B-2017-1784 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1784
21050 MCCLELLAN RD CUPERTINO,CA 95014-4229(359 05 133) HOEFLER WALT S
AND MARY R
TRUSTEE
15122 SPERRY LN
•
SARATOGA CA,CA
95070-6262
OWNER'S NAME: HOEFLER WALT S AND MARY R TRUSTEE DATE ISSUED: 10/18/2017
OWNER'S PHONE:408-314-4414 PHONE NO:None
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
•
License Class # •
Contractor
ctorrHOEFLER WALT S AND MARY R TRUSTEE Date X10/18/2017 BLDG _ELECT _PLUMB •
MECH RESIDENTIAL X COMMERCIAL
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:'
REPAIR DAMAGED ROOF TILES
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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.
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
permit is issued. Sq.Ft Floor Area: Valuation:$1700.00
APPLICANT CERTIFICATION
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 359 05 133
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,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations.per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date Issued by:Jasmine Archbold
Date: 10/18/2017
-BUILDER DECLARATION
lit Ihereby affirm that I am exempt from the Contractor's License Law for one of the ' O! S:
following two reasons: All roofs shall be inspected prior to.nay r•.fin:material being installed.If a roof is
1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an spe•do- agree to remove all new materials for
compensation,will dbthe work,and the structure is not intended or offered for i peg ton.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed wig�e re of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code).4�. •te:
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. I haveand 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
2. 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
Section 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 Municip. Co.e,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)sho •1st e or handle hazardous
shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equip • or d• ices which emit hazardous
air contaminants as defined by the Bay • e'Air !uality Management District I
Worker's Compensation laws'of California. If,after making this certificate of will maintain compliance with the Cup: t' o nicipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the t,e Health&Safety Code,'.•cns 5505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall /
be deemed revoked. • n'' or authorized agent:
APPLICANT CERTIFICATION.
I certify that I have read this application and state that the above information is CONSTRUC ION LENDING AGENCY
correct.I agree to comply ith all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building con ucti.-,a•d hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the ab a m- tion-d property for inspection purposes. (We)agree Lender's Name
to save indemnify a k'-p ha less the City of Cupertino against liabilities,
judgments,costs,and -xpen -s which may accrue against said City in Lender's Address
consequence o,fie of this permit. Additionally,the applicant understands
and will 1/wit, all n. -point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,S .1.. I understand my plans shall be used as public records.
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COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 .
4.52.19.
(408) 777-3228 • building@cupertino.org PEMIT#B-2.9 ( - Irl$1/4-1
CUPERTINO RENT# DEF#
0 NEW CONSTRUCTION ❑ADDITION ILTERATION 0•T.I. 0 MEP ❑RE-ROOF ; 0 SWIMMING POOL/SPA
PROJECT ADDRESS 1 APN# -
' 21050 McClellan road,cupertino,ca 95014 359-05-133 '
OWNER NAME PHONE„ E-MAIL
wait&mary hoefler • 408-314-4414 , wshoefler@comcast.net
STREET ADDRESS $TATE,Zit'
/ c i 2 2 Sherry (c,,,r , ,COc C( i CIS- , 9 o70c. '
O CONTRACTOR NAME ❑OWNER-BUILDER COMPANY NAME ", LICENSE NUMBER LICENSE TYPE
STREET ADDRESS CITY,STATE, ZIP
E-MAIL PHONE }BUS.LIC#
❑ARCHITECT OWNER I OWNER AGENT OCONTRACTOR AGENT❑ENGINEER❑DEVELOPER 0 TENANT I '
CONTACT NAME '. E-MAIL
bret hoefler , bret@coastres.com '
STREET ADDRESS CITY,STATE,ZIP PHONE
1761 university ave san Jose,ca 95126 408-410-7700 ' ,
DECRIPTON -
replace broken roof tiles that are a result of fumigation '
❑SINGLE-FAMILY/DUPLEX OMULTI FAMILY ❑INDUSTRIAL I COMMERCIAL
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES# TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION($)
REMODEL REMODEL KITCHEN 1REMODEL OTHR GARAGE 0 ATTACHED
BATHROOM SF SF SF SF 0 DETACHED '
EXISING0 NOS EICHLER ®'NOS SECONDSTORYADDITION YES
.
FIRE SPRINKLERS
DWELLINGfISECOND DWELLING [LYES 0ATTACHEL,0DETACHED OTHER
UNITS It (UNIT ADDITON: O No S F
POOLS[ El FIBERGLASS ❑VINYL-LINED ❑GUNITE ❑PREFABRICATED
POOL-.SF SPA-SF I. SPA ATTACHED❑YES ❑NO TOTAL-SF
D BY: 0 TOTAL VALUATION:
Commercial or Multi-Familu Buildings with Public Swimming Pools requires Department of Environmental Heath avvroval 61/1\Z, k I A / 700
RE-ROOF EXISTING ROOF TYPE: 0 BUILT-UP ROOF 0 ASPHALT SHINGLES Q WOOD SHAKES 0 WOOD SHINGLES 0 TILE OTHER(S• WY)
REMOVE/REPLACE®NOIF NO ' PLYWOOD ❑1" Q 3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
0yEsl #OF LAYERS THICKNESS 0 5/8" OTHER DOSS 0 CDX OTHER , .121 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF ❑ASPHALT SHINGL 0 WOOD SHAKES❑WOOD SHINGLES 0 OTHER
*Provide a signed copy of the Cupertino's Tear-Off 'pil SF itof SQUARES -.
By my signature below I certify to each of the f: •'ii : I am the property owner or authorized agent to act,on the property owner's behalf. I
have read this application and the informati• Ap:v• .rovided is correct. I have read the Description of Work and verify it is accurate. I agree
to comply with all applicable local or.' . c J. • state laws relating to building construction. I authorize rep •sentativ•'s of Cupertino to
enter the above-identified property.for •e'.o• purposes. I acknowledge and authorize all information cont. •d on . •s application form
to be made available for public record. ,
Signature of Applicant/Agent:'''"'' ' - Date: /e /r
SUPPLEMENTAL INFORMATION i -' 'ED '
*New SFA/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.
410A-Provide a letter of approval from the Home Owner's Association
' B1dgApp 2017.doc revised 08/01/17
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OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
's�,,g10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
4
(408)777-3228•FAX(408)777-3333•buildinca(a.cupertino.orq
CUPERTINO
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 ADDRESS2 1 0 44 (...i.e,
ilete1/4OWNr
p) APN BP#OWNERNAMIA,(f 11- V a cilt-j l4c -('e' _ S/2 7 S vv (4111 e Set Lehr SCr CF 7 S 7 t.
DESCRIPTION OF WORK:
12d-I'tlia 12-P BOG,;. /
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 notissue 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
(DIRECTION 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-
'Builder" building permit that erroneously implies that the property owner is providing his Fr 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 aw'are of the limits of my
insurance';coverage for injuries to workers on my property.
rj1"1-2. I understand building permits are not required to be signed by property owners unless they are responsible for
the Instruction and are not hiring a licensed Contractor to assume this responsibility. up
q':' 3. I 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.
4.;I understand Contractors are required by law to be licensed and bonded in California and to list their license
ntlmbers'on'permits and contracts.
-'5,I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
totalivalueof my construction is at least five hundred dollars($500), including labor and materials, I may be
con'idered an"employer"under state and federal law.
i,,,
6. I understand if I am considered an "employer"under state and federal law, I must register with the state and
feta 'ral government withhold payroll taxes, provide workers'compensation disability insurance, and contribute to
unernployment compensation for each"employee." I also understand my failure to abide by these laws may subject
me t; serious financial risk.
71{I al 0 understand under California Contractors' State License Law, an Owner-Builder;who builds single-family
residentialstructures 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. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
ally financial'or personal injuries sustained by any subsequent owner(s)that result from.any latent construction
defects'in'the workmanship or materials.
OwnerBuilderFor/n 2010.doc revised 04/14/10
f;9. I 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.cslb.ca.gov for more information about licensed
contractors.iia/
(j�'�10. I 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.
1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by al applicable laws and requirements that govern Owner-Builders as well as employers.
2. 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 fore• u t be completed and signed by the property owner and
returned to the agency responsible for issui h= •-rmit. Note:A copy of the property owner's driver's license,
form notarization, or other verification accept a t6 - city may be required to be presented when the per it is i -ued
to verify the property owner's signature.
Property Owner's Signature: / 'Date: (6
ipoppr
(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 t I t e property owner for the address listed above and I personally filled out the
above information and certify its a r cy. ote:A copy of the property owner's driver's license,;form notarization, or other
verification acceptable to the city ay be r quired to be presented when the permit is issued to,verify the property owner's
signature.
Property Own'er's Signature: Date: C'Q/
OwnerBuilderForm 2010.doc revised 04/14/10