13120155 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1538 PRIMROSE WAY CONTRACTOR:RICHARD&SHERIL PERMIT NO:13120155
WOODBURN
OWNER'S NAME: RICHARD&SHERIL WOODBURN 1538 PRIMROSE WAY DATE ISSUED: 12119/2013
OWNER'S PHONE: 4084834076 CUPERTINO CA, 95014-5230 PHONE NO:
❑
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL 0 COMMERCIAL 0
REMODEL(E)KITCHEN(255 S.F.),WIDEN KITCHEN
License Class Lic.# ENTRY.ADD(N)SKYLIGHT IN KITCHEN,REPLACE 1 (E)
WINDOW&ADD(N)DESIGNATED GAS LINE TO FUTURE
Contractor_ Date FP
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:
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.FtTloor Arca: Valuation:$70000
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:366150I5.00 Occupancy e:
permit is issued, p y Typ
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 X80 DAYS T 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 1 L ALLED 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
grantinggranting of this permit. Additionally,the applicant understands and will comply ed hy: Dat .
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Sign re 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.
1 DOWNER-BUILDER DECLARATION
_
I hereby affirm that i am exempt from the Contractor's License Lawfor one of Signature of Applicant: Dale:
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 of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
onstruct 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(x)should 1 store or handle hazardous
I 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 I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino tunicipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sect' ns 25505,2 33,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: Z.i l
dl ,Z:
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 ofexemption,I 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. works 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 ofthis city to enter
upon the above mentioned property for inspection purposes.(We)agree to save �RCHITE�I'S DECLARATION
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 understand my plans shall be used as public records.
granting ofthis permit.Additionally,the applicant understands and will comply
with allno Dint source r 0 ulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signatu Date
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION `�/
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 !
CUPERTINO (408)777-3228•FAX(408)777-3333•buildingC&cupertino.org
❑NEW CONSTRUCTION ❑ ADDITION ® ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS 1538 Primrose Way APN A 366-15-015
OWNER NAME Richard&Sheri Woodburn PHONE 40BA83-0076 F-MAIL rswoodbum@Gomcast.net
STREETADDRESS 1538 Primrose Way CITY' STATE,ZIP Cupertino, CA 95014 FAX
CONTACT NAME Sheri Woodburn PHONE 408-483-4076 E-MAIL rswoodburn@comcast.net
STREET ADDRESS 1538 Primrose Way CITY,STATE._ZIP FAx
Cupertino,CA 95094
IR OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME Dan Sullivan LICENSENUMBER 35545540 LICENSE TYPE B BUS.LIC#
COMPANY NAME Dan Sullivan Construction E-MAIL dan@dsullivanounstruction.com FAX
STREET ADDRESS 115 Baymount Street CITY,STATF%ZIP San Cruz,CA 95062 PHONE 831-425-1511
ARCMTECTIENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,IIP PHONE
DESCRIPTION OF WORK Remodel kitchen in existing location,widen interior doorway, move door from garage into kitchen on the same wall,n lic
EXISTING USE PROPOSED USE CON E #S DRIES
kitchen kitchen STI USE TYPE OCC. SQ.FT. VALUATION(S)
ExtsTc A FLG0 420 5 AREA 355 NET RFA 355 355
AREA 1420.5
BATHROOM KITCHEN OTHER
RFMODELAREA REMODELAREA355 REMODELARFA
PORCH ABPA DECK AREA TOTAL DECKIPORCH AREA CAGE AREA: DETACH
[W ATTACH
4DWELLINGUNITS: TIS A SECOND UNIT EYES SECONDSTORY []YES
BEINGADDED? UNO ADDITION? ENO
PRH-APPLICATION []YES 1F YES,PROVIDE COPY OF 1S THE BLDGAN [❑YES RECE TOTAL VALIDATION:
PLANNING APDL k ®NO PLANNING APPROVAL LETTER EICHLER HOME? EW �O 000
By my signature below,I certify to each of the following: I am the property owner authorized agent to act on tlI perry 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 acElfrate. I agree to comply with all applicable local
ordinances and state laws relating to building tructipn. I act prize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of ApplicanVAgent: LM",j &J., `, Date: j Z-— l d —ZO 13
SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUFMG SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for OVER-7TtE COUiVTER ❑ BUILDING PLAN REVIEW
existing buiiding(s). Demolition permit is required prior t0 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 ❑ LARG£ ❑ FIRE DEPT
_Copy Of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR C1SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIHONhrEN"fAL EIEALTIi
B1dgApp_2011.doe revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 1538 PRIMROSE WAY DATE: 12/19/2013 REVIEWED BY: MELISSA
APN: 366 15 015 BP#: ! 'sw s'j— "VALUATION: 1$70,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1R3SFDREM
USE: PERMIT TYPE:
WORK REMODEL E KITCHEN 55 S.F. WIDEN KITCHEN ENTRY. ADD N SKYLIGHT IN KITCHEN
SCOPE REPLACE 1 (E)WINDOW &ADD (N) DESIGNATED GAS LINE TO FUTURE FP INSERT
Mech. Plan Chcck Plumb.Plan Check 10-07hrs $0.00 Elec.Plan Check
Much.Permit Fee: Plumb.Permit Fee: 1PPERMIT h'lec.Perniir lice:
Orher,tlecrh.Insp. Other Plumb Insp. Elhrs $47.00 Orher Elee.Insp.
ileeh.Insp. Fee: Plumb. lusp.Fee: Elce.Insp.Fcc:
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addri'l info.
FEE ITEMS (Fee Resohrlion 11-053 Eff:711113) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 F-2-5-5-1 s.f. Remodel,Kitchen(<=300 sf)
Suppl. PC Fee: Q Reg. OT O.a hrs $0.00 $626.00 IREMRESKIT
PME Plan Check: $0.00 1 # Skylight
Permit Fee: $0.00 $418.00 1 1SKYL<10SF <= 10 s.f.
Suppl. Insp. Feer Reg. Q OT 0.0 1 hrs $0.00F$700701PGASRES
# Plumbing
PME Unit Fee: $0.00 Piping,Gas<=4 Outlets
PME Permit Fee: $47.00
Construction Tag':
Administrative Fee: IADMIN $44.00 Q
Work Without Permit? O Yes Q No $0.00 0
Advanced Planning Fee: $0.00 Select a Non-Residential E)
Travel Documentation Fee: ITRA YDOC $47.00 Building or Structure
Strong Motion Fee: 1BSEISMICR $7.00 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $3.00
SUBTOTALS: $148.001$1,114.001 TOTAL FEE: 1 $1,262.00
Revised: 10101/2013
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino,CA 95014-3255
Telephone: 408-777-3228
C U P E RT[N O Fax: 408-777-3333
CONTRACTOR 1 SUBCONTRACTOR LIST
10B DRESS:/S3� t'.i�y� (� e� C St7 PERMIT# f I Z O SS
WNER' NAME: ,3 e1'7/Gp& PHONE
GENERAL CONTRACTOR% 5Lt '�L« BUSINESS LICENSE#35g,5"Ci 3Aa-t g
ADDRESS: IIS l3ae 5+..ScujCjLj 7 CP
t 9S-0IoZ- 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 4�22'e'1es
Cement Finishing /
Electrical Q O
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood plq,?
Glass/Glazing
Heating
Insulation q
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing Z
Roofing 44 li' E 3�Z 7 r
Septic Tank
Sheet Metal
Sheet Rock .") S C, Gt t'U 32.z
Tile
caner 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• building4)cupertino.crq
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 APN BP#
15 Vic;M r V"1 11) 1
OWNER NAME OWNER ADDRESS
'��c.�+lav a � .7 � �CC� '�Y1
DESCRIPTION OF WORK: e vti ( `
V'"My—
Ajv�`IA
t{y'J��tC'
We are providing you with an Owner-Builder Acknowledgmen{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 farm 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.)
S 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.
N2i 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.
S'1')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.
EieJ 4. 1 understand Contractors are required by law to be licensed and bonded in Califomia and to list their license
numbers on permits and contracts.
L16�5. I 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 "employers under state and federal law.
_�)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.
L, 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.
P-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.
4wnerBuilderForm 2010.doc revised 04/14/10
. w
y 9. 1 understand I may obtain more information regarding my obligations as an'employer'from the Intemal
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.csib.ca.gov for more information about licensed
contractors.
V—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.
JU) 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, 1 will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
L1012. I 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 vedrication acceptable to the city may be required to be presented when the permit is issued
to verffy the property owner's signature.
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. p
Scope of Construction Project(or Description of Work): (i tdke v,- fq t\.,V
Project Location or Address: ti S 3 $ ?r+m rn s e J ku- G r.A cr+f rvo CA 9 SQ I Y
Name of Authorized Agent: I& i\r-a A Tel No
Address of Authorized Agent: fxM iNwLL"-t 7- of SOln-2-
I
I declare under penalty of perjury that 1 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:o � jx� �� G-c - Date: /L - / - 2-013
OwnerBuilderForm 2010.doc revised 04/14/10