Vd 7 tko 4
J-0/
Permit Number: V -,UI-+- llpq
Scope of Work: Add 6 Nk 46, j A J� &44
Own er/Applicant'Name: Phone: 1Y0f.- 2 ? " '�a L J
Address:
Date: 2�' prepared By:
,(i'l l )rvc C ap'_+ wa
City Authorized Representative
1, as property owner or authorized agent, acknowledge that all Cupertino Sanitary District requirements
will be met and all required fees will be paid prior to the approval of final inspection for proposed project.
Date: OZ/1 7 Signature: -
Owner / Authorized Agent
CUPERTINO SANITARY DISTRICT OFFICE USE ONLY
Pre -inspection Required Final Inspection Required
Date Scheduled:
Date: Conditional Approval By:
Authorized Representative
Cupertino Sanitary. District
District will notify owner of the required fee within 5 days after Pre -Inspection has been completed and cc
City of Cupe 'no.
i,lnspection Fee Paid Date Paid: -22 — r' 7
Inspection// Fees:
$250/unit -Single Family Residential already connected, but new cleanout is required
$,150/unit - Single Family Residential already connected with existing cleanout in working order
060 Minimum — Commercial and Retail Actual Amount:
0 ;$200/each _ Disconnect and/or abandon lateral service
Connection Permit Fees:
$3'50/unit - Single Family Residential connecting to existing lateral
0
$650/unit — Single Family Residential connecting with new lateral
D $1,00/unit — Multi; Hotel, Living Units,'etc, Actual Amount:
0 $5,'001/connection - Commercial and Retail Actual Amount:
Gonnectio'n'Use Fees (See Attached Calculation Sheet):
;lt--7]Area!'and Frontage Fees Amount:
Residential Excess Fees over 3.5 unit/acre Amount:
Cb mmercial and Retail Connection Fees Amount:
D Gommercial and Retail Change in Use Fees Amount:
Date: 2 l 7 Final Approval By:
Authori Re resentative
Cupertino S tary District
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE e CUPERTINO, CA 95014-3255
(408) 777-3228 - building@cupertino.or PEMIT #B - un— ' 1
CUPERTINO REV # DEF #
n NEW CONSTRUCTION n ADDITION n ALTERATION n T_T_ n MFP n RE -ROOF n SWIMMING POOL/SPA
PROJECT ADDRESS Ave./
ACv
APN #
r.4Zfto
1061 1 .S¢®ker
,
OWNER NAME PHONE
fl-6<✓�- h/V.
yob -37r- yoZ� "
E-MAIL
v®b A,�,L.-✓e w/o - C®N,
STREET ADDRESS
l ode Av..
CFN, STATE, ZIP
. e A q ro ® y
�� �, �,
❑ CONTRACTOR NAME WNER-BUILDER COMPANY
NAME
LICENSE NUMBER LICENSE
TYPE
STREET ADDRESSCITY,
STATE, ZIP
E-MAIL
PHONE BUS. LIC #
❑ ARCHITECT WNER ❑ OWNER AGENT ❑ CONTRACTOR AGENT [:1 ENGINEER ❑ DEVELOPER ❑ TENANT
CONTACT NAME
Ro�9 —+ 14c% WV e'
E-MAIL /
v0 4 4to-ve G c& 00 . C orea
STREET ADDRESS
1001 S'�.l.�v, '.
CITY, STATE, ZIP PHONE
C.► t.koCA Iroly
yof-37r-5'o�/
DECRIPTON I
�J� 10 Guvr.ei ��
l
. K f4DN/ Qv T 6/1 q (OCA /N 4OD
� Ile 'J
C a /n I=C
[a5 NGLE-FAMILY/DUPLSX ❑ MULTI -FAMILY ❑ INDUSTRIAL ❑ COMMERCIAL
USE
TYPE
OCC
SQ.FT.
VALUATION ($)
EXISTING USE
EXISTING SF
NEW FLOOR SF
PORCH
SF DECK SF
DEMO SF
STORIES #
TOTAL NET SF
REMODEL
/6
REMODEL KITCHEN
REMODEL OTHR GARAGE
❑ ATTACHED
�.
BATHROOM SF
SF
SF SF
❑ DETACHED
EXISING ❑YES
FIRE SPRINKLERS El NO
EI ❑ CHLER ❑ YES I
" NO
SECOND STORY ADDITION OYES
NO
DWELLING SECOND DWELLING r'❑;YES ❑ATTACHED ❑DETACHED OTHER
UNITS # UNrr ADDTFON:!- ❑ NO SF
POOLS ❑ FIBERGLASS'' ❑ VIIIIlYL-LINED ❑ GUNITE ❑ PREFABRICATED
POOL - SF SPA - SF SPA ATTACHED ❑ YES 0 NO TOTAL - SF
Commercial or Multi-Fandhi Buildings wiih Public Swimming Fools requires Department of Environmental. Heath approval
RECET�VED BY:
j) j� y
ITO VALUATTONr
T, V
W�
RE -ROOF
EXISTING ROOF TYPE: ❑BUILT-UP ROOF ❑ ASPHALT SHINGLES❑ WOOD SHAKES ❑
WOOD SHINGL S ❑ TILE OTHER (SPECIFY)
REMOVE /REPLACE ❑ NOI'
IF, NO
PLYWOOD ❑'h" F13/8" PLYWOOD
TYPE:
PITCH:
ROOF CLASS
YES
# OF'LAYERS
THICKNESS ❑ 5/8" OTHER
❑ OSB ❑ CDX OTHER
• 12
A '
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑ WOOD SHAKES ❑WOOD SHINGLES ❑ OTHER
*Provide a signed copy of the Cupertino's Tear -Off Policy SF #of SQUARES
By my signature belowI 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 laws relating to building construction. I authorize representatives of Cupertino to
enter the above identified property for inrp
inspection puoses. I acknowledge and authorize all information contained on this application form
to be made available for public record.
Signature of Applicant%Agent: '' �./ / ✓`C— Date: Z 2 . 7
SUPPLEMENTAL INFORMATION REQUIRED
*New SFD/Second Dwelling Units/Multifamily Dwellings: A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: 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.
*HOA -Provide a letter of approval from the Home Owner's Association
B1dgApp_M7.doc revised 08101117
CUP'ERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 - build ino(c.cuoertino.org
Dear Properly 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: n--loa '
SITE ADDRESS®L` cV ✓two
1001 SA &,j A
yf��
APN� r _ BP# 1m
[.lX 1
OW ER NAME
todyiDD Sfok: t �va . v ,.�� v ek tiro f
DESCRIPTION OF WORK; L/owvew4:ti <- CfoSJ hex f fa 4 br.7 4
4. K-kowai. ivy .
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.)
0 1. i 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.
At I 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.
99 3.1 understand as an "Owner -Builder" I am the responsible party of record on the permit.,,) 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.
A 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.
let( 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.
RK 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.
BH 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.
8. 1 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.
OwnerBuilderForm 2010.doc revised 04/14/10
_LX 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.cs[b.ca.gov for more information about licensed
contractors.
ek 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.
0 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.
ll, 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.
CONSTRUOTION LENDING AGENCY
(DIRECTIONS: Please complete the following construction lending agency information.)
i
I hereby; affirm thafthere is a construction lending agency for the performance of the work for which this permit is issued
(Sec.309TC v.)
ii,
Lender Name: Lender Address:
Before a.'- buiilding permit can be issued, this form must be completed and signed by the property owner and
retu'r'ned tolthe 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 verifvlhe' property owner's signature.
Property,fQwner'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:
Address of Authorized Agent:
Tel No
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:
014,raeiBuilderFornz 2010.doc remised 04114110
•
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
, 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
CUPERTINO
(408)777-3228• FAX(408)777-3333• buildinq(o cupertino.orq _
�it.?'a. ».y' .� a A `r ,gat 3?s e WMAR F"1 g:A A z sa_:.3M b s c :z .'S
-��eg ER11 IT CANNOT BE RINAL�ED UNTIL;,�OHI-S CERTIFICATE 7t7,0: 22ZEW' HAS�BEENN '
ja:F114, CO LETTDD,SIGNED RETURNED TOTHEkB e DiVISI O� %
°t.?W.. ..,._.a.-.;.�mra,x.;a.�zxr a.�n._.. ....x.,wv�r mxn ,.,:sr-..�- .._w'arc...•«T"""^.'-?.,-g:a,... .ti.,:�vat._.i-Faa.,%,. .._..z:�,f;a..Y �.v..snr i.YaaSa.a...< .a.�xi,n:.n.�'R�'�a-'
PURPOSE
This affidavit is a self-certification for the installation of all required Smoke and Carbon Monoxide Alarms
for compliance with 2016 CRC Section R314,2016 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 level 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: /069/ 3toka! /9✓r Cic�.�.�� Permit No.O2 1? —/1 SF
Specify Number of Alarms: #Smoke Alarms: I % I #Carbon Monoxide Detectors:
I have read and agree to comply with the terms and conditions of this statement
Owner(or Owner Agent's)Name: /f
Rai 1-!k ( Signature - `._.._._. . Date://2/-I)
Contractor Name:
Signature Lic.# Date:
Smoke and CO fonn.doc revised 12/15/16