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12050145 CITY'OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18485 CHELMSFORD DR CONTRACTOR:DAN&LINDA PERMIT NO: 12050145 Y UKAWA OWNER'S NAIVE: DAN&LINDA YUSUKAWA IS 85 CHELMSFORD DR DATE. ISSUED:0511812012 OWNER'S PHONE: 4082420554 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL U COMMERCIAL License Class Lic.H CONVERT EXISTING TUB/SHOWER COMBO INTO SHOWER ONLY Contractor Date "30 MIN DIAMETER AND TILE TO 72" INSTALL I hereby affirm that I am licensed under the provisions of Chapter 9 SMOKE/CARBON MONOXIDE DETECTORS (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 1 hereby affirm under penally 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 Labra Code,for the performance of the work for whichthis permit is issued, Sq.F1 Floor Area: Valualion:$9500 1 have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for bre performance of the work for which this APN Number:31522048.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION 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 upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may acerae against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply 155ued by: ,�C�N I�/l/� Date: ✓ 'IB '�p 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 bong installed.If a roof is installed without first obtaining an inspection.1 agree to remote all new materials for inspection. OWNER-BUILDER DECLARATION : 1 hereby affirm That 1 am exempt from the Contractor's License Lew for one of Signature of Applicant Dale: the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) 1,as owner of the properly,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Scc.7044,Business&Professions Code)., , 1 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 following7h Q. maintain compliancewith the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(x)should 1 store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's - material. Additionally,should t use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for whichthis permit is issued. will maintain compliance with theerlino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Section 2 505,25533,and 25534. Section 3700 of the Labor Code,for bre performance of the work for which this permit is issued Owner or authorized agent: ale: I certify that in the performance of the work for which this permit is issued,I shall not employ any person inany manner so as to became subject to the Worker's Compensation laws of Cal ifomo. If,after making this certificate of exemption,I CONSTRUCTION I-ENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,1 most 1 hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 and state laws relating to building construction,and hereby authorize 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, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-poin sourceregula'crs per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature tri..-. a . Dale CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 31522048. 00 DATE ISSUED. . . . . . . : 05/18/2012 RECEIPT #. . . . . . . . . : BS000016855 REFERENCE ID # . . . : 12050145 SITE ADDRESS . . . . . : 18485 CHELMSFORD DR SUBDIVISION . . . ... . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : DAN & LINDA YUSUKAWA ADDRESS . . . . . . . . . . : 18485 CHELMSFORD DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : DANIEL YASUKAWA CONTRACTOR LIC # *OWNER* COMPANY . . . . . . . . . . : DAN & LINDA YUSUKAWA ADDRESS . . . . . . . . . . : 18485 CHELMSFORD DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- -------— ------- ---------- 1BCBSC VALUATION 9, 500 .00 1. 00 0.00 1 .00 0.00 1BSEISMICR VALUATION 9, 500 .00 0. 95 0. 00 0.95 0.00 1STINSP UNITS 2 .00 260. 00 0. 00 260 .00 0.00 TOTAL PERMIT 261. 95 0 . 00 261 . 95 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- ----------- CHECK 261.95 4525 --------------- TOTAL RECEIPT 261. 95 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333• buildti-ngacuoertino.ora I :zb!50 J � [I NEW CONS'IRt1C-110N ❑ ADDITION ALTT?RA-n0N/T1 LJ REVISION/DEFERRED ORIGINALPERMITH PROII':(.T ADDRESS /r///8S G �S APN q 5c Ol\'NEER NAME 7�q.� A H NP110Nn :J /i-MAIL CC1 STRlil:l'ADDI(IiSS a/ftlS c CITY,6u /I/�n FAX CONT ACT NAMI- o�`I bLl.]vl nGSU 'li- vluice Y>vcn. STREET ADDRESS 14.l�� CNS/r')'Ir /Lt k7Y CITY, TATE. ZIP FAX O0`7f u ✓f ins (!!C C DI rig,WNIiR OWNERI-BUILDER �❑ OWNERAGFNr ❑ CONTRACTOR ❑CONTRACTORAGF.NI ❑ ARCHUECT ❑ENGINEER ❑ DEVEWPER ❑TENANT CONTI(AC'I'OR NAMIi ��,,}y L LICENSE NUMBFR& ��LICINSETYPE J3/ EUS.LICIT COMPANY NAMEY •��eudy Cuyt fir]✓uL fMAIL Wti✓C✓i� �-' !IG/- r' FAX T STREErADDR1;SS /� �- rJ(r/[` �Q�� CITY,STATE.ZIP PIIONE 6 PC-0 S-b o -1140•. ARCIH I'IiCI'A;N(11NEER NAME NA LICENSE NUMBER /Y l .rr^ BUS.LIC 0 N� COMPANY NAME Air�'r /NtIiMA1L 1 /^'T FAX SI RE6f ADDRESS k44 CITY,STATE%ZIP tit PHONE hj14 DEsclurrION OF WORT: f06H tJC✓"l" P r`IF1„c '544Jr/SLtoWr../ fo M,bp IhfO /Tc cJ s/?oGJI✓ 7rtcic.a/n cf Cna�t'CtfJtOr' '�l l I �rG J i<Io P/�dvt, Lj a✓t a. S ca/-1 rev 4A r f r D H7 Pc lnsl�Gf O)� ,,151 INC.USii PROPOSED USE CONSTRTYPE YSTORIES Si at./l Sine/C »vl W`ed Z USE TYPE OCC. SQ,FI'. VALUATION(S) E.XISTG NEW'[LOOR DEMO TOTAL AREA -776 AREA Q AREA C.7 NETAREA 277 6//' Sr)Tj IP •til nL1nP✓ Z7n / O u / KITCHEN OTHER RE MIOOFIO.AREA /Xl 1 RF.MODELARFA AY 1A REMODELAREA y PORCII ANI:A DECK EEA TOTALDECK/PPOr RCRARFA GARAGEAR}A: DETACH TT N^I N^ M ' T ACH ODWEL1.INGUNFFS'. 'T I.SASECONDUN'RV ❑YES SRCOND S?ORY ❑YES BEING ADDED? NO ADDRION? CPO PRE-APPLICATION []YES IF YES,PROVIDE COPY OF IS THE BLOC AN ❑YES 'RI'(fIVE NY` � j PLANNINGAPPLO QNO PIANNINGA OVALLETTER EICULFR HOME? bt10 ... TOTAL VALUATION: Ilv my signature below,1 certify to c hof c following: 1 am the properly owner or authorized agent to act on the property owner's behalf. 1 hm'c read this application and the information 1 hav prov ed is rn I have read the Description of Work and verify it is accurate. 1 agree to comply with all applicable local ordinances and slate laws relating to b ild' co on 1 aulhorim rcprescnla ivcs of Cupertino to enter the above-identified property for inspeclion Purposes Signalure of ApplicanllAgern:_ _ _�'�./�... 'Date: _I g_f Sl1PPLIdMfiN"fA NPO ON RGQUIRPD r PLAN IPCRT1Ph% Rolmu u.IP New SPD or Multifmnily dwellings: Apply for demolition penrlit for -ls r ovt R nT 7t colnTFE .e.uu mNc An RtUtqcXIStili6bmldtng(s) 1)Cmolition Pit is required prior to issuance of buimrzg permit for new building. F XMX ti � ❑. PLANNING PLAN REV]t w ,_ _Commercial Bldgs: Provide a completed Ha�arclous Materials Disclosure ❑ sT}n DARD 0 ❑:-PUBI IC WORKS form it any I la/.ardous Materials are being used as part of this project. .- 5n55 mYY _Copy ol'Planning Approval Letter or Meeting with Planning prior to ❑,MA.R1R'=.x L 4� f❑ 5.1\IT,\RY St.\VhR DISTRICT.: submittal ol'Bttilding Permit application. r _M1 +.�.-,}4 ❑. ENVIRONMENTAL IIF\1 T11}+ lfldgApp_2011.do revised 06/11111 CITY OF CUPERTINO FEEESTIMATOR,— BUILDING DIVISION ADDRESS: 18485 CHELMSFORD DR DATE: 05118/2012 REVIEWED BY: Sylvia APN: BP#: 'VALUATION: $9,500 "PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD Or Duplex PENTAMATION 1GENRES USE: PERMIT TYPE: WORK CONVERT EXISTING TUB/SHOWER COMBO INTO SHOWER ONLY 30" MIN DIAMETER AND SCOPE TILE TO 72"). INSTALL SMOKE/CARBON MONOXIDE DETECTORS IS EXISTING SFD. Alech. Plan Cheek Phunb, Plan CherA lave. Ilan Cheek ,llrrh. P',rmit Fee: Phenh. Pcronii Fac: Flee-, Pee mh Fre: Ocher.1 fvvh. Insp. Other Plumb Insp. odder Oe'. In ,Rech_ hr'p. Fea Phunb. /nrp. Fee: Pact.Insp. Fee: NOTE:This estimate does not include fees due to other Departments(ie.Planning, Public Works,Fire,Sanitary Sewer District,School District,etc). Thesefees are based on the prefimina information available and are only an estimate Contact the Deal for addn 7 info. FEE ITEMS (hee Resolution 11-053 Eff. 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? Q Yes E) No $0.00 0 hours Plan Check,Hourly Suppl. PC Fee: E) Reg. Q OT 0.0 hrs $0.00 $0.001 1 PME Plan Check: $0.00 Permit Fee: Hourly,Only?: 0Yes 0 No $0.00 Suppl. Insp. Fee:Q Reg. Q OT0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 C'unso uction Tax. Admillisurtiive Fee: O Work Without Permit? O Yes E) No $0.00 E) Advanced Planning Pee: $0.00 2 hours Inspections T;urel Documentnlion Fees: $260.00 ISTINSP Inspection, Hourly 0 Strong Motion Fee: IBSEISMICR $0.95 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $1.95 $260.001 TOTAL FEE: 1 $261.95 Revised: 04/01/2012 - i OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228-FAX(408)777-3333- building(a)cuoer ino.ora 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 ADDE S APN BPM 'edOW ME ` -OWNERADDRESS ! ,!,NA DESCRIPTION OF WORK: e 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.) I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- I eI- building permit that erroneously implies that the property owner is providing his or her own labor and material pers nally. 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. WI understand building permits are not required to be signed by property owners unless they are responsible for eonstruction and are not hiring a licensed Contractor to assume this responsibility. We 3. 1 understand as•an "Owner-Builder' I am the responsible party of record on the permit. I understand that I may ct 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 15Aers on permits and contracts. 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. . I understand if I am considered an "employer' under state and federal law, I must register with the state and e er I 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. 4I understand under California Contractors' State License Law, an Owner-Builder who builds single-family esntial structures cannot legally build them with the intent to offer them for sale, unless all work is performed by ed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work i erformed under contract with a licensed general building Contractor. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for y Inancia1 or personal injuries sustained by any subsequent owner(s)that result from any latent construction def cts in the workmanship:or materials. OwnerBuilderFornl 2010.doc revised 04/14/10 I understand I may obtain more information regarding my obligations as an"employer"from the Internal �p�q{�'nue 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 c tractors. . I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I party legally and financially responsible for proposed construction activity at the site address listed above. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all pplicable laws and requirements that govem Owner-Builders as well as employers. 12. 1 agree to notify the issuer of this form immediately of any additions, deletions,or changes to any of the int rmation 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 responsibl or Issuing the permit. Note:A copy of the property owner's driver's license, form notarization, or other verificatio ceptable to the city may be required to be presented when the permit is issued to verify the property owner's sin t Property Owner's Signature' Date: ----- ------------- - --- ---- ---- -------- ---- ------- ---b----------- - - ----- ------pert------ ----- y--- ---- --------- -g--a-The following Authorization Form is required to e 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 owners signature. Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revised 04/14/10