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14070059 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21749 STEVENS CREEK BLVD CONTRACTOR:URI FREELAND& PERMIT NO: 14070059 BATTIA FRIEDLANDER OWNER'S NAME: URI FREELAND&BATTIA FRIEDLANDER 753 EDGE LN DATE ISSUED:07/15/2014 OWNER'S PHONE: 6508234543 LOS ALTOS,CA 94024-4908 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL E] COMMERCIAL 0 KUMAN TUTORIAL-CHANGE OCCUPANCY FROM B TO License Class Lie.# E.. Contractor Date COMM. T.1 2143 SQ FT 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. 1 hereby affirm under penalty of perjury one of the following two declarations: 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. Sq.Ft Floor Area: Valuation:$22000 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:32620048.21749 Occupancy Type: permit is issued. APPLICANT CERTIFICATION 1 certifv 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 180 DAY M LAST CALLED 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 �— granting of this permit. Additionally,the applicant understands and will comply Issued by: Dater with all non-point source regulations per the Cupertino Municipal Code,Section 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. OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that 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 I,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) I,as owner of the 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 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District performance of the 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,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: 7 �� permit is issued. certify that in the performance of the 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,1 COr�STRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I 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 I 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 I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. I (� Signature Date 7 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION �u •CUPERTINO, CA 95014-3255 10300 TORRE AVENUE \0 (408) 777-3228• FAX(408) 777-3333•building d-cupertino.org CUPERTINO ElNEW CONSTRUCTION [JADDITION ALTERAIION/TI ❑ REVISION/DEFERRED O GINAL PERMIT# PROJECT ADDRESS APN# ASs G2��K vp. :&Z(,- OWNER NAME PHONE EMAIL Oki VE50 v 650 -82 -45 3 STREET ADDRESS CITY, STATF,ZIP �� FAX 110o 't'veV CONTACT NAME PHONE E-MAIL E 090-1-%-,-> V t=_Alm (v 0e tQ0� b4oo(? At4ga.cowl SIRE RESS CITY,STATE,ZIP FAX — zf�LlfJL. C Gam ❑OWNER ❑ OWNER-BUILDER R, OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT PeARCHITECT 11 ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC 4 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITEC(ENGINEER NAME LICENSE NUMBER BUS_LIC# v e»awvNoF G- S COMPANY NAME E-MAIL FAX L r Z00eci-,7 A>sf 0 Agoo.C dw] STREET ADDRESS CIT14,STATE,ZIP TWYNF 02- ldt7kVEL 56 DESCRIPTION OF WORK t'5 U w 1rVtO 2 S ! Vj M 0 N 'tvtLSRI e 5M L ea- 'Thr)eWA,!;4 zatG3 i �it\j 1p45 amm P?0,;Z9el� EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES V I C USE TYPE OCSQ.FT. VALUATION(S) �O�II dflt:/�cG GeMM�G�4Sl- EXISTG NEW FLOOR DEMO TOTAL 1 AREA Z/ A 1 AREA O AREA 5()s r- NET AREA BATHROOM'"t KITCHEN OTHER REMODEL AREA 32.5i= REMODELAREA D RFMODELAREA PORCH AREA rDECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH / 0 ATTACH #DWELLINGONrIS_ IS A SECOND UNIT []YES SECOND STORY YES BEING ADDED? Iwo ADDITION? ONO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: TOTAL VALUATION PLANNING APPI.# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? "aNO 2-ZCV` f By my signature below,I certify 9v whzrf foll wing: I am the property owner or authorized agent to act on-Me property owner's behalf. I have read this application and the informa 1 have"Ovi i co Z11hhe read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state la relating to buildi s tihorize representatives of Cupertino to enter the above identifi pro y for inspection purposes. Signature ofAppli t/AgenC ` Date: UPPLEMF,NTA FORMAT RFQUiRED PLAN CHECK TYPE ROUTING SLIP New SF or Multi dwellings: Apply for demolition permit for ❑ OYER-THF COUNTER ❑ BUILDING PLAN REVIEW existing build (s . molition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_201 Ldoc revised 06/21111 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 21749 SCB DATE: 07/15/2014 REVIEWED BY: Mendez APN: BP#: /lf��� `VALUATION: $22,000 'PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY PENTAMATION USE: Commercial Building PERMIT TYPE: 1 E T� WORK KUMAN TUTORIAL- CHANGE OCCUPANCY FROM B TO E.. COMM. T.l 2143 SQ FT SCOPE OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. s.f. E (Tenant Improvements) II-B,III-B,IV,V-B 2,143 $3,958.16 IETIPLNCK $3,798.70 IETIINSP TOTALS: 2,143 $3,958.16 $3,798.70 MECH,HOURLY 0 Yes (D No PLUMB,HOURLY Q Yes (F) No ELEC,HOURLY Q Yes 0 No Ll NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . Theseees are based on the preliminar information available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS (Fee Resolu/ion 11-053 Eff T/V13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $3,958.16 Select a Misc Bldg/Structure Suppl. PC Fee: Q Reg. 0 OT 0.0 hrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: $3,798.70 Suppl. Insp. Fee:(D Reg. Q OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 F-1 0 Work Without Permit? © Yes (2) No $0.00 E) Advanced Planning l=ee: $0.00 Select a Non-Residential E) Building or Structure 0 i Strong Motion Fee_ IBSEISMICO $6.16 Select an Administrative Item Bld,Stds Commission Fee: IBCBSC $1.00 1 1 SUBTOTALS: $7,764.02 $0.00 TOTAL FEE: $7,764.02 Revised: 07/10/2014 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014 -3255 Telephone: 408- 777 -3228 Fax: 408 -777 -3333 JOB ADDRESS:21749 Stevens Creek Boulevard PERMIT # 14070059 OWNER'S NAME: Uri Freeland PHONE # 650-823-4543 GENERAL CONTRACTOR: N/A - Owner Builder 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 Please check applicable subcontractors and complete the following information: Date 8/14/14 Owner / Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing X Electrical Muhamed Cisic Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing C &S Mechanical Roofing Septic Tank Sheet Metal Sheet Rock Tile 8/14/14 Owner / Contractor Signature Date OWNER-BUILDER DISCLOSURE FORM ELI COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228• FAX(408)777-3333• building(a)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 ADDRE S APN BP# vE `s c Ize z 6 20-o & �/ U 70� OWNER NAME OWNER ADDRESS DESCRIPTION OF WORK: CiV i_Q L a r ( -3 mew cw i R� V¢D t ICP 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 (DIREEC�TI.-ONS:Please read and initial each statement below to signify you understand or verify this information.) 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 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. te 2. 1understand building permits are not required to.be signed by property owners unless they are responsible for construction and are not hiring a licensed Contractor to assume this responsibility. J-3. 1 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. t . I understand Contractors are required by law to be licensed and bonded in California and to list their license ers on permits and contracts. h an 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. 6. 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. U 7. I 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. L�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. OwnerBuilderFonn 2010.doc revised 04/14/10 P. I understand I may obtain more information regarding my obligations as an "employer"from the Internal ue 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. 4`__amthle 0. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I 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. Z�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 is , this form must be completed and signed by the property owner and returned to the agency respo le fo Issuin e p mit. Note:A copy of the property owner's drive's license, form notarization, or other ve 'ication a cept t city may be required to be presented when the permit is issued to verifythepropertyown s si nature Property Owner's Sign ure: Date: ----------- - - 6w_ii_n_g__A_---- -------- -------------------------------------------------------------------------------------------------- (NOTE: The foil orization Form is required to be completed by the property owner only when designating an agent of the propwner 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 B Construction Project(or Description of Work):12 Wise_l6) t*-!� 2-npA em Project Location or Address: 217'4 5rMVuNA GQgatc. +bewo Name of Authorized Agent: W0-0*bt.Z> Tel No 65o"224-- sem Address of Authorized Agent:��� �1�1RK-cam�J�? CLMk 00 1 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 itsacy. Not :A copy of the property owner's drive's license, form notarization, or other verification accept,,'r y be eq re to b resented when the permit is issued to verify the property owner's signature. Property Owner's Date: 7114114 OwnerBuilderForm 2010.doc revised 04/14/10 UNREASONABLE HARDSHIP EXEMPTION FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL CUPERTINO 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228•FAX(408)777-3333•buildingaa cupertino.ora For Tenant Improvements where the Cost of Construction does not exceed $136,06 SITE ADDRESS r APN BP# / c CITYGUGte.a6k( ZIP 5128 TOTAL CONSTRUCTION COST A $......;--Z. C!dd.e. ................. DESCRIPTION OF WORK: i Vi 'f�Tt ` fit` Imb .2 Cl°-ntwde!Actas eluu;ro New po w► t?ZavIQG pokrLAWAY Arece%r, 19raam stQew to The following is a list of costs to provide access features in order to comply 100%with the current State Title-24 Disable Access Standards.(AII costs to be documented by actual bids or other information accepted by the Bui ding Official. Accessible Features Complies with If not,list required upgrades in order for Cost to make feature current standards? features to fully comply? fully accessible? 1.Path of travel to accessible entrance. NO N(ew PAtitwXY r-4sm e.M.rc 15 &Q=yzM60'Ty cbse f vess°f< $ 2,O 2.Cost of providing a primary entrance. (Including but ctgk- tom(? PntB,s,,t� not limited to,thresholds,landings,door hardware, Nb $ 50 max.door pull,etc. 3.Cost of providing the primary path of travel to the Mc�a wktrt�i�l,.iert NOO y specific area of alteration,structural repair,or iJ0 mss; $ 15,4506 addition. 4.Cost of providing accessible restroom facilities. O $ 1 O,GUD 5.Cost of providing an accessible drinking fountain. (If �. $ required or if a drinking fountain is provided.) 6.Cost of providing accessible public telephones(if $ provided) 7.Cost of providing other accessible features,including 11_17 O $ S�Q� but not limited to,parking,storage,alarms etc. TOTAL COST OF ACCESS FEATURES(8): $ 7 SC') Has the same tenant performed work in the same tenants ace within the last three ears? N O Calculate(8/A)x 100% 2` Description of access features to be provided: Ne w ADN 9.4sym tc sg±' i +. lexym w V w TOTAL COST OF PERCENTAGE (20%minimum LR.A ° PROPOSED UPGRADE $ Z 21OaO expenditure is re uired) r Q d to ARCHITECT OR ENGINEER OF RECORD INFORMATION: I certify that the above noted information is true and correct. Name(print): L,a0F,$VO V yNr,&f- Signature: v���''�� Date: -7 Firm address: O I?c5Oki Title: Phone: 6G62Z4'"62- --------------------- FOR DEPARTMENT USE ONLY -----------------------------—--------—-------------------------------- ❑ The above named project has been denied an unreasonable hardship exemption under 2010 CBC Section 1134B.2.1. XThe above named project has been granted an unreasonable hardship exemption from the requirements of the State of California CCR-Title 24 (Regulation for the Accommodation of the Disabled)pursuant to 2010 CBC Section 1134B.2.1. COMMENTS: Building Official Designee(print): Lo HJT 1- Signature: Date: —7ZI 51 HardshipExemptionForm 2012.doc revised 06125112