13050109 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10450 SERRA ST CONTRACTOR:ADZICH ROBERT PERMIT NO: 13050109
TRUSTEE&ET AL
OWNER'S NAME: ADZICH ROBERT TRUSTEE&ET AL 10164 CARMEN RD DATE ISSUED:07/11/2013
OWNER'S PHONE: 4082344835 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL L1 COMMERCIAL
License Class Lic.# NEW 500 SQ FT SWIMMING POOL IN REAR YARD AREA
**SEE NOTES**
Contractor Date
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 which this permit is issued. Sq.Ft Floor Area: Valuation:$38000
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:34259013.00 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 180 DAYS FRO 1VA `%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 Iss Date:
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 he y 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
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)
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. I will
I 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
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use el uipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Ba Are Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with th ertin Municipal Code,Chapte 9.1 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Secti s 5 05,2 33,an 25534.
Section 3700 of the Labor Code,for the performance of the work for which this j
Owner or authorized agent: Date-
permit is issued.
I 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,l CONSTRUCTION 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 propertyAr inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmles the C of Cupertino against liabilities,judgments,
costs,and expenses is y ace against said City in consequence of the l understand my plans shall be used as public records.
granting of this pe it.Ad i onall the applicant understands and w.11 c ply
with all non-point s urce r latio er the Cupertino Municipal Co e,S ction Licensed Professional
9.18. -
Signature Date !�
1
SWIMMING POOL 1 SPA PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 S P
CUPERTfN4 (408)777-3228• FAX(408)777-3333 •building( cupertino.org
PROJECT ADDRESS lO .1 5-0 APN#
WNAME PHONE fy� 1'
OWNER NAPHONE E-MAIL �O JC I tcal G LO N'
STREET ADDRESS`O y sO .n A�] v�1J j CITY, STATIM`/ N o C A— FAX
CONTACT NAME PHONF9Ot/� 23 0 E MAIL
STREET ADDRESS to,L�D 5�� S i CITY,STATE V P "-O „p^ FFAX
❑ OWNER OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ,❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME Ta 0 LICENSE NUNffiER LICENSE TYPE BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEERNA.ME LICENSENUNffiER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
USE OF SFD or Duplex ❑ Multi-Family TYPE MATERIAL E(CODE) AREA (SQ.FT_.)) VALUATION(S)
STRUCTURE: ❑ Commercial POOL sr,
POOLJSPA MATERIAL TYPE CODES: SPA
V - VINYL-LINED
F - FIBERGLASS DE
G - GUNTE
RECu°nma T T V
P — PREFABRICATED p],%� (nom]
# E 1� V
s
By my signature below,I certify to each of t e follo mg: I am the pro wner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have p d is co ect. I have read the Description of Work and verify it is accurate. I a ee to omply with all applicable local
ordinances and state laws relating to b Id, nst ion. I authorize representatives of Cupertino to enter the above-i l ;. 1perty for inspection purposes.
S i gnature of Ap plicant/Aaent: Date: JYr 3
SUPPLEMENTAL tFORMTtON REQUIRED r � '
-'
Commercial or Multi-Family Buildings with Public Swimming Pools: '�4 �,i, ^ ,. �,�x�� -� �,� �., �=&g��. �
a
OVER THE COUNTERD BUILDING DEPT tg ;
Department ofEnvironmental Health approval required. fn
.
Q EXPRESS% 02%�s vQ PLANNIIvG AEPT,4
❑'STDARD ❑z PUBLIC WORKS DEPT
❑ LARGES ❑ ENVII20NMENTALHEAL-rHz'
fzt.Ek, X fl d.i :'Z vx G
❑-MA70R D",SAA'ITARY.SEWERDISTRICT::
Swim PoolA,pp_2011.doc revised 03/15/11
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 10450 SERRA ST DATE: 05/14/2013 REVIEWED BY: MELISSA
APN: 342 59 013 BP#: ✓o 5` 'VALUATION: 1$38,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION RBSP
USE: PERMIT TYPE:
WORK NEW 500 SQ FT SWIMMING POOL IN REAR YARD
SCOPE
Lj Li El
1 1 "J
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These ees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/12, FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00500 s.f. Swimming Pool
Suppl.PC Fee: Q Reg. Q OT 1 0,0 hrs $0.00 $1,464.00 IPooz,GUNIT Gunite
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee:Q Reg. Q OT 0 0 hrs $0.00
PME Unit Feer $0.00
PME Permit Fee: $0.00
ti fhl ilii fl'i 'rt j;'rY' .. . . 4
Work Without Permit? 0 Yes Q No $0.00 0
Advanced Plannin&Fee: $0.00 Select a Non-Residential E)
cl Building or Structure 0
Strong Motion Fee: IBSEISMICR $3.80 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $2.00
SUBTOTALS: $5.801$1,464.00 TOTAL FEE: $1,469.80
Revised: 04/29/2013
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U PE RTI N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: PERMIT# 3 U �^ v/ O
OWNER'S NAM L PHONE# D O Z3 3-
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
ner/Contractor Signature Date
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228- FAX(408)777-3333•building aQcupertino.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 O S � S - AP BP#
` Z - 59 - 0l3 l30s alo5
OWNER NANM A-h Z�, OWNER ADDRESS Zo �t� ) sem - S� (1w, ,a
DESCRIPTIONOFWORK: N U� �j foo�- J L/ I
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
(Dl ,CT/ONS:Please read and initial each statement below to signify you understand or verify this information.)
1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner—
wilder" 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.
(J�2. 1 understand 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.
3. 1 understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may
rotect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
n e instead of my own.
0b4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
ers on permits and contracts.
45. I.understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
alvalue 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.
I understand if I am considered an "employer" under state and federal law, I must register with the state and
eral 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
serious financial risk.
g7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family
esidential 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
421 under contract with a licensed general building Contractor.
erstand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderForm 2010.doe revised 04/14/10
9. I understand I may obtain more information regarding my obligations as an "employer"from the Internal
venue 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
tractors.
f
� 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
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
4or(t_�v!—allil
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 .
mation I.have provided on.this form. Licensed contractors are regulated by laws designed to protect the pubic. 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 accept#e to till city may be required to be presented when the permit is issued
to verify the property owner's si nature.
Property Owner's Signature: Date: t x(13
-
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(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 owners driver's license, form notarization, orother
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owners
signature.
Property Owner's Signature: Date:
OwnerBuilderFoi-n1 2010.doc revised 04/14/10