B-2018-0070CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS;
CONTRACTOR:
PERMIT NO: B-2018-0070
10561 CYPRESS CT CUPERTINO, CA 95014-2423 (316 30 057)
HOMEOWNER
BUILDER
OWNER'S NAME: CUMINE ROSS ET AL
DATE ISSUED: 0I/11/2018
OWNER'S PHONE: 408-489-2160
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lie. #
Contractor HOMEOWNER BUILDER Date
X BLDG _ELECT _PLUMB
MECH X RESIDENTIAL 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 Cade and that my
license is In full force and effect.
JOB DESCRIPTION:
2ND FLOOR BATHROOM REMODEL (45 S.F.)
I hereby affirm under penalty of perjury one of the following two declarations;
r. 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.
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: $2000.00
APPLICANT CERTIFICATION
I certify that I have read this application and slate 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
316 30 057
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 11111 018
Issued by: Abby Ayende
Date: 03/11/2018
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
following two reasons:
All roofs shall be inspected prior to any roofing material being installed. Iia roof is
r. 1, as owner of the property, or my employees with wages as their sole
installed without fust obtaining an inspection, I agree to remove all new materials for
compensation, will do the work, and the structure is not intended or offered for
inspection.
sale (Sce.7044, Business & Professions Code)
z. 1, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code),
Date: 1/11/2018
1 hereby affirm under penalty of perjury one of the following three declarations;
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
r. 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.
HAZARDOUS MATERIALS DISCLOSURE
z. 1 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. 1 will
permit is issued.
maintain compliance with the Cupertino Municipal Code, 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(x) should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area AhQuality Management District I
Worker's Compensation laws of California. If, after making this certificate of
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sections 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
_.,�f
Owner or authorized agent: —A 1/,
APPLICANT CERTIFICATION
y�6
Date: 1/1112018
I certify that I have read this application and state that the above Information is
CONSTRUCTION LENDING AGENCY
correct. I agree to comply with all city and county ordinances and state laws
I hereby affirm that there Is a construction lending agency for the performance
relating to building construction, and hereby authorize representatives of this city
of work's for which this permit is Issued (Sec. 3097, Civ C.)
to enter upon the above mentioned property for inspection purposes. (We) agree
Lender's Name
to save Indemnify and keep harmless the City of Cupertino against liabilities,
Judgments, costs, and expenses which may accrue against said City In
Lender's Address
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non -point source regulations per the Cupertino Municipal
ARCHITECT'S DECLARATION
Code, Section 9.18
L
1 understand my plans shall be used as public records.
/f% �—
Slgnatur �// Date 11111 /2018
Licensed
professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 131
12 (408)777-3228, building@cupertino.orQ PEI.4IT kB - 2o1 g 1 U
CUPERTINO REV#_ DEF#_
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PROJECTd
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OWNER NAME PHONE
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STREETADDRESS
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CITY, STATE, ZIP
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❑CONTRACTORNAME DWNER-BUILDER COMPANYNAME
LICENSE NUMBER
LICENSE TYPE
STREET ADDRESS
CITY, STATE, ZIP
E-MAIL
PHONE BUS. LIC R
❑ ARCHITECT F OWNER [] OWNERAGENT ❑ CONTRACTORAGENT❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTAT NAME�t d� _
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E-MAIL ,t
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STREET ADDRRSS
CITY, STATE, ZIP
PHONE
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DESCRIPTON
A 00 4 S l+nWC-74- A-iV D ! Z L T -(-o EX
VINGLE-FAMILY/DUPLEX ❑MULTI -FAMILY ❑ INDUSTRIAL [DCONIMERCIAL
USE
TYPE
OCC
SQ.FT,
VALUATION (§)
EXISTING USE
EXLSTING SF
NEW FLOOR SFPORCH
SF DECK SF
DEMO SF
STORIES @
TOTAL NETSF
BAAODEL THROOM SP
SP
SP MODEL OT�
SF
SF RAGE KDATTACHED
ETA HED
2 aad
EXISING EjjrIT YES
EICHLER [] YES
SECOND STORY ADDITION O
PIKE SPRINKLERS 'NL NO
❑ NO
DWELLING
SECOrONDDWELLING []YE3 []ATTACHED[]DETACHED OTHER
UNITS#
UNITADDITON: �iy'NO SF
POOLS ❑ FIBERGLASS Q VINYL -LINED ❑ GUNHE I] PREFABRICATED
POOL -SF SPA -SF I SPAATTACHED DYES ❑ NO TOTAL -SF
RECEIVED BY:
TO
L VALUATION:
Curumemial ar Milli-Fu,,ay Mldml.dth Public Sn. ,'us No 111 a il. Drnn t enf of Em,,W nWH.IhnP nN
RE -ROOF EXISTING ROOF TYPE:]BUILT-UPROOP❑ ASPHALT SHINGLES ❑WOOD SHAKES❑WOOD SHIN LES ❑ E OTHER(SPECIFY)
REMOVE REPLACE NO
IF NO
PLYWOOD ❑ �A" ❑ 3/8" PLYWOOD
TYPE:
PITCH:
ROOF CLASS
YES
P OF LAYERS
THICKNESS [:15/8" OTHER I
[]OSB ❑ CDX OTHER
- •12
A
PROPOSED ROOF TYPE: []BUILT-UP ROOF []ASPHALT SHINGLES I]WOOD SHAKES❑WOOD SHINGLES El OTHER
*Provide a sib Ted copy of the Cupertino's Tear -Off Policy SF gof SQUARES
By my signature below I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I
have read this application and the information I have provided is correct. I have read the Description of Work mid verify it is accurate. I agree
to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to
enter the above -identified property fox inspection pur oses. I acknowledge and authorize all information contained on this application form
to be made available for public record. J p
1 ®
Sim nature of Applicant/Agent- Date: / O
SUPPLEMENTAL INFORMATION REQUIRED
*New SFD/Second Dwelling Units/Multifaumly 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.
*HOA -Provide a letter of approval from the Home Owner's Association
B1dgApp2017.doc revised 08101117
CUPERTINO SANITARY DISTRICT
20863 Stevens Creek Blvd #100, Cupertino, CA 95014
Tel (408) 253-7071 • Fax (408) 253-5173
F, th
IV I is It E'o `� CUPERTINO
SANITARY DISTRICT PERMIT METIER
Cupertino Sanitary District has adopted Resolution No. 1263.
Building Permit Request
(Over -the -Counter)
E12 gle Family Project ❑ Multi -Family Project ❑ Commercial Project
Project Address: �, �,t,r0��S5 1..""1 .
Permit Number: V5-
Scope of Work: 1ailhftyx
Owner/Applicant Name: V056 l.i✓1.ywyy1 , Phone: 406- Ll 8�q - 2— Q( 0
Address:
Date: k lI I a
Prepared By:
City Authorized Representative
1, as property owner or authorized agent, acknowledge that all Cupertino Sanitary District requirements
will be met and all required fees will be paid prior to the approval of final inspection for proposed project.
Date: 611 /$ Signature:
Owner / Authorized Agent
CUPERTINO SANITARY DISTRICT OFFICE USE ONLY
Pre -inspection Req 'red ❑ Final Inspection Required
Date Scheduled: I I Z I
Date: (I I Conditional Approval By:
Authorize ep esentative
Cupertino ' a ary District
District will notify owner of the required fee within 5 days after Pre -Inspection has been completed and cc
City of Cupertino.
❑ Inspection Fee Paid Date Paid:
Inspection Fees:
D $250/unit - Single Family Residential already connected, but new cleanout is required
$150/unit - Single Family Residential already connected with existing cleanout in working order
$350 Minimum — Commercial and Retail Actual Amount:
O $200/each — Disconnect and/or abandon lateral service
Connection Permit Fees:
D $350/unit - Single Family Residential connecting to existing lateral
0 $650/unit — Single Family Residential connecting with new lateral
$100/unit — Multi, Hotel, Living Units, etc. Actual Amount:
$500/connection - Commercial and Retail Actual Amount:
Connection Use Fees (See Attached Calculation Sheet):
Area and Frontage Fees Amount:
C� Residential Excess Fees over 3.5 unit/acre Amount:
Commercial and Retail Connection Fees Amount:
D Commercial and Retail Change in Use Fees Amount:
Date:
Final Approval By:
Authorized Representative
Cupertino Sanitary District
V
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 okupertino.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 ADDRESSJG �G /LC -:SS C 1.
APN
BP#
OWcsS NER NAME
Cc�hz�.v
TOWNER ADDRESS
�cSS
DESCRIPTION OF WORK:
A 'F" %1 GC it 12 C 1'M C 10 c L
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.)
&(-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.
1L(L-2. I 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.
%l C 3. 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.
C 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.
/LC 5.1 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 "employer" under state and federal law.
�C 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.
161C 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.
k8. 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.
OirnerBuilderFornt 2010.doc revised 04114110
7
&9. 1 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.csib.ca.gov for more information about licensed
contractors.
110. 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.
& _i 1. 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.
k12. 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 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 the city may be required to be presented when the permit is issued
to verify the property owner's signature.
Property Owner's Signature: Date: D
---------------------------------------------------------------------------------------------------------------------------------------------
(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:
Address of Authorized Agent:
Tel No
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.
Property Owner's Signature:
Date:
Oii�iierBuilderFor-n: 2010.doc revised 04/14110