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12100137CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: 18485CIIELMSFORD DR CON1'RACI'OR: YASUKAWA DANIEL G PERMITNO: 12100137 AND LINDA L OWNER'S NAME; YASUKAWA DANIEL G AND LINDA L 18485 Cl I ELMSFORD DR DATE ISSUF,D: 10/172012 OWNER'S PRONE: 4082420554 CUP iRTINO, CA 95014 PRONE NO: ❑ . LICFNSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT Cl PLUMB r License Class Lie. t! J DfECIf — RESIDENTIAL COMMERCIAL 'd Contactor Date hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. 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 Section 3700 of the Labor Code, for the performance of die work for which this permit is issued. AI'PLICA\ I' CFR'1'IFIGVI'ION I certify that I have read this application mid state 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, costs, and expenses which may aceme against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date ❑ O\VNF-R- RUILDER DECLARATION 1 hereby affirm that I am exempt from (he Contractor's License I -a" for one of the following two reasons: 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) I, as owner of (he property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). hereby oflirm under penalty of perjury one of the following three declarations: 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. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the perfomance of the work for which this permit is issued. I certify that in the perfommnce 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 Compensation laws of California. If, after making this certificate of exemption, 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. APPLICANT CERT'IFICAT'ION I certify that I have read this application and state that the above information is correct. 1 agree to comply with all city and county ordinances and state lows 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 Cupenino against liabilities, judgments, costs, and expen5 which may accrue against said City in consequence of the granting of this p d. Additionally, the applicant understands and will comply with all non -poin s r1n rce regulations per the Cupertino Municipal Code, SCCEmn 9.18. A ,JOB DESCRIPTION: ADD ONE ELECTRICAL CIRCUIT FOR INSTALLATION OF NUI1BAT FLOOR HEATING SYSTEM FOR BATI (ROOM Sq. Ft Raor Area: I Valuation: $775 APN Number: 37522048.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS _FROM / LAST CALLED INSPECTION. Issued by: %7i// Date: IU',/%,IJ RE-ROOFS: All roofs shall be inspected prior to my roofing material beiig installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS NIATF-RIAIS DISCLOSURE have read the hazardous materials requirements under Chapter 6.95 of the California Ilealth & Safety Code. Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Coda Chapter 9.12 and the Ilealth & Safety Coda Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by (he Bay Area Air Quality Management District I will mainta compliance with the Cupertino Municipal Code. Chapter 9.12 and the lleallhafety Code. Sections 25505. 25533, and 25534. Ow iet nr aut nri >, pgen ' I 9 Date: CO,NSTRUC1'ION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION WFADDRESS: 18485 Chelmsford Dr. DATE: 10/17/2012 REVIEWED BY: Sean UNITS APN: BP #: 'VALUATION: $775 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: $45 PENTAMATION 1REAP10 PERMIT TYPE: WORK Add one electrical circuit for installation of Nuheat floor heating system for bathroom. SCOPE APPLIANCE / EQUIP TYPE FEE ID Plumb. Plat Cheek QTY UNITS BP FEES Elec. Permit Fee: IEPERMIT Recep /Switch /Outlets 1BREMRECEP Other Elec. Insp. 0.0 hrs $45.00 1 # $45 Permit Fee: Suppl. /nsp ree PME Unit Fee: $45.00 PME Permit Fee: $45.00 Construction Tae: Administrative Fee: IAD,tfhv $42.00 Work Without Permit? O Yes Q No $0.00 TOTALS: Travel Documentation Fee: ITR.IVDOC $45.00 Strong Motion Fee: IBSEISAHCR NOTE: This estimate does not include jeer due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sever District, School District. e1c. ). These lees are based an the nredintinan information available and are onh, an estimate Contact the Dent for arddn'I Into. FEE ITEMS (1?ee Resohuion 11 -053 L•Yt 711112) Xlech. Plan Check Plumb. Plat Cheek Elec. Plan Check 0.0 1 hrs $0.00 Alech. Permit Fee: Plumb. Permit Fee: Elec. Permit Fee: IEPERMIT Other,lfech. Insp. Other Plumb Insp. Other Elec. Insp. 0.0 hrs $45.00 .Ilech. Insp. Fee: Plumb. /nap. ree• Flee. Insp. rec: NOTE: This estimate does not include jeer due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sever District, School District. e1c. ). These lees are based an the nredintinan information available and are onh, an estimate Contact the Dent for arddn'I Into. FEE ITEMS (1?ee Resohuion 11 -053 L•Yt 711112) FEE QTY /FEE MISC ITEMS Phan Check Fee: Suppl. PC Fee PME Plan Check: $0.00 Permit Fee: Suppl. /nsp ree PME Unit Fee: $45.00 PME Permit Fee: $45.00 Construction Tae: Administrative Fee: IAD,tfhv $42.00 Work Without Permit? O Yes Q No $0.00 Advanced Planning reel: Travel Documentation Fee: ITR.IVDOC $45.00 Strong Motion Fee: IBSEISAHCR $0.50 Select an Administrative Item Bldg Sids Commission Fee: IRCRSC $1.00 SUBTOTALS: 1 $178.50 $0.00 TOTAL FEE: 1 $178.50 Revised: 10/0112012 CUPERTINO OWNER- BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • buildino cuoenino.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 ADDRESS IDTD liVl $�j_{'� BP# OWNER NAME--t,,, H SL[ W OWNERADDRESS CtrPIINrS cl DESCRIPTION OF WORK: — P oz 47) e P P i✓rp d e I P L % 0- P I ✓ 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 verity this information.) l I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Build 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 I e c nslruction 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 Prot 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. I understand Contractors are required by law to be licensed and bonded in California and to list their license A*n e.rs on permits and contracts. 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the ota 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 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 m to serious financial risk. I understand under California Contractors' State License Law, an Owner - Builder who builds single - family resl ential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by lice sed 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. I understand as an Owner - Builder if I sell the property for which this permit is issued, I may be held liable for any fi ancial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defec s in the workmanship or materials. OwnerBuilderFor-m 2010.doc revised 04 114 110 V `1 N nuI understand I may obtain more information regarding my obligations as an "employer" from the Internal e 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 c tractors. W0. 1 am aware of and consent to an Owner - Builder building permit applied for in my name, and understand that I amt a party legally and financially responsible for proposed construction activity at the site address listed above. 1. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide applicable laws and requirements that govern Owner - Builders as well as employers. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the in or t non I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you c lract 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.) 1 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: WA Lender Address: k 14, Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible f issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification cc ptable to the city may be required to be presented when the permit is issued to verify the ro ert owner's si natu Property Owner's Signature: t~ U Date: Z (NOTE: The following Authorization F--o- r-m is -r-e- q--u-i-re-- equired to -b- e completed by the property owner only when designating -a- n 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: 1►L.] 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: OwnerBuilderFomi 2010.doc revised 04 114110 CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • buildinD(8cuoertino.ore 2-( v U l 3� MEP nPLUMBINC nMECI1ANICAL IXIELECIRICAL nMiSCELLANEOUS {a PROJECT ADDRESS 'I G"I �j C 11 e f wIS�I3�G) APN a O - C. -315, -� a - 0'7 8 OWNER NAME ' L) ti elf, \�'Q �^ fFKS FIIOLC•T�' ` �. ` .' S' E.1rVL C STREET ADDRESS I (` (U� C i o GI ' C7Y �7 • �A ` 4 '`r SO L I FAX CONTACT NAME —lS PHONE E -MAIL STREET ADDRESS CRY. STATE. ZIP FAX 11 OWNER ❑ OWNER- BUILDER ❑ OWNERAGENT ❑ com RACrOR O comrRACrORAGENT 13 ARCHRECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORNAME I i t'G.a. LICENSE NUMBER j&'e � LICENSE TYPE BUS. LIC0 COMPANY NA)61E / /I tl (G SJYNC B -MAIL FAX STREET ADDRESS P Q L7 - S(7S(o -4 7 Ise CRY. STATE. ZIP �" h ,�� - / PHONE ARCHITECTJENORJEFR NAME LICENSE NUMBER BUS. LIC a COMPANY NAME E-bNIL FAX STREET ADDRESS CRY, STATE, ZIP PHONE USE OF PSFDmDUPLEX ❑MULTLFAMILY BUILDING: COMMERCIAL PROJECT IN WILDLAND ❑YES URBAN INTERFACE AREA NO PROJECTIN ❑YES FlAOD LANE NO ISTNE BLDG AN ❑YES EICHLERHOMEa NO DESCRIPTION OF WORK: ,(' A "r e PLyylCs e I J ktv AP Pali-P TOTAL VALUATION: -77SItEG ©VEU 13y my signature below, I certify to cac of he follati 1 am the property owner ar authorized agent to act on the property owner's behalf. I have read this application mid the infonmalim l lave v is I have lead the Dewriptvan of hock and verily it is accumte. I agree b comply with aR applicable local ordinances and state laws relating to Iildi g con 1 authorize representatives of Cupertino to enter the above - identified properly for inspection purposes. Signafurc of Appiicanl/Agent: r1� .G hJ� Data: S JiME L INFORMA'T'ION R1iQl11RHD � ,t,,OFF7CRtLSF OBI \.R M L i OV.A+s6 I 1lti� r a0 \'F.R- TItE•CO twm, ..° .. _ -7 - hn AERLliscrl pp 10I hloc revised 0612 / /11 CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 18485 CHELMSFORD DR OWNER'S NAME: YASUKAWA DANIEL G AND LINDA L OWNER'S PHONE: 4082420554 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lie. N Contractor �aW I hereby affirm that I am licensed under the provisions of Chapter 9 (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 - insme 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 Section 3700 of the Labor Code, for the performance of the work for which this 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 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, costs, and expenses which may accrue against said City inconsequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date- rOWNER- BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: I, as owner of the property, or my employees with wages as thew sole compensation, 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 construct the project (Sec.7044, Business & Professions Code). CONTRACTOR: YASUKAWA DANIEL G I PERMIT NO: 12100137 AND LINDA L 18485 CHELMSFORD DR DATE ISSUED: 10/172012 CUPERTINO, CA 95014 I PHONE NO: JOB DESCRIPTION: RESIDENTIAL ADD ONE ELECTRICAL CIRCUIT FOR INSTALLATION OF NUHEAT FLOOR HEATING SYSTEM FOR BATHROOM 3/1/13 ADD NEW SCOPE OF WORK: �e�a r r rep /AZ& skw> -x `oa. t- Av; f4444( IF (7Y.Sb Sq. Ft Floor Area: I Valuation: $775 I APN Number: 37522048.00 I Occupancy Type: I hereby affirm under penalty of perjury one of the following three 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 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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 Compensation laws of California. If, after making this certificate of exemption, 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. 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 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 hmtnless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this ppinit. Additionally, the applicant understands and will comply with all non-poi f t o r- urce re tons per the Cupertino Municipal Code, Section 9.18. / / PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FR CALLED INSPECTION. All roofs shall be 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 inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by th ay Area Air Quality Management District I will maintain compliance with thelciperfinoXimicipal Code, Chapter 9.12 and the Health & Safety Code, Sectio 2J5505,2f5f, and 25534. ' Owner or authorized agent: ( (/ ��-WC� Date: CONSTRUCTION LENDING AGENCY I hereby affirm that Orion lending agency for the performance of work's for which this a 97, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional �� CITY OF CUPERTINO � rr W W U errrn,r A rPnlD _ 72T TTi 11TN(- TIiV I RION hfech. Plan Check. Plumb. Plan Check E'lec. Plan Ch[rck rbfeclr. Peron! Feu,. Plumb. Permit Fee: Glee. Pernut Fee: Other Mech. In'I Other Plum In.ep. Other Elec. Insp. A'lech. Lisp. Fee: Plumb. Insp. Fee: Elec. Insp, Fee. NOTE: This estimate does not includejees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District ,etc.). 7nese ees are nasea an FEE ITEMS (Fee Resolution 11 -053 Eff 711112) FEE -- -- » -- QTY/FEE -• -- - -- ---- -- - - - -- - - - - - -- MISC ITEMS ADDRESS: 18485 Chelmsford dr DATE: 03101 /2013 REVIEWED BY: melissa APN: 375 22 048 BP #: `VALUATION: $800 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY PME Plan Check: PENTAMATION SFD or Duplex PERMIT TYPE: USE: $0.00 Suppl. Insp. Fee:Q Reg. O OT 10.0 WORK REMOVE E SHOWER PAN & REPLACE. REPAIR WATER DAMAGE SCOPE PME Unit Fee: hfech. Plan Check. Plumb. Plan Check E'lec. Plan Ch[rck rbfeclr. Peron! Feu,. Plumb. Permit Fee: Glee. Pernut Fee: Other Mech. In'I Other Plum In.ep. Other Elec. Insp. A'lech. Lisp. Fee: Plumb. Insp. Fee: Elec. Insp, Fee. NOTE: This estimate does not includejees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District ,etc.). 7nese ees are nasea an FEE ITEMS (Fee Resolution 11 -053 Eff 711112) FEE -- -- » -- QTY/FEE -• -- - -- ---- -- - - - -- - - - - - -- MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? O Yes 0 No $0.00 Suppl. Insp. Fee:Q Reg. O OT 10.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: Administrative Fee: Work Without Permit? O Yes Q No $0.00 Advanced Planning Fee: $0.00 Select a Non - Residential Building or Structure O . A Travel Docinnentation Fees: Strong Motion Fee: 1BSEISMICR $0.50 1.0 hrs Inspections $133.00 tST1NSP Inspection, Hourly Bldg Stds Commission Fee: IBCBSC $1.00 $1.50 $133.00 K TOTAL FEE: $134.50 Revised: 01/0112013