10090099 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20084 WHEATON DR CONTRACTOR:JOHN DURBIN HUSHER PERMIT NO: 10090099
OWNER'S NAME: JOHN DURBIN HUSHER 20084 WHEATON DR DATE ISSUED:09/14/2010
ER'S PHONE: 4082535099 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATIONr r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: SLIDING GLASS DOOR REPLACEMENT LOCATED IN
(commencing with Section 7000)of Division 3 of the Business&Professions MASTER
Code and that my license is in full force and effect. BEDROOM
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
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$2000
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:31623084.00 Occupancy Type:
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, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date Issued p�" 7 ^`"' Date:.
a
�] OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed cont",to ignature of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code). �w —
I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the
I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued.
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by
compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this
Safety Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. O mer or suth ize ent:
P Y P P �� - Date:�,�I y�Zo/•c1
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the performance of work's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
,unify and keep harmless the City of Cupertino against liabilities,judgments,
.,and expenses which may accrue against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18.
1�/ I understand my plans shall be used as public records.
Signature � G Date �� 2. 6 Jo
Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR--BUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: *VALUATION: 1$2,000
xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY I t 1 f:1L PENTAMATION 1 GENRES
USE: SFD or Duplex l-i.(XN ;r'f"1, PERMIT TYPE:
WORK
SCOPE
-EIF-t- E3--[-
hfW,
t)thc r afcr. , t�ticr P ,Ir Utitef f7,'� Ixst.
FCC,
NOTE: These ftes are based on the prelinddnary in ormation available and are only an estimate. Contact the Dept for addn'1 info.
FEE ITEMS(Pee Resolution 09-051 Ef. 711.,'10) FEE QTY/FEE MISC ITEMS
Plan Check Fee: 10.00 = # Window/Sliding Glass Door
Suppl.PC Fee: 0 Reg. 0 OTF67,61 hrs g 0.00 $380.00 I WINREP Replacement
PME Plan Check: 10.00
Permit Fee: $0.00
Suppl. Insp.Feer Reg. 0 OT 10.01 hrs 1,0.00
PME Unit Fee: $0.00
PME Permit Fee: 90.00
ConsIna lion Ko-
F-I=-
Acoustical Fee: 0 Yes 0 No 50.00 0
Work Without Permit? 0 Yes E) No 50.00
Planning Fee: :10.00 Select a Non-Residential 0
Building or Structure 0
71-avel Ooctotic'wolion Fees_
Strong Motion Fee: 1BSEISAffCR $0.50 Select an Administrative Item
Bldg_Stds Commission Fee: 1BCBSC 61.00
SUBTOTALS: $1.50 $380.00 TOTAL FEE: $381.50
Revised: 9/14/2010
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Bl-c-: Lot:
APN . . . . . . . . : 31523084 . 00
DATE ISSUED. . . . . . . : 09/14/2010
RECEIPT #. . . . . . . . . : BS000011458
REFERENCE ID # . . . : 10090099
SITE ADDRESS 20084 WHEATON DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER JOHN DURBIN HUSHER
ADDRESS 20084 WHEATON DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : KAREN L HUSHER
CONTRACTOR LIC # *OWNER*
COMPANY JCHN DURBIN HUSHER
ADDRESS . . . . . . . . . . : 2C084 WHEATON DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- - --------- ---------- ---------- -----
1BCBSC VALUATION 2, 000. 00 2 . 00 0 .00 2 . 00 0 .00
1BSEISMICR VALUATION 2, 000 . 00 1 .00 0 .00 1 .00 0 .00
1WINREP EACH 8 1. 00 760 . 00 0 . 00 760 . 00 0 .00
- --------- ---------- ---------- ----------
TOTAL PERMIT 763 . 00 0. 00 763 . 00 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 763 . 00 MC
---------------
TOTAL RECEIPT 763 .00
INPUT ■ ■ A0
M.Indoor Air Quality and Finishes
1.Use Low/No-VOC Paint 1 IAQ/Health pts y=yes 0
2.Use Low VOID,Water-Based Wood Finishes 2 IAQ/Health pts y--yes 0
3.Use Low/No VOC Adhesives 3 IAQ/Health pts y--yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes D
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes 0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0
7.Seal au Exposed Partioleboard or MDF 4 IAQ/Health pts y=yes 0
B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y--yes 0
N.Flooring
1.Select FSC Certified Wood Flooring B Resource pts y—yes 0
2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y—yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
Total Points Available: 1 1401 130 57
Total Points Project Received: r 0 0 0
J
G:data/progslgr!enbulidngguidelinestremodelerslgreenpointsfinal212Mprolecled.xls
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO CA 95014-3255
GUPERTINO (408)777-3228-FAX(408)777-3333-,wildinaQcupertino.org
Dear Property Owner(s):
An application for a building permit has been submitted in dour name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS APN IPZ� �� �' Zf BjQi
OWNER
2+MME � 40-J-42A q• OWNER ADDRESSM13 � �!}2�-� «` 1 S do, .0 Z
D
DESCRIPTION OF WORK: 1-e S I JJ
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 indicatod. An agent of the owner cannot execute this notice unless
you,the property owner, obtain the prior approval of the pi;rmitting 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. I understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner-
uilder' 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.
(rW2. 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.
��3. 1 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 icensed Contractor and having the permit filed in his or her
name instead of my own.
WA I understand Contractors are required by law io be licensed and bonded in California and to list their license
tubers on permits and contracts.
1otal5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
value of my construction is at least five hundred bollars($500), including labor and materials, I may be
considered an"employer" under state and federal la".
e6. I understand if I am considered an "employer" under state and federal law, I must register with the state and
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.
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 structureE does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
8. I understand as an Owner-Builder if I sell the )roperty 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.
OwnerBuilderForn: 1010.doc revised 04114110
Iunderstand I may obtain more information regarding my obligations Ps an"employer"from the Internal
(i9n-
ue Service,the United States Small Business Administration,the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I als:)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.
�i10. 1 am aware of and consent to an Owner-Build ar building permit applied for in my name, and understand that I
the party legally and financially responsible for pro)osed 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
y�all applicable laws and requirements that govern O Nner-Builders as well as employers.
4orm
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any o t e
ation 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 resultof 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 statu;of their workers'compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following constructicn 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 mu
;t be completed and signed by the property owner and
returned to the agency responsible for issuing the pe rmit. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the c ity may be required to be presented when the permit is issued
to veri the grope owner's si a re. Date: °tel
Property Owner's Signature:
-------------------------------- ------------------------------------------------------------------------------------------------------------
(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 p grmit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Propeersonr(s owactrashe execution cf which I undersand my agent(s)t�apply for, signtand1s my personal file he documents responsibility,
necessary akin an
authorize the following p )
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent:
-fel 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 cop; 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:
Cate:
Owne?-BuilderFonn_201 0.doc revised 04/14/10
V U 9/Y i
CITY OF CUPERTINO
CUPE�T1NO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # 1 Date:
o�q
Building Address:
Mailing Address (if d erent from building address):
Are Hazardous Materials being used as part of thi., project? Yes No
HOA: (Exterior work only) Yes ❑ No yes, provide letter from HOA
Owner's Nar ie: Phone#:
ctor: one:
F .
Contractor License#: molu
Cupertino Business License#:
Contact: Phone:
4L Fax:
Residential LZ Commercial
Job Description:
�' lookCiLebs
�( tU V,- - C
Building Permit Info:
' Bldg Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/III B, IV-HT, V-:3 [-3--
Valuation: Square Footage:
Project Size: Express Standard ❑ Large 1] Major ❑ 7J-T C -
-Green Building: Please complete relevant portion of the Green B ' ding/LEED Checklist& attach it
to the application or if applicable, include in plan set & the sheet index.
'oints Achieved:
For help, contact Build it Green at www.builditri:en.or
Revised 07/14/09