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11100032 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 6125 BOLLINGER RD CONTRACTOR:PETERSON KURT PERMIT NO: 11100032 OWNER'S NAME: PETERSON KURT 34872 HERRINGBONE WAY DATE ISSUED: 10/05/2011 �'vNER'S PHONE: 5104713416 UNION CITY,CA 94587 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT f— PLUMB License Class Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions f Chapter 9 JOB DESCRIPTION:NEW SIDING(1,080SQFT)&14 WINDOWS&DORR (commencing with Section 7000)of Division 3 of the Business&Professions RPLACEMENT,NEW T-1 11 AT"O.C.,KEEP GARAGE DOOR 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 Sq.Ft Floor Area: Valuation:$4500 permit is issued. APPLICANT CERTIFICATION APN Number:37538010.00 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-poin source regulati s r the Cupertino Municipal Code,Section 9.18. •d Issuedby: Date:f�_S" l 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 1,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 I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I 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, ections 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 O or aut ror' agent: S forthwith comply with such provisions or this permit shall be deemed revoked. Altf: Date: OF CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION 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 wrk'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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address cr and expenses which may accrue against said City inconsequence of the t g of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION wiL„dll non-point source regulations per the Cupertino Municipal Code,Section 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional i �!>2 fto 'p CONSTRUCTION PERMIT APPLICATION r©coecrE° 8 COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION /� 20 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228- FAX(408)777-3333- buildingCcDcupertino.org , CUPERTINO LkAf • ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/7 ❑ REVISION/DEMME�D, 0 # PROTECT ADDRESS r ,✓/`�� L (L' `y�'/" �✓ OWNER NAME �%��V 9,1: ' i` � j.� �n/ PHONE E-MAIL STREET ADDRESS CITY, STaTE,IZIP is FAX tr P ' t5 ✓ CONTACT NAME HONE�G � E-MAIL � � � /�E.✓ STREET ADDRESS tJ!�{ CITY.STATE, ZIP � �/1` y FAX OWNER .bWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑cONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECTIENGINEER NAME /' LICENSE NUMBER BUS.LIC# COMPANY NAME / j' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK A ^ At' 1 EXIMG USE PROPOSED USE CONSTR.TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXLSTG NEW FLOOR DEMO TOTAL /J AREA AREA AREA NET AREA �- BATHROOM KITCHEN OTHER V / REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA I GARAGE AREA DETACH ❑ATTACH #DWELLING UNITS: IS A SECOND UNIT ❑YFS SECOND STORY []YES BEING ADDED? []NOADDITION? [JNO PRE-APPLICATION E]YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVfiD BY; C/�� TOT VA�� PLANNING APPL# []NO NO PLANNING APPROVAL LEITER EICHLER HOME? NO By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prsrperty owner's behalf. I have read this application and the information 1 have provided is correct. I have readdie Description of Work and verify it is accurate. I agree to comply with allapplicable local ordinances and state laws relating to buil ' constructign. I an V4 representatives of Cupertino to enter the ab/oye-identifie _perty br inspection purposes. Signature of Applicant(Agent Wit. Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CBECIK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for OVER-=-COUNTER [ - 1iNG PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. C3EXPRESS ❑fLAK INGPLANREVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDAIW ❑ PUBLIC wORTO form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ mz DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 6125 bollinger rd. DATE: 10/05/2011 REVIEWED BY: bob s. APN: BP#: "VALUATION: 1$4,500 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY PENTAMATION 1 GENRES USE: SFD or Duplex PERMIT TYPE: WORK new 1080 s.f. siding and 14 window and door replacement , new t-1 11 at 4"o.c. keep garage door. SCOPE Lj NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . These fees are based on the prelinina information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11-053 Gtf '%'1.%'l1) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 1,080 s.£ Siding Suppl. PC Fee: � Reg. () OT 0.0 hrs $0.00 $784.00 1SIDEOTHER All Other PME Plan Check: $0.00 14 # Window/Sliding Glass Door Permit Fee: $0.00 $522.00 1 WINREP Replacement Suppl.Insp.Feer Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Work Without Permit? Yes Q No $0.00 Advanced Planning Fee: $0.00 Select allon-Residential Building or Structure 0 7T= i Stroh Motion F e: 1BSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $1.501$1,306.001 TOTAL FEE: $1,307.50 Revised: 10/01/2011 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 (408)777-3228- FAX(408)777-3333• building(aDcupertino.org 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 ADDRESS /-7 67 /20 Y/tf/ APN BP# OWNER � ��® Nr OWNER ADDRESS �j DESCRIPTION OF WORK: 'r��J�/V �rz f' 1// N� 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.) e1. 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. �. I 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. I�VA. I understand Contractors are required by law to be licensed and bonded in California and to list their license num ers 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. y-E6. 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. W8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for ."ynancial 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 04/14110 9. 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 contractors. �► . 10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the parry legally and financially responsible for proposed construction activity at the site address listed above. a.%11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. 4412. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information 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.) ��y ) Lender Name: 4 l Lender Address: v " 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 th9lity may be required to be presented when the permit is issued to verify the property owner's sigrJ06reN, Property Owner's Signature: Date: L --------------------------------------------------------------------------------- ----------------------------------------------------------- (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 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: OwnerBuilderForna 2010.doc revised 04114110