11120057A-4( CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDA7SS: 10377 AVENIDA LN CONTRACTOR: CHAWLA SHRI C AND PERMIT NO: 11120057
SUMITRA
OWNER'S NAME: CHAWLA SHRI C AND SUMITRA
10377 AVENIDA LN
DATE ISSUED: 12/08/2011
JftFR'R PHONE: 4089968858
CUPERTINO, CA 95014.3946
PHONE. NO:
❑ LICENSED CONTRACTOR'S DECLARATION
r r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lie. p
MECH r RESIDENTIAL r COMMERCIAL
Contractor Date
I hereby affirm that 1 am licensed under the provisions of Chapter 9
JOB DESCRIPTION: DEMO PREBUILT ILLEGAL DECK
(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.
I have and will maintain Worker's Compensation Insurance, as provided for by
Sq. Ft Floor Area:
Valuation: $500
Section 3700 of the Labor Code, for the performance of the work for which this
APN Number: 34245039.00
Occupancy Type:
permit is issued.
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 and state laws relating
PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
180 DAYS FROM LAST CALLED INSPECTION.
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
all non -point source regulations per the Cupertino Municipal Code, Section
Issued by: Date:/2-4C-7?'
9w Sh
Signature Date
RE -ROOFS:
OWNER -BUILDER DECLARATION
All roofs shall he 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
hereby affirm that I am exempt from the Contractor's License Low for one of
inspection.
the following two reasons:
,
1, as owner of the property, or my employees with wages as their sole compensation,
Signature of Applicant: Date:
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
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following three
HAZARDOUS MATERIALS DISCLOSURE
declarations:
1 have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self -insure for Worker's
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
Compensation, as provided for by Section 3700 of the Labor Code, for the
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
performance of the work for which this permit is issued.
Safety Code, Section 25532(a) should 1 store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance, as provided for by
Additionally, should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code, for the performance of the work for which this
contaminants as defined by the Bay Area Air Quality Management District 1 will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
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
Owner orrAorled a1r.
Compensation laws of California. If, after making this certificate of exemption, I
Dale: P_ I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION
for which this permit is issued (Sec. 3097, Civ C.)
I certify that I have read this application and state that the above information is
Lender's Name
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
Lender's Address
upon the above mentioned property for inspection purposes. (We) agree to save
nify and keep harmless the City of Cupertino against liabilities, judgments,
and expenses which may accrue against said City in consequence of the
ARCHITECT'S DECLARATION
ting of this permit. Additionally, the applicant understands and will comply
I understand my plans shall be used as public records.
with all non -poi source regulat' s per the Cupertino Municipal Code, Section
9.18.
/�J 6�v»
Licensed Professional
Signature Date
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3 ITEMS OF 3
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 34245039.00
DATE ISSUED.......: 12/08/2011
RECEIPT #.........: BS000015520
REFERENCE ID # ...: 11120057
SITE ADDRESS .....: 10377 AVENIDA LN
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA ......:
OPERATOR: patg
COPY # : 1
OWNER ............: CHAWLA SHRI C AND SUMITRA
ADDRESS ..........: 10377 AVENIDA LN
CITY/STATE/ZIP ...: CUPERTINO, CA 95014-3946
RECEIVED FROM ....: VIJAY CHAWLA
CONTRACTOR .......: LIC # *OWNER*
COMPANY ..........: CHAWLA SHRI C AND SUMITRA
ADDRESS ..........: 10377 AVENIDA LN
CITY/STATE/ZIP ...: CUPERTINO, CA 95014-3946
TELEPHONE ........:
FEE ID
----------
UNIT
-------------
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
NEW BAL
1BCBSC
VALUATION
----------
500.00
----------
1.00
----------
0.00
----------
1.00
----------
0.00
1BSEISMICR
VALUATION
500.00
0.50
0.00
0.50
0.00
1STINSP
UNITS
1.00
130.00
0.00
130.00
0.00
TOTAL PERMIT
----------
131.50
----------
0.00
----------
131.50
----------
0.00
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT :
AMOUNT
---------------
131.50
---------------
131.50
VOICE ID DESCRIPTION
-------- ----------------------------
704 DEMO
REFERENCE NUMBER
--------------------
AMEX
VOICE ID DESCRIPTION
-------- ----------------------------
DEMOLITION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildinG(dlcuoertino.GrG
( ( I �- oc�:$57
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PROJECT ADDRESS (0��1 ,`�/.rs O ( J1I 1>tJ�
APNM 32 CJ
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OWNER NAME %11'
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STREET ADDRESS o s I `7 A t/ e tit V`a Vr 4
CRY' STATE, ZIP C AIb
FAX
CONTACT NAME t r'r-. r�
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MEET ADDRESS
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CrrY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER -BUILDER Ll O"ERAGENT ❑ COM CrOR ❑CONTRA=R A0ENr ❑ ARCHr1ECr ❑ ENOMBCA ❑ DEVELOPER ❑ TENANT
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CONTRACTOR NAME 1
1
IJCHNSE NUMBER
I.iCEN581YPa
BUS. UC tl
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CfrY, STATE, ZIP
PHONE
OESCR7nON OF WORK 'rte U'l l L
RESIDENTIAL
0DWELLING
'r'' -e• " - 1 - f.+'s«"' -. ,. -
n
OOR AREA
UNCl9arc
FLOOR AREA
TYPE OF CONSTRUCTION
ASTORIES
AQPVM JOB NUMBER }y
" aemngp➢rpY r _� - " "� j
VALUAT{gN:
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By my signature below, I certify to each of the following: I son 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 and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building trioti. a orize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature ofApplicanUAgenD Date: �Z _
SUPPLEMENTAL INFO QU RED PRIOR TO ISSUANCE OF DEMOLITION PERMIT
—Provide Job Number from Bay Area Air Quality Management District wvnv.baaemd.orE @415-749-4762,
_ Provide three copies of a site plan showing protection for any trees 19' in diameter or more at 3' above grade.
Provide letter from PG&E (408-725-3325) stating all gas and electric has been disconnected.
_ Provide a letter of inspection, tests, and abatement of any Hazardous Materials. Letter in be initiated by person(s)-,"
,y?>
certified in asbestos, mercury and/or hazardous material examination.
_'�.: NFA�aiiit,^ ��' " ..a "
_ Planning Dept clearance to verify building is not considered an historical landmark. Allow 10 business days.
- ,-
_ Provide letter of clearance of all vermin from a licensed pest control contractor.
Applicant shall call the Public Works Department at 408-777-3104 and schedule a "habitable dwelling" inspection.
Provide signed Debris Bim and Recyclable Materials form.
Y 1 w L"S
Commercial Buildings Only: Provide Fire Dept clearance for fire suppression / alarm system review.
•
DemoApp_201I.dac revised 03/16/11
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�� CITY OF CUPERTINO
ISI FEE ESTIMATOR - BUILDING DIVISION
NOTE: This estimate does not include fees due to other Deparnrtents (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc. ). These fees are based on the Drellminary Information avrdlahle and are an/v an ovilm to. Cnnmrt tho Don/ far nddn'/ info
FEE ITEMS (Fee Resolution /1-053 Ejj 7/1/11)
ADDRESS: 10377 avenida In
DATE: 12/08/2011
REVIEWED BY: bob s.
Mech. Perruri Piro:
APN:
BP#:
'VALUATION:
$500
*PERMIT TYPE: Demolition Permit
PLAN CHECK-7'4PE: '
PRIMARY SFD or Duplex
USE:
Eler, Ince. Fee
PENTAMATION 1SFDWL-DEM
PERMIT TYPE:
WORK
demo re -built illegal deck.
SCOPE
0,0
NOTE: This estimate does not include fees due to other Deparnrtents (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc. ). These fees are based on the Drellminary Information avrdlahle and are an/v an ovilm to. Cnnmrt tho Don/ far nddn'/ info
FEE ITEMS (Fee Resolution /1-053 Ejj 7/1/11)
lferh. Thur Cho, Ic
A'ln,ub. Platt Check
Elea Plan Chcek
Mech. Perruri Piro:
Plun:h. Perini[ Five:
E/"e. Permit Fire:
Other dlrch. 17rsP-
f)fhr.r Phtorh brsp,
Ofhe,Efer: Lr.gz
,11'ech. InV>. Fee:
Plumy. lnvp. Pce:
Eler, Ince. Fee
NOTE: This estimate does not include fees due to other Deparnrtents (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc. ). These fees are based on the Drellminary Information avrdlahle and are an/v an ovilm to. Cnnmrt tho Don/ far nddn'/ info
FEE ITEMS (Fee Resolution /1-053 Ejj 7/1/11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
Supp!. PC Fr e
F'lrnnh. %A�e[:h.11 he
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. Q OT
0,0
1 hrs
$0.00
1'lrunb.9Ylech.:"lk;c
Plamh_:ldech..L'lec Permit Fee:
C inWrucfitm Tcr.c:
Aelntinistrative Fee'
Yf'ork IT'ithout Parmil?
Idvanced Planning Fees:
T raves Docomcmation Fees:
Strong Motion Fee: IBSEISMICR
$0.50
1.0 hrs Inspections
$130.00 ISTiNSP Inspection, Hourly
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$1.50
$130.001 TOTAL`FEE:
$131.50
Revised: 12/04/2011
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CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(406) 777-3228 - FAX (408) 777-3333 - buildina(a)cuoertho.oro
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: r
LI
SITE ADDRESS' �� pl,-; ' ,^
l./ I
AP y _ ys^D�
BP#
OWNER NAME ay�L��{�/k1lJ�
OWNER ADDRESS .., ^. ejA '
LYl/
DESCRIPTION OF WORK: /
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
(DIR,,E,,rrCTIONS: Please read and initial each statement below to signify you understand or verify this information.)
V`1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
3 r?*' 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.
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.
. 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.
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
"_'C5. 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 "employer' under state and federal law.
1\,�_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.
V--7. 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
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
• his performed under contract with a licensed general building Contractor.
—9-1 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.
avnerBuilderForm 1010.doc revised 04114110
_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 vvww.cslb.ca.gov for more information about licensed
contractors.
V`_10. lam 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.
V' 11. 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.
V�_12. 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 perml 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 verifv the orooerty owner's signature. ___11n n
Property Owner's Signature:
(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:
OwnerBuilderFonr n 2010. doc revised 04/14/10
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