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15030037CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10402 LAS ONDAS WAY CONTRACTOR: MEHTA HARSHAD PERMIT NO: 15030037 OWNER'S NAME: MEHTA HARSHAD 656 LYNDALE CT DATE ISSUED: 03/05!2015 OWNER'S PHONE: 6103047188 PAOLI, PA 19301 PHONE NO: JOB DESCRIPTION: RESIDENTIAL COMMERCIAL F] CTOR'S DECLA TION ❑ LICENSED CONTRA �` REMODEL KITCHEN (180 SQ FT), THROUGHT OUT TO INCLUDE FAMILY, DINING & LAUNDRY ROOM (420 SQ License Class Lic. # FT) Contractor Date TO INCLUDE M,E,P'S I hereby affirm that I am licensed under the provisions oChapter 9 (commencing with Section 7000) of Division 3 of the Busi ess & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the folio mg two declarations: I have and will maintain a certificate of consent to self-insur for Worker's Compensation, as provided for by Section 3700 of the Labo�Code, for the p p Valuation: $50000 performance of the work for which this permit is issued. Sq. Ft Floor Area: 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 APN Number: 36928034.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATIO 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 180 DAYS F T CALLED INSPECTION. upon the above mentioned property for inspection purposes (We) agree to save indemnify and keep harmless the City of Cupertino againstiabilities, judgments, costs, and expenses which may accrue against said City in consequence of the Issued by: Date.. 3 granting of this permit. Additionally, the applicant understi rids and will comply 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' License Law for one of ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER the following two reasons: I, as o of the property, or my employees with wages as their sole compensation, wil o the work, and the structure is not intended or offer for sale (Sec.7044, siness &Professions Code) [, as owner of the property, am exclusively contracting withlicensed contractors to HAZARDOUS MATERIALS DISCLOSURE 19 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 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 -i ure for Worker's material. Additionally, should I use equipment or devices which emit hazardous as defined by the Bay Area Air Quality Management District I Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants will maintain compliance with the Cupertino Munici Code, Chapter 9.12 and performance of the work for which this permit is issued. afety Code, Sections 25505, 25533 aA 534. 1 have and will maintain Worker's Compensation Insuran the Health , as provided for by � .b�� O O ! S for this S on 3700 of the Labor Code, for the performance of the work which Owner or authorized agent: Date: Kermit is issued. _. 1 certify that in the performance of the work for which thi permit is issued, I shall not employ any person in any manner so as to become sul ject to the Worker's CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I I I hereby affirm that there is a construction lending agency for the performance of become subject to the Worker's Compensation provisions of the Labor Code, must work's for which this permit is issued (Sec. 3097, Civ C.) forthwith comply with such provisions or this permit shal be deemed revoked. 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 ordin ces and state laws relating to building construction, and hereby authorize represents Ives of this city to enter upon the above mentioned property for inspection purpo s. (We) agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino agair st liabilities, judgments, expenses which may accrue against said City i a consequence of the I understand my plans shall be used as public records. costs, and granting of this permit. Additionally, the applicant under tands and will comply with all non -point source regulations Cupertino Municipal Code, Section Licensed Professional 45 5ianature D e UA'. CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinga-cupertino.org ❑ NEW CONSTRUCTION .. ❑ ADDITION 13 ALTERATION / T1 ❑ ,REVISION / DEFERRED ORIGINAL PERIMIT 4 PROJECT ADDRESS /D O ^ �Y n _ ao „ /q APN # X 6 9 - 2 8 - v.3 OWNER NAME / / f� / �/ PHONE/ O 3O �• 71 i E MAII Y Zo �/ STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME .5-4-8 IS -A PHONE rjU STREET ADD S to 2 'av, .Onal�s v✓a CITY, STATE ZIP . ,•.f-, ,2v 1 9Soi y FAX _ OWNER ❑ OWNER -BUILDER' ❑ OWNER AGENT ❑ CONTRACTOR - ❑ CONTRACTOR AGENIT ❑ ARCHITECT []-ENGINEER- ❑ DEVELOPER ❑ TENAN7 CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE A.RCHITECTIFNGINEER NAME ' LICENSE NUMBER BUS. LIC # COMPANY NAME i E-MAIL FAX STREET ADDRESS 2- 57 D �VK i CITY, STATE, ZIP fl �` , 1 NaJ IV 'r PHONE 7 Q 2 q �' 2? d C � � 43 �7 ` VDESCRIPTION OF WORK + t 044 M 1'80 l"Tf N © (Z• N Ocre'=Rfotl . (t/pow E>3STING USE PROPOSED USE CONSTR. TYPE # STORIES t LvS� _ f �. os £ No l USE TYPE OCC. SQ.FT. VALUATION ($) EA'ISTG NEW FLOORDEMO TOTAL AREA AREA AREA NET AREA BATHROOM CHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREAFOTAL DECKIPORCH AREA GARAGE AREA:DETACH []ATTACK I # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY []YES d� 7dtA-L Sd BEING ADDED? ❑NO ADDITION? ❑NO l'I PRE -APPLICATION []YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES ,X TOTALAIA LUATION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTF14 EICHLER HOME? ❑ NO By my signature below, I certify to each of the followilg: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the infonnation I have provided is corgct. 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 construct on. I authorize re tives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: "�' Date: SUPPLEMENTAL INFORD INFORMATION REQOWN ot�xuvcsLlP., New SFD or Multifamily dwellings: APP1Y building(s). Demolition is or demolitionpermit for d to issuance of building IIOUNTE �� existing permit requi for building. prior x permit new j1 i?ES`� � .F� � � PLA'I�"�?�NG PLAI�RES iEW' _ Commercial Bldgs: Provide a completed H ardous Materials Disclosure sr .nRp UBLICVVORKS *� form if any Hazardous Materials are being used part of this project. Y. _ Copy of Planning Approval Letter or Meetin submittal of Building Permit application. with Planning prior to;"� ® iATOR AI�TrARY S ERI$rR3CT K ,; ' ��� ENViRONAIENJUAL HE4LTH­r BldgApp_2011.doc revised 06/21/11 CITV OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10402 las ondas way DATE: 03/05/2015 REVIEWED BY: Mendez APN: BP#: �s�. 'VALUATION: $50,000 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY PENTAMATION 1R3SFDREM USE: SFD or Duplex PERMIT TYPE: WORK remodel kitchen 180 sq ft),throu ht out to include family, dining & laundry room 420 sq ft SCOPE NOTE: This estimate does not inctuae fees uue co utner .,cpu. u.ac...� �. �• - • ••••••••e. - - - -- __ _ _- _, _ it.- t)...d fi.r nddn't infn_ District, etc . These fees are basea on the retinunur FEE ITEMS (Fee Resolution 11-053 Eff.� 7%11131 in o.,nuuv.s uru....o.� FEE Oumb. Plan Checti Elec. flan Check Plumb. Fermi Elec. Permit Fire 01hcr Aicch. latj' �7rher Plumb Insp Other Elec. Insp. 13ech, hlSp- Fee: Phrnrh hrsp• h?v, 1, ,'. G':.- C.., ;i. C—or nictrirt-Schaal NOTE: This estimate does not inctuae fees uue co utner .,cpu. u.ac...� �. �• - • ••••••••e. - - - -- __ _ _- _, _ it.- t)...d fi.r nddn't infn_ District, etc . These fees are basea on the retinunur FEE ITEMS (Fee Resolution 11-053 Eff.� 7%11131 in o.,nuuv.s uru....o.� FEE .••» »• QTYIFEE �••• -•- _ ___-_____ _ --_ MISC ITEMS Plan Check Fee: $0.00 =s.f. $645.00 Remodel, Kitchen (<=300 sf) IREMRESY-IT Suppl. PC Fee: I'J Reg. Q OT 0.0 hrs $0.00 1 PME Plan Check: $0.00 F420 s.f. $503.00 Remodel, Other 1REMRESOTH Permit Fee: $0.00 Suppl. Insp. Fee.e Reg. OOT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tar: 'fihninietrafira Fire. Work Without Permit? O Yes Q No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure E) O Trm,e/ Docurnentalion Fees: Strony- Motion Fee: IBSEISMICR $6.50 Select an Administrative Item Bldg* Stds Commission Fee: IBCBSC $2.00 SUBTOTALS: $8.50 $1,148.00 TOTAL FEE: $1,156.50 Mevl5eU. vcr iwrcv io CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 •FAX (408) 777-3333 • building(a cupertino.orp 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 10 14 0 2. L4.5 Orb P/} -S W Ay C_ LA , „e, C—n 41-7414 APN BP# �� OyvNER NAME 131H A ✓ri A I �1 "t H A -o " HTS OWNER ADDRESS &S 6 L ti, d Ite All C,, I 7° ►4 3c / DESCRIPTION OF WORK: u __4 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.) "?„A1. 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. 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. I 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. �,n►J�4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. ��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 �con idered 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 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 o serious financial risk. T 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 lid"' \ 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. �J78. 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 J9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal �evenue Service, the United States Small Business Administration, the California Department of Benefit Payments, y84f1 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. 0. 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. ty11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide all applicable laws and requirements that govern Owner -Builders as well as employers. _IL12. 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 *ry� 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: iJ/ A Lender Address: 1J/ A 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 acceptable to th city may be required to be presented when the permit is issued to verify the property owner's si nature. Property Owner's Signature: ,c// ---k ro,-J_� Date: , j- --------------------------------------------------------------------------------------------------------------------------------------------- (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: 10 L+ 0 2 L-A s p 74 D AS w pry r+e � C- Name of Authorized Agent: Ste -J, Tel No 4 o fi 2 a - 1 3 IS Address of Authorized Agent: 16 4o-2- L,:;� S 8-1, J, -J ", G� �A1L'� h a % qSu I �y 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. /�� rYl e1 Property Owner's Signature Date: OWneYBuildeYForm 2010.doc revised 04/14/10