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12010123 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10358 GLENVIEW AVE CONTRACTOR:MOHAN SRINIVASAN PERMIT NO: 12010123 OWNER'S NAME: M(_)HAN SRINIVASAN 103511 GLENVIEW AVE DATE ISSUED:01/19/2012 OWNER'S PHONE: 4082037443 CUPERTINO CA,CA 950144511 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB f License Claus Lic.# j__.. MECH RESIDENTIAL COMMERCIAL ' Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPAIR GARAGE DAMAGE DUE TO CAR RUNNING (commencing with Section 7000)of Division 3 of the Business&Professions ACCIDENT(PREVIOUS PERMIT EXPIRED#10040007) Code and that ruy license is in full force and effect. I hereby affirm under penalty of perjury one of the following t7wo declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided to(-by Section 3700 of the Labor Code,for the performance of the work fae which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$13000 Section 3700 of the Labor Code,far the performance of the work for which this permit is issued. APN Number:36911023.00 Occupancy Type: 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 haws relating to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnity and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 1$0 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 1$0 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.13• Issued b �--'"-•. Date: Signature Date j" OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is �Ikhe affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining art inspection,I agree to remove all new materials for the following two reasons: inspection. 1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is riot intended or offered for sale(Sec.7044, Signature of Applicant: Date: Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(:Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby af►irtu under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation.as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of tire work for which this Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the perfarntance of tie work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Compensat€on laws of California. If,after making this certificate of exemption,I Owner o author' ed agent: become subject to the Worker's Compensation provisions of the Labor Code,I must Date: forthwith comply with such provisions or this permit shall be deerned revoked. t:ONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the perfortna.nce of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs.and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. '*� �kI / icensed Professional Signature Date ` 1 OWNER-BUILDER DISCLOSURE FORM is COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)777-3333• building(a-�cuoertino.org 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 ADDRESS --� C� i APN BP# JZ) 5 / V OWNER NAME OWNER ADDRESS DESCRIPTION OF WORK: C 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- wilder' 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. - 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. 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 vlotal 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. ��/v6. 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. 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 is performed under contract with a licensed general building Contractor. 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. OianeiBuilderForn: 2010.doc revised 04/14/10 C/N59. 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.cslb.ca.gov for more information about licensed contractors. .' 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. -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. Vnfor 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the mation 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 si n Property Owner's Signature: L Date: Yi `� --------------------------------------------------------------------------------------------------------------------------------------------- (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 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. 1 Property Owner's Signature: Date: �� Z VP V Ox,»erBuilderForm 2010.doc revised 04/14/10 CITY OF CUPERTINO 3 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp; Rng: Sub: Blk: Lot: APN . . . . . . . . : 36911023 . 00 DATE ISSUED. . . . . . . : 01/19/2012 RECEIPT #. . . . . . . . . : BS000015784 REFERENCE ID # . . . ; 12010123 SITE ADDRESS . . . . . : 10358 GLENVIEW AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : MOHAN SRINIVASAN ADDRESS . . . . . . . . . . : 10358 GLENVIEW AVE CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4511 RECEIVED FROM . . . . ; MOHAN SRINIVASAN CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : MOHAN SRINIVASAN ADDRESS . . . . . . . . . . : 10358 GLENVIEW AVE CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4511 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ----•------ ---------- ---------- ---------- 1BCBSC VALUATION 13, 000 .00 1. 00 0 .00 1 .00 0. 00 1BSEISMICR VALUATION 13, 000 .00 1 .30 0 .00 1 .30 0. 00 1STINSP UNITS 2 .00 260 . 00 0 . 00 260 .00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 262 .30 0. 00 262 .30 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 1, 744 . 30 MC --------------- TOTAL RECEIPT 1, 744 . 30 12,01 CA Z� CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION 3 ADDRESS: 10358 glenview ave. DATE: 01/19/2012 REVIEWED BY: bob s. APN: BP#: 'VA I I J A TION: $Q/ PERMIT Tt'PE: Building Permit PLAN CHECK TYPE: Alteration /Repair PRIMARY SFD or Duplex PENTAMATION USE: PERMIT TYPE: WORK repair garage damage due to car running accident. SCOPE Ll Li ]VOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These Les are based on the prelinina information available and are onl an estimate. Contact the Det or addn'l in o. FEE ITEMS I?es,._ f;c>rr , f);i3 ''7 1 FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure Suppl.PC Fee: Q Reg. Q OT El hrs $0.00 or Element of a Building PI't-tE Plain Check: $0.00 Permit Fee: Hourly Only? 0 Yes Q No $0.00 Suppl. lisp. Fee-0 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee:: $0.00 PME Permit Fee: $0.00 Work `'Without Permit? 0 Yes (D No $0.00 _1 eek $0.00 hours Inspections { $260.00 1 STINSP Inspection,Hourly 0. - Fee:: $0.00 Select an Administrative Item $0.00 SUBTOTALS: $0.00 $260.00 TOTAL FEE: 1 $,-460'.001 Revised: 1/01/2012 l CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333• buildingCcDcupertino.org CUPERTINO nQ � ❑NEW CONSTRUCTION ❑ ADDITION ,�.L�J1 ALTERATION/TI ❑ REVISION'/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS APN# / `j 1 L?��s`� t��sv �v 1 C AV>= OWNER NAME ONE -7 U }—� f N' S�l N f V A S/t PH -2 "}- 1 4� E-MAIL STREET ADDRESS CITY, STATE,ZIP L FAX CONTACT NAME �.�.__�� PHONE E-MAIL STREET ADDRESS CITY,STATE, ZIP FAX OWNER 11 OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT 13 ARCHITECT 11 ENGINEER El DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK - P A,tA EXISTING USE PROPOSED USE CONSTR TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION(S) NEW FLOOR DEMO TOTAL AREA /� AREA AREA AREA NET.4REA _J{ BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA DETACH ❑ATTACH #DWELLING UNITS: IS A SECOND UNIT []YES SECOND STORY ❑YES BEING ADDED? []NO ADDITION? [-]NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: TOT _ VALUATION: PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO By my signature below,I certify to each of the following: I am the property owner or authorized agent to act o 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 const'ructign. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of ApplicandAgdnt: J Date: G' SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for �R-THE-COUNTER El BUII DING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANnARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANrrARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_201 1.doc revised 06/21/11