13030006CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11128 SUTHERLAND AVE
CONTRACTOR: KOPP ROGER G AND
PERMIT NO: 13030006
RIENA
OWNER'S NAME: KOPP ROGER G AND RIENA
11128 SUTHERLAND AVE
DATE ISSUED: 03 /012013
OWNER'S PHONE: 4082557009
CUPERTINO, CA 950144731
PHONE NO:
JOB DESCRIPTION: RESIDENTIALD COMMERCIAL
❑ LICENSED CONTRACTOR'S DECLARATION
REMODEL (E) KITCHEN (177SQFT) & 2 (E) BATHROOMS
License Clazs Lie. k
(91 SQFT), NO STRUCTURAL CHANGES
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 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 tabor Code, for the
-
Valuation: $34500.
performance of the work for which this permit is issued. -
Sq. Ft Floor Area:
1 have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 35617058.00
Occupancy Type:
Section 3700 of the Labor Code, for the performance of the work for which this
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
WITHIN 180 DAY F PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
180 D AST CALLED INSPECTION.
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
y, Dole:
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section Zo
9.18.
RE- ROOFS:
Signature Date
All roofs shall be inspected prior to any roofing material being installed. It 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
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
the following two reasons:
I, as owner of the property, or my employees with wages as thew sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
HAZARDOUS MATERIALS DISCLOSURE
property, rty, am exclusive) contracting with licensed contractors to
1, as owner of the roe y g
(Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
construct the project
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
Health & Safety Code, Section 25532(a) should I store or handle hazardous
declarations:
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
as defined by the Bay Area Air Quality Management District I
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants
will maintain compliance with the Cupertino Muni ipal Code, Chapter 9.12 and
performance of the work for which this permit is issued.
the Health &Safety Code, Sectio 50 3 3 n 5534.
I have and will maintain Worker's Compensation Insurance, as provided for by
for this
/`3
Section 3700 of the Labor Code, for the performance of the work which
Owner or authorized agent: Date.
permit is issued.
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
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, after making this certificate of exemption, I
I
I hereby affirm that there is a construction lending agency for the performance of
become subject to the Worker's Compensation provisions of the Labor Code, must
work's for which this permit is issued (Sec. 3097, Civ C.) _
forthwith comply with such provisions or this permit shall be deemed revoked.
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
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
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 non -point source re lions er the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Date �/ �I3
Signature
CONSTRUCTION PERMIT APPLICATION o o�°
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION o�
10
10300 TORRE AVENUE • CUPERTINO, CA 950143255
CUPERTINO (408) 777- 3228• FAX ( 408) 777- 3333•building"— cuoertino.orO
❑ NEW CONSTRUCTION El ADDITION ❑ALTERATION/TI ❑ REVISION/ DEFERRED ORIGINALPERMIT#
PROJECT ADDRESS 1112
Q Sw. erlat A Ave
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APN# 356
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OWNER ❑ OwNER.BUDDER ❑ OwNERAOENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME C ELF
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LICENSE NUMBER
LICENSE TYPE
BUS. LIC#
COMPANY NAME
EMAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAME
LICENSETRIMeER
BUS. LTC #
COMPANY NAME
EMAIL
FAX
STREET ADDRESS
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PHONE
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DESCRIPTION OF WORK �Q IMO pn
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TYPE
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VALUATION (S)
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DEMO
TOTAL
AREA
AREA
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NEr AREA
BATHROOM KIT HEN -T G OTHER
REMODEL /) /S REMODEL AREA / T RFMODELAREA
PORCHAREA DE AREA TOTALDECK/PO GARAOE AREA:
DETACH
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#DWELLING UNRS:
IS A SECOND UNIT OYES
SECONDSTORY OYES
BEINGADDED? ONO
ADDITION? ONO
PRE - APPLICATION OYES IFYES,PROVmECOPYOF
PLANNTIGAPPL# ONO PLANNINOAPPROVALLEIT6R
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By my signature below, I certify to each of th wing: I am the property owner or autho a act on th roperty owner's behalf, I have read this
application and the information I have p (tied' rrec tie d the 'peon o Work and verify it is ac te. I agree to comply with all applicable local
ordinances and state laws relating to as on. I re en ' of Cupertino to enter the above - identified prypertyy�l6rr i7nsp purposes.
/5cuu0n
Signature of ApplicanNAgent: Date:_ 0 �s —' 42 /
SUPPLEMENTAL 0 A ON U D
PLANCHECKTYPE
ROUTING SLIP
OVER- TH&COUNTER
�` BUILDING PLAN REVIEW
New SFD or Multifamily dwe rags: Apply for demolition permit f r
existing building(s). Demolition rmit is required prior to issuance of building
permit for new building.
❑ EXPRESS
❑ PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
C1 STANDARD
❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
❑ FIRE 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 06121111
CITY OF CUPERTINO
impute ve,rrntr A'rnp — RTf TTi plINf_ nlVTCION
I
.•btech. Plan Check Plumb. Plan Cheek Elec. Plan Check
Xlech. Permit Fee:. Plumb. Perma Pee: Eec. Permit Fee: -
Other Mech. Insp. Other Plumb Insp. Oilier Elec. Insp.
Afech. Insp. Fee: Plumb. Insp. Fee: Elec. Insp. Fee.,
NnTF- Thiv estimate does not include fees due to other Departments (La Planning, Public Works, Fire, Sanitary Sewer District, School
Dstriet etc ). these fees are oasea on me reummw
FEE ITEMS (Fee Resolution 11 -053 E . 711112)
FEE
.... _...
QTY/FEE
--
MISC ITEMS
ADDRESS:
DATE: 03/01/2013
REVIEWED BY: MELISSA
177 s.E
$600.00
APN: 356
*VALUATION: $34,500
*PERMIT TYPE:
CHECK TYPE: Alteration / Repair
=PermitPLAN
PRIMARY
SFD or
PME Plan Check:
PENTAMATION 1R3SFDREM
PERMITTYPE:
USE:
f-9-17 s.£
$600.00
Remodel, Bath (< =300 sf)
IREMRESBAT
WORK
REMODEL E KITCHEN 177SQFT & 2 E BATHROOMS 91 SQFT NO STRUCTURAL
SCOPE
CHANGES
I
.•btech. Plan Check Plumb. Plan Cheek Elec. Plan Check
Xlech. Permit Fee:. Plumb. Perma Pee: Eec. Permit Fee: -
Other Mech. Insp. Other Plumb Insp. Oilier Elec. Insp.
Afech. Insp. Fee: Plumb. Insp. Fee: Elec. Insp. Fee.,
NnTF- Thiv estimate does not include fees due to other Departments (La Planning, Public Works, Fire, Sanitary Sewer District, School
Dstriet etc ). these fees are oasea on me reummw
FEE ITEMS (Fee Resolution 11 -053 E . 711112)
FEE
.... _...
QTY/FEE
--
MISC ITEMS
Plan Check Fee:
$0.00
177 s.E
$600.00
Remodel, Kitchen (< =300 sf)
IREMRESKIT
Suppl. PC Fee: 0 Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
f-9-17 s.£
$600.00
Remodel, Bath (< =300 sf)
IREMRESBAT
Permit Fee:
$0.00
Suppl. Insp. Fee-.0 Reg. 0 OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax:
Administrative Fee:
0
e)
Work Without Permit? 0 Yes No
$0.00
Advanced Planning Fee:
$0.00
Select Non - Residential
Building or Structure
O
0
Trarel ]documentation Fees:
Strong Motion Fee: IBSEISMICR
$3.45
Select an Administrative Item'
Blda Std s Commission Fee_ IBCBSC
$2.00
f f'�fw.yry,,ji ra`4
$5.45
$1,200.00
TQTALFEEc
$1,205.45
Revised: 01101/2013
Y
CUPERTINO
OWNER- BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 - buildino(a)cuoertino.ora
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS ///2 A2N BP#
(/y
/',
OWNER NAME Zh V
DWN
c
DESCRIPTION OF WORK: K F
We are providing you with an Owner - Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner - Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
QG61. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
Btilder" building permit that erroneously implies.that the property owner is providing his or her own labor and material
personally. I, as an Owner - Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner - Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
�$w 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
theconstruction and are not hiring a licensed Contractor to' assume this responsibility.
4AK3. 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
nam e instead of my own.
OkK I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
QAP 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
�c�onnsisidered an "employer" under state and federal law.
KJl46. 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.
x,71 f_' 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.
zjr8. 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.
OwnerBuilderFornl 2010.doc revised 04119110
A9. 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.cslb.ca.gov for more information about licensed
contractors.
p
t �F 10. 1 am aware of and consent to an Owner - Builder building permit applied for in my name, and understand that I
a�m�jhe party legally and financially responsible for proposed construction activity at the site address listed above.
RAt 11. I 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.
RR(fZ 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 form must be completed and signed by the property owner and
returned to the agency responsible for uing the permit. Note: A copy of the property owner's driver's license,
form notarization, or other verification 9ecepoble to t ity may be required to be presented when the permit is issued
to verify the roe owner's si nat
Property Owner's Signature: Date: _
--- -- - ---- - - •--- - -- ••••-• - -- -- - ---- - - - a - -by-t - - - --- - - -- - --o- -----o y.wh. n ------------..-...
(NOTE: The following Authorization orm 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:
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 city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
0"i erBuilderForm 2010.doc revised 09 114110
KF, (dome Planner Printout
Name: Forslag 1,25/2/MO
Description: Forslag 1, 25/2/MO
loll,
R V-
Qi JRA
1813.1
2/25113 9:19 PM
1& 4114 L(
IO'•
Current design drawing ID number: 0000 - 4104 -3930
IKEA cannot accept any liability for the accuracy of measurements or furniture layout. Prices in this program are for
products you collect from IKEA, take home and assemble yourself. All requested delivery, assembly and installation
services are charged separately and not included in the price. Although we do try to ensure that the information in
this program is correct, we apologise for any product alterations that may occur. All prices are valid until June 30,
2013
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CUPERTINO
CONTRACTOR /SUBC0NTR,M
Building Departments
City Of Cupertino
10300 Torre Avenue
Cupertino CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS:
NO BUILDING FINAL, OR FINAL OCCUPANCY INSPECTION(SJ7
OWNER'S NAME: PI.,'.11 t>11, 12
PHONE
GENERAL CONTRACT )6ke -1
ll LICENSE LICENSE Bu
ADDRESS:
JCITY/zIPCOPE�!,
*Our municipal code requires all businesses working in the city tobave',-w
NO BUILDING FINAL, OR FINAL OCCUPANCY INSPECTION(SJ7
GENERAL CONTRACTOR AND ALL SUBCONTRACTORSIRAVE."OBTAINI
BUSINESS LICENSE. W
M
1 am not using any subcontractors:
Signature
Please check applicable subcontractors and complete the Mo.
BUSINESS NA
NAME
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring Carpeting
:7
Linoleum Wood
Glass Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting /Wallpaper
Paving
Plastering
business license.
MULED UNTIL THE
ITY OF CUPERTINO
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