11090119 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20659 SHELLY DR CONTRACTOR:SQUARCIA LARRY G AND PERMIT NO: 11090119
YOLANDA
OWNER'S NAME: SQUARCIA LARRY G AND YOLANDA 20659 SHELLY DR DATE ISSUED:09/20/2011
VER'S PHONE: 4083147575 CUPERTINO,CA 95014-2923 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F_ ELECT F PLUMB r
License Class Lic.# r
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE EXISITNG HVAC UNDERFLOOR DUCTING WITH
(commencing with Section 7000)of Division 3 of the Business&Professions NEW
Code and that my license is in full force and effect. + TITLE 24 COMPLIANT
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
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$1500
permit is issued.
APPLICANT CERTIFICATION APN Number:35911024.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by" -� Date:
Signature Date
OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
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
1 hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 1 have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
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 w r 'or ai gen • O
forthwith comply with such provisions or this permit shall be deemed revoked. JfW 4017"Date: •
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of"ork's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
4emnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
s,and expenses which may accrue against said City in consequence of the
panting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non- oint source regulation r the Cupertino Municipal Code,Section
9.18. r0 1 understand my plans shall be used as public records.
Signature 'r/�"�� Date Licensed Professional
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 35911024 . 00
DATE ISSUED. . . . . . . : 09/20/2011
RECEIPT #. . . . . . . . . BS000014797
REFERENCE ID # 11090119
SITE ADDRESS . . . . . : 20659 SHELLY DR
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER SQUARCIA LARRY G AND YOLANDA
ADDRESS . . . . . . . . . . : 20659 SHELLY DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2923
RECEIVED FROM LARRY G SQUARCIA
CONTRACTOR LIC # *OWNER*
COMPANY SQUARCIA LARRY G AND YOLANDA
ADDRESS 20659 SHELLY DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2923
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- -------------
---------- ---------- --------
lADMIN HOURS 1. 00 41. 00 0. 00 41 .00 0. 00
1BAPPLOTHE NO OF APPLIAN 1 . 00 65. 00 0 . 00 65 . 00 0 . 00
1BCBSC VALUATION 1, 500 .00 1. 00 0 . 00 1. 00 0 . 00
1BSEISMICR VALUATION 1, 500 . 00 0 .50 0 . 00 0 .50 0. 00
1MPERMITFE FLAT RATE 1. 00 44 . 00 0. 00 44 .00 0. 00
1TRAVDOC FLAT RATE 1 .00 44 . 00 0 . 00 -----44_00 ------0_00
---------- ----------
TOTAL PERMIT 195 .50 0. 00 195 .50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- ----------
CREDIT CARD 195 .50 VISA
---------------
TOTAL RECEIPT 195. 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- -
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 501 FINAL ELECTRICAL ENERGY
502 FINAL PLUMBING ENERGY 503 FINAL MECHANICAL ENERGY
505 FINAL ELECTRICAL 507 FINAL PLUMBING
508 FINAL MECHANICAL
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
JI[ADDRESS: 20659 shelly drive DATE: 09/20/2011 REVIEWED BY: larry s
PN: BP#: "VALUATION: 1$1,500
PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Du lex PENTAMATION 1 RMAP1
USE: p PERMIT TYPE:
WORK re lace existing hvac underfloor ducting with new title 24 compliant.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Other Appliance/Equip 1BAPPLOT 1 # $65
TOTALS: $65.00
Mech.Plan Check 0.0 hrs $0.00
Mech.Permit Fee: IMPERMIT
Other Mech.Insp. Fo.0 hrs $44.00 Lj Ll
NOTE. This estimate does not include fees due to other Depts(i.e.Public Works,Sanitary Sewer District,School District,etc.).
Theseees are based on the preliminaryin ormadon available and are onlyan estimate. Contact the De t or addn'1 info,
FEE ITEMS (I'ee Rc sohrtion 11-053 Elf.' %1.-11) FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $65.00
PME Permit Fee: $44.00
Administrative Fee: 1ADMIN $41.00
Work Without Permit? Q Yes E) No $0.00
Travel Documentation Fee: ITRA VDOC $44.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
131da Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $195.501 $0.00 TOTAL FEE: $195.50
Revised: 09/02/2011
//0q o //
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
La 408 777-3228• FAX(408)777-3333• building(cDcupertino.org misc
CUPERTINO ( )
❑PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS O ��t f-a y I\ (7 I V ti- APN#
OWNERNAZIZy Z C i 1/ PHONE G�O� 3 J 1 J E-MAIL
ME owl
STREET ADDRESS Z 0 S S�7 v�LL ./ /\n CITY, STATE,ZIP C k-�/S'��/C\/-o FAX
CONTACT NAME / I �n� PHONE 3 E-MAIL
STREET ADDRESS CCSvv/ �y�G— CITY,STATE, ZIP FAX
❑OWNER OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
----i7
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHTTECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF El SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ElYES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK )av 0 CL\ v
C � �
TOTAL VALUATION: �C RECEIVED BY:
By my signature below,I certify to each of the following: I am 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 uilldddiing construc'on`I au onze representativEs of Cupertino to enter the above-identifiedpropJerty or inspection pukposes.
Signature of Applicant/Agent: ✓( Date: / v ,
IV
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
❑ OVER-THE-COUNTER
a
❑ EXPRESS
U
U
W ❑ STANDARD
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❑ LARGE
a
❑ MAJOR
1EPMiscApp_2011.doc revised 06/21111
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
is 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228- FAX(408)777-3333- building(d)cupertino.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 APN BP#
OWNER NAME OWNER ADDRESS
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
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
1. I 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
/ .in✓surance coverage for injuries to workers on my property.
L" . ; - 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.
L&4,/ 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
I?Vy
S5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
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.
6. I understand if I am considered an "employer' under state and federal law, I must register with the state and
ederal 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
esidential 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.
�. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
ny financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
ObvnerBuilderForm 2010.doc revised 04/14/10
��O. I 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.csib.ca.gov for more information about licensed
;contra ors.
. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
a the party legally and financially responsible for proposed construction activity at the site address listed above.
t4�(�. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
all applicable laws and requirements that govern Owner-Builders as well as employers.
2. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
i formation 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 signature.
Property Owner's Signature: Date:
-- -
---- ---------------- ----------------------------------------------------------------------------------------------------------
(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
abovq 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:
GYvnerBuilderForn1 2010.doc revised 04114110