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11030078CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 19060 STEVENS CREEK BLVD OWNER'S NAME: UNITED POLARIS INC 011VNER'S PHONE: 4089058798 L LICENSED CONTRACTOR'S DECLARATION License Class Lic.# Contractor Date 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 - 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. 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 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. Signature Date OWNER- 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 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 property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). 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 pen-nit shall be deemed revoked. C'-1 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, c- — and expenses which may accrue against said City in consequence of the ng of this permit. Additionally, the applicant understands and will comply w,.,, all non -point source regulations per the Cupertino Municipal Code, Section 9.18. natP V t C� /I i CONTRACTOR: UNITED POLARIS INC PERMIT NO: 11030078 PO BOX 1805 DATE ISSUED: 03/15/2011 CUPERTINO CA, CA 95014 PHONE NO: BUILDING PERMIT INFO: BLDG r ELECT f— PLUMB F MECH F RESIDENTIAL I— COMMERCIAL f— JOB DESCRIPTION: SEWER REPAIRS AT TRASH ENCLOSURE 4" SEWER LINE Sq. Ft Floor Area: Valuation: $1200 APN Number: 37507046.19060 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued RE- ROOFS: 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. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(x) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: Date: C NSTRUCTION LENDING AGENCY I 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 Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional 5 ITEMS OF 5 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 37507046.19060 DATE ISSUED.......: 03/15/2011 RECEIPT #.........: BS000012912 REFERENCE ID # ...: 11030078 SITE ADDRESS .....: 19060 STEVENS CREEK BLVD SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OWNER ........ ADDRESS ...... CITY /STATE /ZIP RECEIVED FROM CONTRACTOR ... COMPANY ...... ADDRESS ...... CITY /STATE /ZIP TELEPHONE .... UNITED POLARIS INC PO BOX 1805 CUPERTINO CA, CA 95014 UNITED POLARIS, LLC LIC # *OWNER* UNITED POLARIS INC PO BOX 1805 CUPERTINO CA, CA 95014 OPERATOR: patg COPY # : 1 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---- - - - - -- 1BCBSC ------- - - - - VALUATION -- ---- - - - - -- 1,200.00 ---- - - - - -- 1.00 ---- - - - - -- 0.00 ---- - - - - -- 1.00 ---- - - - - -- 0.00 1BSEISMICO VALUATION 1,200.00 0.50 0.00 0.50 0.00 1PCSEWER UNITS 1.00 21.00 0.00 21.00 0.00 1PPERMITFE FLAT RATE 1.00 42.00 0.00 42.00 0.00 1TRAVDOC FLAT RATE 1.00 42.00 0.00 42.00 0.'00 TOTAL PERMIT ---- - - - - -- 106.50 ---- - - - - -- 0.00 ---- - - - - -- 106.50 ---- - - - - -- 0.00 METHOD OF PAYMENT --------------- -- CHECK TOTAL RECEIPT AMOUNT --------------- 106.50 --------------- 106.50 VOICE ID DESCRIPTION -- - - - - -- ---------------------- - - - - -- 106 SEWER & WATER REFERENCE NUMBER --------------- - - - -- #1012 VOICE ID DESCRIPTION -- - - - - -- ---------------------- - - - - -- 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 507 FINAL PLUMBING CUPERTINO PROJECT ADDRES� ^ /f O OWNER NAME ZZ, STREET ADDRESS GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 •FAX (408) 777 -3333 • building acupertino.org //a3 00�,? MEP MISIC UMBING Lj MECHANICAL ELECTRICAL I MISCELLLANEOUS APN � l ©V �j. / {" �� L-�� PHONE ^ O E-MAIL �L 2 v � 1, ��T @ C- A Z Z- Xa S C�-01 CITY, STATE, ZIP FAX APPLICANT NAME`S L / L o - PHONE - ZW E -MAIL STREET ADDRESS v CITY, STATE, ZIP FAX � OWNER lJ OWNER- BUILDER ❑OWNER AGENT ❑ CONTRACTOR 1:1 CONTRACTOR AGENT ❑ ARCHITECT C3 ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME ,� C� -7 LICENSE NUMBER LICENSE TYPE BUS. LIC k 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 USE OF STRUCTURE: ❑ Residential Commercial PROJECT IN WILDLAND URBAN INTERFACE AREA ❑ Yes ❑ NO PROJECT IN FLOOD ZONE ❑ Yes ❑ No TOTAL VALUATION: 4 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 bui?�iag construction. I authorize representatives of Cupertino to enter the above - identified property for inspection purposes. -. �- Signature of Applicant/Agent: r- ­ Z -L Date: / SUPPLEMENTAL INFORMATION REQUIRED oFiCE'TJSF OAY MEPMiscApp_2011.doc revised 03102111 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION baADDRESS: 19060 stvns crk blvd. QTY/FEE DATE: 03/15/2011 REVIEWED BY: bobs. BP FEES APN: BP #: "VALUATION: 1$1,200 r PERMIT TYPE: Plumbing Permit # PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY Commercial Building USE: PENTAMATION 1CPSS PERMIT TYPE: WORK SCOPE PME Unit Fee: APPLIANCE / EQUIP TYPE FEE ID QTY/FEE QTY UNITS BP FEES Sewer, Sanitary 1PCSEWER 1 # $21 PME Unit Fee: $21.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes G No $0.00 TOTALS: Travel Documentation Fee: ITRAVDOC $21.00 Strong Motion Fee: IBSEISMICO N:)TF.- Thoso fool aro hasod nn tho nroliminary infarmatinn availahlo and aro nnly an octimato_ rnntart tho nont far add" 11 infn_ FEE ITEMS (Fee Resolution 09 -051 F.,ff ' 1. -1 ( FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $21.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes G No $0.00 Travel Documentation Fee: ITRAVDOC $42.00 Strong Motion Fee: IBSEISMICO $0.50 Select an Administrative Item Bld, Stds Commission Fee: IBCBSC $1.00 SUBTOTALS; $106.50 $0.00 TOTAL FEE: 1 $106.50 Revised: 01/15/2011 CUPERTINO OWNER- BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • building(dQcupertino.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 1 4� /J e 1 V APN BP# OWNER NAME !_ L C G1C�c� OWNER ADDRESS G� ��5- tM�a C/ DESCRIPTION OF WORK: t"4 �- 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.) c 1. 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 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. _�_13. 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:L4. 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. 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 considered an "employer' under state and federal law. O 7 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 me to serious financial risk. �] 7. 1 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. td8. I 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. OwnerBuilderForm 2010.doc revised 04114110