15120155CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20990 HOMESTEAD RD
CONTRACTOR: SILVERCREEK YUBA
PERMIT NO: 15120155
LLC
OWNER'S NAME: SILVERCREEK YUBA LLC
777 N 1ST ST, FLOOR 5
DATE ISSUED: 12/16/2015
OWNER'S PHONE: 4083933522
SAN JOSE, CA 95112
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ❑
INSTALL 2 PANELS OF 5/8 TYPE X DRYWALL ON 2
License Class Lic.#
WALLS
AT ENTRY WAY (206 S.F.)
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 her 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
Sq. Ft Floor Area:
Valuation: $150
-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
APN Number: 3.2609060.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITFIIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned, property for inspection purposes. (We) agree to save
180 PAYS FROM LAST ALLED INSPECT N.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
L�dJ �,i�-�1.
Issued by. Date:
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.
RE -ROOFS:
Signature Date
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.
OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the (lowing two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
. , 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 (See. 7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety. Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
d will maintain Worker'sCompensation Insurance, as provided for by
the Health & Safety Cod jtions 25505, 25533, and 25534.
rhave
700 of the Labor Code; for the performance of the work for which this
�Z !�,sissued.Owner or authorized ageri[: Date:hat
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
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for-which.this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
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,
ARCHITECT'S DECLARATION
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all LLji. w, oint source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
17
Signature Date
CONSTRUCTION PERMIT APPLICATION
COMMiiUNITY DEVELOPMENT DEPARTMiiENT • BUILDING DIVISION
10300 T ORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTIO, (408) 777-3228 • FAX (408 777-3333 - buildino(a-cuDerino.ora
t�t
[I NEW CONSTRUCTION u ADDITION ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT r
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PRWEECr ADDRESS APN
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STREET ADDRESS lJ M ^� I
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ITY, STATE, Z�v �� 1 C
CONTACT NAME
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E3 OµR cR Ol' 1hT_P.-BUIIDER ❑ 0WNERAGENT ❑ CONTRACTOR ❑ CONTPACTOR-AGE?T ❑ ARC=- 1rir.CT ❑ ❑ TrN,/,N-r
CON T P.ACi OR NA , LICENSE NUh�BER
I LICENSE T 1 rE
I BUS. LIC R
COWANTNAAS
I E-MAIL
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STREET ADDRESS
CIi Y, STA -12, ZIP
I PHOT�t
ARCr ITECTrNGINEER Nf�fE LICENSE N'U-MBBR
I BUS. LIC R
C014PA2\TY NAME E-MASL
FAX
STREET ADDRESS I CITY, STATE, ZIP
I P iODiE
DESCRIPTION OF WORK
5/8-17- 4
fr� h � ,
F-MSTLNG USE PROPOSED USE CONST& TYPE f r STORMES
14- _Lr=
USE I
TYPE I
OCC.
SQ.FT. I
VALUATION! (S)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
N= AREA
BATI.1t00M
KrrC11EW
OTHER
REMODEL AREA
REMODEL AREA
REMODELARBA
PORCHAREA
DECKAREA
TOTAL DECKPOP.CHA&=.A
GARAGE AR A: DETACH
❑ATTACH
4 D ATLLD.G UNITS:
ISA SECOND UNrr ❑ YES I
SECOND STORY ❑1=S
BEING ADDED? ❑NO
ADDITION? ❑NO
ppr.enorIC.0.TION ❑YFS IFYES, PROVIDECOPY OF I
PL),NNING APPL R ❑ NO PLAI.'I\ZNG APPROVAL LETTER
IS THE BLDG AN ❑YES
EICHLER H01,IE? ❑ NO
r j �D3Y -
T T,�%ALUATION:
1
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By my signature below, I certify to each of the following: I am the propact on the prop --,,T ov,;Ier's behalf. I have read this
application and the information I h-ve provided is co„ect. 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 ilding con ` ction. I authorize representatives 'of Cupertino to enter the above-ideer�nnti led pr py=ry for inspection purposes.
Signature of ADplicanUAgent: Date:
STL•PPLEME?\ITAL INEOR TION REQUIRED
,'PLaC)sECK� E•--
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_3.Oi,TL�GSLIP f
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New SFD or Multifamily d%-e11i gs: Apply for demolition permit for-
existing building(s). Demolition permit is required prior to issuance of building
- _ OL�TER -
RE«r ITT
permit for new buli_ding.�ExPrsss
-m
E�ZEFT =
d� �T L�e�2D =
Commercial Bldgs: Provide a completed Haardous Materials Discles re
pLEG�oX
_
form if any Hazardous Materials are being used as part oft his project.
SRGL
kIF�E�DFF T
_ Copy of Planning Approval Letter or Meeting with Planning prior to
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Y
i�I2�ISIRIGT
submittal of Building Permit application.
J�?A-��TySE
.3!d.-PP_2011.doc revised 06/21/11
W.-W
CITY OF CUPERTINO � slDul��j�.
FEE ESTIMATOR -BUILDING DIVISION
ADDRESS: 20990 Homestead Rd
DATE: 12/16/2015
REVIEWED BY: PAUL
`' APN: 326 09 060
BP#:
VALUATION: $150
APERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration /Addition /Repair
PRIMARY
USE: Commercial Building
Suppl. PC Fee: (j) Reg. 0 OT
Civil /Religious activities
in BQ zone? 0 Yes (j) No
PENTAMATION
PERMIT TYPE:
WORK
install 2 panels of 5/8 Type X drywall on 2 walls at entry way 206 S.f.
SCOPE
Fee:
EleL;..t' :IitYi.
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These lees are based on the preliminary information available and are only an estimate. Contact the Deptjor addn'l info.
FEE ITEMS (Fee .Resolution .1.1-053 F ff: 711113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: (j) Reg. 0 OT
0.0
1 hrs
$0.00
PME Plan Check:
$0.00
Permit Fee: Hourly Only? 0 Yes (E) No
$0.00
Suppl. Insp. Fee:(@ Reg. Q OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax: IBCONSTAXC
$0.00
Fee:
0
(@
Work Without Permit? Yes • No
$0.00
Advanced PlatiningFee:
$0.00
Select a Non -Residential
Building or Structure
(@
0
�
Strong Motion Fee: 1BSEISMICO
$0.50
2.0 hrs
$286.00ISTI1V
Inspections
SP Inspection, Hourly
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$1.50
$286.00
TOTAL FEE:
$287.50
Revised: 10/01/2015
c�T.l9s
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(Dcupertino.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
APIC.. ao
BP#
OWNERNAME
C?WNERADDRESSI
DESCRIPTION OF WORK: AZ l� ) '
.. ._ b. ^
We are providing you with an Own J. -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. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
B r ilder" 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
th /3.
struction 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
pr tect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
Wnumberls
stead of my own.
understand Contractors are required by law to be licensed and bonded in California and to list their license
on permits and contracts.
5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
tot value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
consred 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
andfe eral 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
JidIMs
ential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
ed dsubcontractors and the number of structures does not exceed four within any calendar year, or all of the work
;ay
rformed under contract with a licensed general building Contractor.
8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
inancial 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 04/14/10
9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal
R venue 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.cslb.ca.gov for more information about licensed
contractors.
10. 1 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.
11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
V
licable laws and requirements that govern Owner -Builders as well as employers.
agree to notify the issuer of this form immediately of any additions, deletions, or changesto any of the
n --l-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 maybe in civil court. If 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 held liable for damages. If
you obtain a perrriit-as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or note
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 own er's,,signatura.
Property Owner's Signature: N, (K Date: (:� -/6 /5
(NOTE: The following Authorization Form is required to be co m-- p--I-e-t-e- Y 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:
Address of Authorized Agent:
Tel No
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-ritv may 4e required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature:
Date: ,
OwnerBuilderForm 2010.doc revised 04114/10
:1
Tfl
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L �-li
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CUPERTINO C
Building Department
2015
D 1
REVIEWED FOR CODE COMPLIANT
2 1 0 iKag-J �r�
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COM U ' tv - TI
�lDEPARTMENT
UILDIMG DIVISION - C;UPERTI O
AP ROV D
This s .t of plans and specifications MUST be ept at the
job si . during constru .tion. It is inlawful to snake any
chary es or ilterati ns on smme, or to deviate
theref-om, wit, out ap roval iron the �uildin. Official.
The S amping f this pl n and spe �inca� ons S iALL NOT
be he d to peps l or to be an ap )roval of !N. violation
of an "V1si rs of ar y,City Or `Mate Law -
BY t. U — —
DAT----
PERviIT#�---
OFFIC""..'El C -71"P,
1
I !0' — I
F -A -+,`l
MjNr-�
13,
RECEIVED
13Y