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12080170 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRISSS: 6445 BOLLINGER RD CONrRACI'OR: FRUEN WILLIAM J JR AND PERMIT NO: 12080170 LYN ETfG GTR OWNER'S NAME; FRUBN WILLIAM 11R AND LYNI ITE G TR 93 KIiLLOGG WAV DATE ISSUED:08/152012 OWNER'SPRONE: 4088368075 SANTA CLARA.CA 95051 1'110NEN0: ❑ LICE,NSrD CONI'RACI'OR'S DECLARATION BUILDING PERMIT INFO: 131.DC r ELECT r PLUbIB r License Class Lia# M ECH r RESIDENTIAL r COMMERCIAL r Contractor Date herchv affirm That I am licensed under the prnrisions of Chapter 9 JOB DESCRIPTION:6445 R 6445(DUPLEX)-REMOVE AND REPLACE(10) (coil]niencing with Section 7000)of Division 3 of The Business S Professions WINDOWS l'O DUPLEX Code and That nn•license is in Fiji]force:rad effect. 1 hereby affirm under penalty of perjury one of the following too declarations: I have and will maintain a cenificate 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:$8368 Section 3700 of the Labor Code,for the performance of doe work for which this permit is issued. APN Number:36920031.6445 Occupancy'['pc APPIACANf CERTIFICATION I certify That I have read this application and state Etat the above information is correct.I agree to comply with all city and county ordinances and state Imus relating to building construction,and hereby authorize representatives ofthis city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City ofCupenino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs.and expenses which may accme against said City in consequence ofthe Igo DAYS FROM LAST CALLED INSPECTION. granting ofihis permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 'J 9.18. Issuer) by: .�/✓ _ A/Gam/ Date: Signamre Date OWNF-RIBUILDER DECLARATION RF-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that 1 am exempt from the Contractor's License Lav for one of installed without first obtaining an inspection,1 agree to remove all nevi,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 not intended or offered for sale(Sce.7044, Signature of Appliamt: Date: Business B Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to construct The project(Sec.7044,Business S Professions Code). ALL ROOF COVERINGSTO RE CI-ASS"A"OR RETITR hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS NIATFRIAIS DISCLOSURE 1 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 Ilealth S Safely Code.Sections 25505,25533,and 25534. 1 will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code.Chapter 9.12 and the Ilealth S I have and will maintain[Porker's Compensation Insurance,as provided for by Safety Code.Section 25532(x)should 1 store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should 1 use equipment or devices which emit hazardous air permit is issued. contaminants as defined he the Bav Area Air Quality Management District I mill maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Ilealth S Safety Coda Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Compensation laws ofCalifomia. If,,after making this certificate ofexemption,I Ovine m ¢c e become subject to the Worker's Compensation provisions of the Labor Code,I in Dale. `J/rte %Z0 /'L forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLIC\N I'CERTI FICATION 1 hereby affirm that there is a construction lending agency for the performance of oork's 1 certify that I have read this application and sale that the above information is for which this permit is issued(Sec.3097,Civ C.) cored. 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 ofCupenino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Licensed Professional Signature �"" - Date 7/7 7 /o'b/�— ® �Q 19 61 I a 3 n J O o ov. 3 2. a ° o U' p..{ o,c a cK �I m • wK g mom g� 0 ov - 90a D cZio a 00, � a rood a t -Ow -,a o m ._. o` m � O z x . . m d m Z ❑ m�? �,w J m ° o m O C 1 z> .. fA m (n .a m o m O m 1 r x J ' Z m mom \~ y0 m O NQ r:. SG.3�h 35-. I/y x5-6.r/1 x � 04 ev d4xa/�-1u na W "� DVS -�V -C z T "•, ilk 0� '� c Pbyr Z `� /� O -4n 18 ' : b .N w o y zy fit • b �C mx f3 CTInus LE OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE"CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333• buildina(alcuoertino.oro 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 ADDRE // APN BPA ( ,44S Tel I7 3O��,�vtiti OWNER NAME OW ER ADDRESS �, I /t INR C 4.�s� F� wJ �31<k11 ,t 1 DESCRIPTION OF WORK: 2 F_ 7�/J C r� /U W- N 1-3'o J 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 (DIRE TIQNS: Please read and initial each statement below to signify you understand or verify this information.) 11. 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 /nss}�rraance coverage for injuries to workers on my property. v 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for g3I nstruction and are not hiring a licensed Contractor to assume this responsibility. . 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 na nstead of my own. 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license nu rs on permits and contracts. l —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 co ered an "employer" under state and federal law. 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 _e to serious financial risk. 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 X8-- ormed 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 is financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. OR'l1erB1(i1derFonn 1010.doc revised 04/14/10 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION :91 ADDRESS: 6445 BOLLINGER ROAD DATE: 08/15/2012 REVIEWED BY: SEAN APN: BP#: `VALUATION: $8,368 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY PENTAMATION USE: SFD or Duplex PERMITTYPE: 1GENRE A WORK Remove and replace 10 windows to duplex. SCOPE Meeh. Wan Check Plumb. Plan Check Elec.Plat Check Meeh. Permit Fee: Plumb.Permit Fee: £let. Permit Fee: Other dlech.Insp. Other Plumb Insp. L-1 I Otter Elec./nsp. Hoch-hasp. Fee: Plumb, beep. Fee: Fier.Imp. Fee: NOTE: This erti nate does not include jeev due to other Departments(i.e. Planning, Public ;Yorke, Fire,Sanitary Sewer District,School District, etc.). These feev are baser/nn the prefintinan information available and are on1v an evtinate. Contact the De t or aildn7 info. FEE ITEMS (Fee Resoludon I1-053 Eff i/l/ll) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 10 # Window/Sliding Glass Door Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $533.00 rn'hvRFP 7 Replacement PME Plan Check: $0.00 Permit Fee: $0.00 SuppI. Insp. Fee-.0 Reg. Q OT 0,0 1 hrs $0.00 PMC Unit Fee: $0.00 PMC Permit Fee: $0.00 Construction Tax: Administrative Fee: O Work Without Permit? O Yes (F) No $0.00 G Advanced Planning Fee: $0.00 Select a Non-Residential Travel Documentation Fees: 7-771 Building or Structure 0 A Suong Motion Fee: IRSEISMICR $0.84 Select an Administrative Item Bldg Stds Commission Fee: IRCBSC $1.00 SUBTOTALS: $1.84 $533.00 TOTAL FEE: 1 $534.84 Revised: 07/01/2012 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• buildino(a)cupertino.orG ,,11,, EI NEW CONSTRUCTION ❑ ADDITION rh,AI:I'ERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERNIIT9 FRUIT APN0i / '-- A OWIFR\AME V1IB Oo 3G gd7Ji STREETORskrI'p Wn cIFy�JA}'e.zIP ,I�M1� 9SOs1 FAX CONTACT NAME PHONE 1 EMAIL STRELI'ADDRISS CITY,STATE,71P � FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNEAAGrM 11CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAMED MA 42O0,4) LICENSE 0JG%1 O LICENSE TYPE BUS.LICA �k ss� /( 03 I.I COMPANYNAME A ! E-lM�A1L 7 FAX T < STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECTD'NGINEER NAME LICENSE NUMBER BUS.LIC 0 COMPANY NAME E-MAIL FAX STRELT ADDRESS CITY,STATE.ZIP PHONE DESCRIPTION OF WORK CO LXISTIG� PROPOS USE CONSTR� •SIO IES -:////�� 17 �/ USE TYPE OCC. SQ.IT. VALUATION ($) EXISTG SEW FLOOR DEMO TOTAL AREA ARE1 AREA NETAREA BATHROOM KITCHEN OTHER IIEMODELAREA RE\IODELARIIA REMODELAREA PORCHARFA DECK AREA TOTALDECKiPORCIIAREA GARAGEAREA: OET CH ATTACH Lj k DWELLING UNIT : IS A SECOND VNIT ❑YFS SF.COSDS'rORY ❑r�YES m..ISGADDKD? �$O ADDITION? P'_ PRE-APPLICATION ❑YES IF YFS,PROVIDE COPY OF IS TDE BLDG A? ❑Y RECF:I VIiD \•: TOT VALUATI�I\: PLANNING APPL 0�27M PLANNING APPROVAL LETT ER EICHLER HOSIE? ' _114%�� � 7 / `j l Y U By my signature below,I cenify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. 1 have read this application and the information I have provided is correct. I It e read c Description of Work and verify it is accurate. 1 agree to comply with all applicable local ordinances and state laws relating to buil g co 1 ion./tho epresentatives of Cupertino to enter the above-idenliGe/Qpro` for inspection purposes. Signature of Applicam/Agem: Date: )c O SUPPLEMENTAL INFOR-MATI REQUIRED PLANCHF.CKTYPE ROUTISGSLIP _New SFD.or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building o`'t:R=rm:-court n?R - !KNBUILDING PLAN REVIEW' permit for new building. ElEXPRESS ❑ PLANN'TNG PLAN REVIF.w' _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ TARGE ❑ FIRE DErr —Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. 11 MAJOR El SAp'1lWR\'$EW'ER OESTmCT ❑ ENv'LNON?IF,\TAC,IIEALTfI BldgApp2011.doc revised 0612///1