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12080028
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10340 VICKSBURG DR CONTRACTOR:FIRESTINE ROBERT K AND PERMITNO: 12080028 IIOANG LOANN OWNER'S NAVE: FIRESTINE ROBERT K AND HOANG LOANN 10340 VICKSBURG DR DA'Z'E ISSUED:08/062012 OWNER'S P110,NE: 4082537005 CUPERTINO.CA 95014 PHONE NO: ❑ LICIiNSEA)C0NI'RAC'r0R'S DECLARATION BUILDING PERMIT INFO: BLDG I— ELECT I- PLUMB r License Class Lie.d IVIECII r RESIDENTIAL COMMERCIAL Contractor Date 1 hereby affirm that tam licensed under the provisions of Chapter 9 3OB DESCRIPTION:PROPERTY LINE CLEANOUT,4INCH SDR,7RENCHLESS (commencing with Section 7000)of Division 3 of the Business&Professions Code and that ray license is in full force and effect. hereby affirm under penally of perjury one of the following two declarations: 1 have and will maintain a cert:ficate 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 far which Ih:s permit is issued. Sq.Ft Floor Area: Valuation:$1200 1 have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of die work for which this permit is issued. APN Number:36914002.00 Occupancy'Iype: .\1'1'LIC\N'I'CP:R'I'IPICA'I'ION I certify that I have read this application:ad state that the above information is correct.l agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to inter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilitics,judgmcnts, r costs.and espenses which may accrue against said City in consequence of the I& D S FROM LAST CALLED INSPECTIOiS. grinding of permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Issued by:. �.rf$'A Dat 9.18. Signature Date - iLX RE-RM)F.SS:: owsl..R.RUILDER DECLARATION All roofs shall be inspected rior to My iobfing''maii r:al being installed If a roof is installed without first obtaining urn:a PZciion,I agree to remove all new,materials for I hereby affirm that I 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 sale compensation, Signature of pp icar '# Dale: will do the work,and the structure:s not:mended or offered for sale(Sec.7044, '"�l l.1 Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to AL1 ROOF COVERINGS TO BE CLASS"A"OR BOFFER construct the project(Sec.7044,Business& Professions Code). hereby affirm trader penalty of perjury one of the following three IIA'LARDOUS 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 Health&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 Code,Chapter 9.12 and the Ileadth& performance of the work for which this permit is issued. Safety Code.Section 25532(a)should 1 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 craft hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 w:11 Section 3700 of the Labor Code,for the performance of the work forwh:ch this permit:3700issued. maintain compliance with the CupertinoMunicipal Code,Chapter 9.12 and the Iealth&Safety Code.Sections_5505,25533,and 25534. 1'certify that in the perlbrmance of die work for which this permit is issued,I shall not employ may person many manner so as to become subject to the Worker's Ow mer or horized it: 'r Compensation laws of California. If,alter making this certificate of exemption,I �� J -Date:K// 6 f / C._ become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this pennit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT'CERTI FIC TION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and stale that the above information is Lender's Name. correct. I agree to comply with all city ani county ordinates mid state laws relating to building consiniclion,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, costs,and expenses which may accrue against said City in consequence of the ARCHITECT"S DECLARATION granting of this permit.Additionally,the applicant understands and will comply 1 understand my plans shall be used as public records. with all non-point source regulations per the Cupertino Municipal Code,Sectiam 948. Licensed Professional Signature Date 6 2 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228 • FAX(408)777-3333•building Qcuoertino.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 v ,(� APN aP# v V �Ksb <<r YI ve OWNERAME -J-UA-LJnC OWNER AD v V .G b 1) DESCRIPTION OF WORK: anskiff -v_Aa . C K. - lG-C �ipe LAS; n kUSS SD '2'20`21 L�-f Sipe-r- S/w.e IL . We are providing you with an Owner-Builder Acknowledgment and Information Verification Form.to m ke 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.) J,d-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. I�iTL. 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. 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 9name instead of my own. (%44. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license ��nu��m��bers on permits and contracts. [�5. 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. Lk8. I 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. Ll 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. 1"k8. 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. OwPnerBuilderForm 2010.doc revised 04/14/10 oQ) ° /co \ \ \ \ \ $_ u / .a \ y ea , : c = ) (Z- (1) LLJ � \ \ � 5 W { E � � k � § /\ \ a ( \ § \ / ; ( 2 \ / a ¢ ]. § G $ R o \\ k \ ) \ > \ 4 F- CC \5 \ 1 \ £ ' ® 2 (0 % . mm f \ o0. ® a. ; \ o / § \ ( f . ._ £ '0 co © a. \ 7 . . . m 2 0 o i o $ } /� . .\ \ z \ \ \ & { EKE w = ta \ ( 2 ƒ \o � [ / b A @ £ } x \ �\ k / - \ \ °� / \% $ R 3 � _ » \ / / ? /k a . \ kms± , § .\ \ ' O k/ � k < 00 \ : ao = 2 == = f 7 = 2:, R 2 = q � Et {\ } 2 \ \ / \ 0 � \ CL ® \ ) _ @ 3 8 % -00 m g \ = E , / �Q\ \ g c s ° < Q' a2 \ ;® c e ° 0 = E \ 0390 a ;? \ \ \ \ \ .� / p CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ,\DURESS: 10340 vicksburg drive DATE: 08/06/2012 REVIEWED BY: larry s ,\PN: BP#: VALUATION: $1,200 *PERMIT TYPE: Plumbing Permit PLAN CIIECK TYPE: Alteration /Addition / Repair PRIMARY PENTAMATION USE: SFD or Duplex PERMITTYPF: 1RPS i WORK ro ert line cleanout 4 inch sdr, trenchless SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1PRSEWER 1 # $23 •I'OTA LS: L $23.00 ,Neth. Plan Check Plumb. Plan Check 0.0 hrs $0.00 F.lec. Plan Check Alech. Permit Fee: Plumb. Permit Fee: IPPERAIIT rlec•.Permir ree: Oihev Meth.Insp. Other Plumb htsp. 0.0 hrs $45.00 Other Flee.Insp. Lj Mad.hup.Fee: Plumb. Insp. Fee: Flee.Imp.Fee: rVOTE: This ertinutte does not inchulefees Flue to other Departments(i.e. Planting, Public Works, Fire,Sanitary Sewer District,School District, etc.). These etc are baser)on the prelintinat3 information available and are onh'nn estimate. Contact the Dept for adrin'I info. FEE ITEMS (Fee Resolution 11-053 Ell' 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check ree: Suppl. PC rec PME Plan Check: $0.00 Permit Fee: Stipp/. Insp ree PME Unit Fee: $23.00 PML' Permit Fee: $45.00 Consntiction Tar: Administrative Fee: MDHIN $42.00 Work Without Permit? O Yes (D No $0.00 Advanced Planning Fees: Travel Documentation Fee: ITR,JMOC $45.00 Strong Motion Fee: IBSFIS,t1ICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $156.50 $0.00 TOTAL FEE: $156.50 Revised: 07/01/2012 GENERAL PERMIT APPLICATION M E F COMMUNITY DEVELOPMENT DEPAR T NIENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 EM - p p ' SC CUPERTINO (408)777-3228 • FAX (� .AX(408)7777-3333 • buildin0cuoertinD.urG �1�a/' PLLryBLNG ❑\,F—C:-:A,NICAL ❑ELECi_2!CAL ❑j\fiiSCuL+NE0U5 XPROJECT ADDRESS IV U V t'C.I(sb" 'of t I L I AP`1a A / I J u Z— OWNER NA11M PHO ✓ E-MAII, ANN yvRN vy 1-�3-7�0� I VY1� oun Qa:r'rou. STREET ADDRESS CITY,STATE,ZIP - - FAX Iu34o V,-Jcsh �r ,' r , o) CONTACT NAME I PHONE I E-MAIL STREET ADDRESS CITY,STATE ZIP FAX ❑OWNER OWNER-BVDDEA ❑ 0W. AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHTTECT ❑ENGINEER ❑ DEVELOPER ❑ T%-IAM CONTRACT' NA;�ff LICENSEE NUMBER LICENSE TYPE I BUS.LIC i COMPANY NAA¢ E-MAIL I FAX STREET ADDRESS I CITY.STA`.ZIP I PHONE ARCH TEMEWO124EEH NAME I LICENSE NUMBER BUS.L7C p COMPANY NAME' I E-MAIL FAX STREET ADDRESS I CITY.STAT-..ZIP I PHONE USE OF ❑SFD-DUPLEX ❑ MULTI-FAMILY PROB:LTN WE LAND ❑ YES PROMCTN ❑ YES IS THE BLDG AN ❑ YES BUILDING: ❑COMMERCIAL I MAN INTERFACE AREA ❑ NO I FLOOD ZONE • ❑NO I MCHLER HOME! ❑NO DESCRIPTION OF WORK TOTAL VALUATION: P I /1 D U I RECEIVED BY By my signature below.I certify m each of the following: I m the property owner or authorized agent to act on the prope y owner's behalf. I have read this application and the inforsadm:I have provided is corecL I have read the Description of Work and verify it is accurate. I agree;o comply with all applicable local ordinances and stare laws relating m building consnucti I authcrim representatives of Cuperti==c:c enter the above-identified prepe.,•for inspection pui'oses. Signature of ApplicandAgenn Date: SUPPM E ITAL RTFORNLATl N RE OFFICE USE ONLY y OVER-THE-COUNTER r ❑ EXPRESS t U ❑ STANDARD U Z ❑ LARGE 5 ❑ MAJOR :LfEPMuc4pp_2011.doc revised 06/21/11