12020041 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20891 MC CLELLAN RD CONTRACTOR:SHAYNE STUBBS PERMIT NO: 12020041
OWNER'S NAME: SHAYNE STUBBS 20891 MC CLELLAN
DATE ISSUED:02/09/2012
OWNER'S PHONE: 6502732271 CUPERTINO, CA 95014-2957 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
License Class Lic.# BUILDING PERMIT INFO: BLDG ELECT PLUMB'
IF—
Contractor Date MECH RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: UPGRADE SERVICE PANEL 200 AMPS
(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 Sq'Ft Floor Area: Valuation:$300
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. APN Number:35913083.00 Occupancy"Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM I AST CALLED INSPECTION.
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 Issued by:
with all non-point Date.
p source regulations per the Cupertino Municipal Code,Section •;
9.18.
Signature Date 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
0 OWNER-BUILDER DECLARATION inspection.
I hereby affirm that 1 am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS:MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
I hereby affirm under penalty of perjury one of the following three California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
declarations: maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I have and will maintain a Certificate of Consent to self-insure for Worker's Health&Safety Code,Section 25532(a)should I store or handle hazardous
material. Additionally,should I use equi mentor devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the
air contaminants as defined by the Bay rea Air Q ity Management District I
performance of the work for which this permit is issued. will maintain compliance wi Cup ti o Mu ,cipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio, 25_ _ 2553 'a 5534.
Section 3700 of the Labor Code,for the performance of the work for which this 2 �/
permit is issued. Owner or authorized agen ate:
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 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 mention,,d property for inspection purposes.(We)agree to save
indemnify and keep harmless the Cit of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,andMEDate?1112el
cr against said City in consequence of the I understand my plans shall be used as public records.
granting ll the applicant understands and will comply
with all no s per the Cupertino Municipal Code,Section
9.18. Licensed Professional
SignatureDate?1`r 2el�--
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228- FAX(408)777-3333- building(cDcupertino.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 ADDRESSAP �; BP#
8 t l Pte 6-te tI,a� Va �5 - ►3 - '
OWNER NAME C OWNER ADDRESS p ,,
DESCRIPTION OF WORK: ��= z
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
(DIRE TIONS:Please read and initial each statement below to signify you understand or verify this information.)
. 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
ins r ce 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
he nstruction 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
' protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
na instead of my own.
I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
/K-51 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
co red 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
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
m t serious financial risk.
. I 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 perf rmed under contract with a licensed general building Contractor.
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 04/14/10
44"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
co,Vrs.
. am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
he party legally and financially responsible for proposed construction activity at the site address listed above.
11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by I pplicable 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
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.)
Lender Name: Lender Address:
Before a building permit can be issued,this orm must be pleted and signed by the property owner and
returned to the agency responsible for issu' 'the permit. ote:A copy of the property owner's driver's license,
form notarization, or other verific ccepta fo the city, ay brequired to be presented when the permit is issued
to verify the property owner's sin ure
Property Owner's Signature: r Date: 1 G' z-.
---------------------------------------------------------------------------------------------------------------------------------------------
(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:
OwnelBuilderForn1 2010.doc revised 04/14/10
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35913083 . 00
DATE ISSUED. . . . . . . : 02/09/2012
RECEIPT # . . . . . . . . . : BS000015971
REFERENCE ID # . . . : 12020041
SITE ADDRESS . . . . . : 20891 MC CLELLAN RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : SHAYNE STUBBS
ADDRESS . . . . . . . . . . : 20891 MC CLELLAN
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2957
RECEIVED FROM . . . . : SHAYNE STUBBS
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : SHAYNE STUBBS
ADDRESS . . . . . . . . . . : 20891 MC CLELLAN
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2957
TELEPHONE . . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 1 . 00 41 . 00 0 . 00 41 . 00 0 . 00
1BCBSC VALUATION 300 . 00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 300 . 00 0 . 50 0 . 00 0 . 50 0 . 00
lEPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00
1ERT<200 UNITS 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 174 . 50 0 . 00 174 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- ------------------ --
CREDIT CARD 174 . 50 ax
---------------
TOTAL RECEIPT 174 . 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
` ADDRESS: 20891 McClellan Rd. DATE: 02/09/2012 REVIEWED BY: jsg
AFN: BP#: ""VALUATION: $300
PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition /Repair
PRIMARY SPD or Duplex PENTAMATION 1 REAP2
USE: PERMIT TYPE:
WORK Elec Service upgrage to 200 am
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services 1 ERT<200 200 Amps $44
TOTALS: $44.00
Elec.Plan Check OA 1 hrs $0.00
\ Elec.Permit Fee: 1EPERMIT
Other Elec.Insp. 0.0 hrs $44.00
NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc). These.Lev are based on the prelimina information available and are only an estimate. Contact the De t or addn I in o.
FEE ITEMS (11ec,Resolytion-11-P1? j'If "I�'111 FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
PME Unit Fee: $44.00
PME Permit Fee: $44.00
Administrative Fee: 1.4DMIAT $41.00
Work Without Permit? 0 Yes No $0.00
Travel Documentation Fee: ITRA UDOC $44.00
StrozagNloti_o Fee: 1BSEIShiICR $0.50 Select an Administrative Item
Bldg Stds{`ommission Fee: IBCBSC $1.00
SUBTOTALS: $174.50 $0.00 TOTAL ITEE.-T $174.50
Revised: 1/19/2012
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO, CA 95014-3255
CUPERTINO
(408)777-3228• FAX(408)777-3333- building(�cupertino.oL
❑PLUMBING ❑MECHANICAL ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS � > 11.4.V /�� APN# L,
OWNER NAME hit
v _
ff 7
� E-MAILEM
STREET ADDRESS CITY, STATE,ZIP FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE, ZIP FAX
❑OWNER OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR N -- v LICENSE NUMBER LICENSE TYPE_ BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE _
ARCHITECT/ENGINEER NAME // LICENSE NUMBER A l BUS.LIC#
COMPANY NAME' / E-MAIL ,V FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF V4FD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WIIAIAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING. ❑COMMERCIAL URBAN INTERFACE AREA 0,'NO FLOOD ZONE PNO EICHLER HOME? WO
DESCRIP'T'ION OF WORK
TOTAL VALUATION: RECEIVED BY:
By my signature below,I certify to each of the fall a�: I am prop owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I h vided is c rr it. hay .read a Description of Work and verify it is accurate. I agree to comply Witt.all applicable local
ordinances and state laws relating to it g cons on. I ori tatives of Cupertino to enter the abb7ove1d+en fled property for inspection pulposes.
Signature of ApplicantJAgent:
Date:
�G�L�� -
SUPPLEtIPENTAL INFORMATION REQUIRED OFFICE USE ONLY
t_1 OVER-THE-COUNTER
❑ EXPRESS
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w ❑ STANDARD
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❑ LARGE
❑ MAJOR
MEPM4cApp 1011.doc revised 06121111