12040037 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 5926 SUTTON PARK PL CONTRACTOR:STEPHEN&COYNE PERMIT NO: 12040037
TRIONA CROFT
OWNER'S NAAIF,: STEPHEN&COYNE TRIONA CROFT 5926 SUTTON PARK PL DATE ISSUED:04/06/2012
OWNER'S PIIONE: 4085683547 CUPERTIN'O,CA 95061-3531 PRONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.N
M ECH r RESIDENTIAL r COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE WATER HEATER
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
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
performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$550
1 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. APN Number:37535032.00 Occupancy Type:
APPLICANT"CERTIFICATION
1 eenify that I have read this application and stale that the above information is
correct.I agree to comply with all city and county ordinances and stale laws relating PERMIT EXPIRES IF WORK ISNOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS O LAST CALLED INSPECTION.
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 Issued by: K Date:
9.18.
Signature Dale
R6-ROOFS:
OWN ER-BILI LDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without firs(obtaining an inspection,I agree to remove all new materials for
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation. Signature of Applicant: Date:
will do the work,mid the structure is not intended or offered for sale(Scc.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to AL1.ROOF COVERINGS TO BE CLASS"A"Olt BETTER
construct the project(Sce.7044,Business&Professions Code).
I hereby affirm under penally of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: 1 have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Ilealth&Safety Code,Sections 25505,25533,and 25534, 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Cade,Chapter 9.12 and the Ilealth&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should 1 use equipment or devices which emit hazardous air
Section 3700 of the labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and the
permit is issued. Ilealth&Safety Code,Sections 25505,25533,and 25534.
1 certify that in(he 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 Ox or autho ' ed ag
Compensation laws of Califomia. If,alter making this certificate of exemption,1 Dale:. 1 !�
become subject to the Worker's Compensation provisions of the Labor Code,1 must "
forthwith comply with such provisions orthis permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
I hereby off rm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
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 Lender's Address
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
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations er the Cupenino Municipal Code,Section
9.18, Licensed Professional
Signalurc Dale—
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE"CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228"FAX(408)777-3333"buildina(a)cuoertino.ore
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:
SRE ADDRESS
,K2& —CIQ I i�N l< P APN BP#
OWNER NAME5,.� —N f OWNER ADDRESS1 !'7: pig 4-)K c
F 'K P�.Ac
.DESCRIPTION OF WORK: L —� `r4 C
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
(DIR1ECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
AAtl
il
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 homeowners insurance may not
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
.kri prance coverage for injuries to workers on my property.
V, 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.
�f� 3. 1 understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may
pro ect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
!\�Jme instead of my own.
J4 4. 1 understand Contractorsare required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
15. I 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.
'1
' 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_�to serious financial risk.
7. 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 performed under contract with a licensed general building Contractor.
�kA8. 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 04/14/10
' 119. 1 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.r-slb.ca.gov for more information about licensed
contractors.
1-10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
111. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
-dl applicable laws and requirements that govern Owner-Builders as well as employers.
12. 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'Slate License Board may be unable to
assist you with any financial loss you may sustaiq 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 si t
Property Owner's Signature: Date: t 9 1-
- --- -- ---h--- ---- ---------- ---- ----•---- ------------ ----------- --------- ------------- -----
(NOTE: The following Authorization Forrn 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.1ts accuracy. Note:A copy of the property owner's drivers license, form notarization, or other
verification acceptable to the city may be required to be resented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: r J Date:
OwnerBuilderForm 1010.doc revised 04114110
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: TraciC
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37535032 .00
DATE ISSUED. . . . . . . : 04/06/2012
RECEIPT #. . . . . . . . . : BS000016474
REFERENCE ID # . . . : 12040037
SITE ADDRESS . . . . . : 5926 SUTTON PARK PL
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : STEPHEN & COYNE TRIONA CROFT
ADDRESS . . . . . . . . . . : 5926 SUTTON PARK PL
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-3531
RECEIVED FROM . . . . : STEVE CROFT
CONTRACTOR . . . . . . . : LIC # -OWNER-
COMPANY . . . . . . . . . . : STEPHEN & COYNE TRIONA CROFT
ADDRESS 5926 SUTTON PARK PL
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-3531
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 550 . 00 1. 00 0 .00 1 . 00 0 . 00
1BSEISMICR VALUATION - 550 . 00 0. 50 0 .00 0 . 50 0 . 00
1PPERMITFE FLAT RATE 1 . 00 44 . 00 0 .00 44 . 00 0 . 00
1PRWHEATR UNITS 1. 00 26 . 00 0 .00 26 . 00 0 . 00
1TRAVDOC FLAT RATE 1. 00 44 . 00 0 .00 44 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 156 . 50 0 . 00 156 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 156 . 50 Visa 163268
---------------
TOTAL RECEIPT 156 . 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- -------------------------- - -
518 WATER HEATER
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 5926Sutton Park Place DATE: 04/06/2012 REVIEWED BY: jsg
APN: S 557(-)6.;k- I BP#: 'VALUATION: $550
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Duplex PENTAMATION PRWHEATR
USE: PERMIT TYPE:
WORK re lace water heater
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1PRWHEATR 1 # $26
TOTALS: $26.00
,t/rch- Plan(.hcrd Plumb.Plan Check 0.0 hrs $0.00 r/ec. P1 an Ch,ck
d eeh. Peraul Fee: plumb. Permit Fee: IPPERMIT !filer. Permit Fre:
Orhm Ale,h. Insp. Other Plumb Insp. 0.0 hrs $44.00 (hbrr tiler•. hrcp.
,llech.Imp. lSr: Planrh. hup. ree: Ince.hup. Fee:
NOTE: This estimate does not include fees due to other Departments(le. Planning, Public Works,Fire,Sanitary Sewer District,School
District,eta). These&es are based on the prelimina information available and are only an estimate. Contact the De t or addn7 itto.
FEE ITEMS(1'ce Resolmion 11-053 F'U. 711111) FEE QTY/FEE MISC ITEMS
Plan Chock Fre:
Sappl. PC Fee
PME Plan Check: $0.00
Permit Fix:
Suppl. hr.sp bee
PME Unit Fee: $26.00
PME Permit Fee: $44.00
Construction Ta.r:
Administrative Fee: IADMIN $41.00
Work Without Permit? 0 Yes 0 No $0.00
Adlymeed Planning Fees:
Travel Documentation Fee: ITRA VDOC $44.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bide Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $156.50 $0.00 TOTAL FEE:F $156.50
Revised: 04/01/2012
GENERAL PERMIT APPLICATION 3�'M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 950143255 I A
CUPERTINO (408)777-3728•FAX(408)777-3333• building(a)cuoertino.OrO 1 /v'
PLUMBING ❑MECHANICAL TRI
ELECCAL ❑IMM LLANEOU5
PROJECrADDREss }6>iCri 5(,ITiOf�l POK Po+cE
OwNFR NAMES TE r l N C Il i PxoNE Og-j'8 -,�;GI- E-MAIL „ y ` j
NL r �F C F C F i 5 L �apl cwiY
STREET ADD „ n. CITY.SLATE.ZIP FAX
sU ton) PA£Yr ALAc.0
CONTACT NAMEn v r PHONE E r
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sTREETADDRESS --J.N CITY,STATE. ZIF
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❑OWNER P`GWNFR-BIHDFR ❑ DW'NERAGENT ❑ CONTIACMIt ❑CONTACTOR AGENT ❑ AROMMCr ❑FNa Nmt ❑ DEVELOpER 01S?NANI'
CONTRACTORNAME LICENSBNUMBER LICENSE TYPE BIDS.LICA
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZTP FHONE'
ARCHTTECVFNGE4M NAME LICENSE NUMBER BUS.UC p
COMPANYNAME' E-MAR FAX
STREET ADDRESS =.STATE,EP PHONE
USE OF jasm.ou 1EX ❑ MUT.TFFAMRY PROnXTiNWIDIAND ❑ YES PROTECT TN ❑YES ITHEBTDGAN ❑Y6
BUDDING: ❑COMUMCIAL URBAN UnTRFACE AREA ❑ NO FLOOD ZONE [I NO ER]DDI HOME? J,NO
DESCIUMON OF WORK P, ' —
TOTAL VALUATION.! SSD .O0 RECEIVm BY:
By my signature below,I certify to each of the following. I am the property owner or authorized agent to act an the property owner's behalf I have read this
application and the information I have provided is carcet have 7d a Description of Work and verify it is acctaam. I agree to comply with all applicable local
ordinances and state laws relating to g coastructiaa I aria tatives of Cupertino to enter the above-ideatifled Perry for inspection purposes.
Signature ofApptirauVAgeoC Dam: 1-i
SUPPLEMENTAL INFORMAITOTTREQUIRM OFFICE USE ONLY
m ❑ OVER-THF.-COUNTER
❑ EXPRESS
Y
U
u ❑ sTANDARD
U
❑ URGE
C
❑ MAJOR
M6PMwcApp_Z011.doc revised 0621111