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11080140CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10310 BEARDON DR I CONTRACTOR: BEN & CHRISTINE ELLIS I PERMIT NO: 11080140 OWNER'S NAME: BEN & CHRISTINE ELLIS 6ER'S PHONE: 4088597210 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. q Contractor Date 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. hereby affirm tinder penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self- insure Ibr Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of [lie 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 perfornance of doe work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above infommtion is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives ollhis city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnity 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 with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. 10310 BEARDON DR . CUPERT'INO, CA DATE ISSUED: 11107/2011 PHONE NO: BUILDING PERMIT INFO: RLDG r ELECT r PLUMB (^ MECHF RESIDENTIAL r— COMMERCIAL I— JOB DESCRIPTION: ADD 783 SQ FT TO GRFAT ROOM AND M. SlA IT, REMODEL KI'I'CI IEN 160 SQ, CONVERT LIVING ROOM] 0 OFFICE 100 SQ Ff. REPLACING All' Sq. FI Floor Area: APN Number: Valuation: $100000 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Date I Issued by: OWNER - BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for one of the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sce.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project(See.7044, Business & Professions Code). hereby affirm under penalty of perjury one of the following three 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. I certify that in the performance of die 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 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. 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 lases 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 I emnify and keep harmless the City of Cupertino against liabilities, judgments, and expenses which may accrue against said City in consequence of the mg of this pemtit. Additionally, the applicant understands and will comply ' wah all non Wfcerea , ti c er tile Cupeninn Micipnl Cnde, Signature Date Date: RE- ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a root is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant:_ Date: AL1, ROOF COVERINGS TO 13E CLASS "A" OR BETITR IIA7.ARDOIIS MATERIALS DISCLOSURE have read the hazardous Imaterials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will mointain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Ileallh & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Arco Air Quality Management District 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 mid the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: Date: CONSTRUCTION LENDING AGENCY I hereby of tai that there is a construction lending agency for the performance i work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name ' Lender's ARCIII'FEC71 "S DF.CLARA'r10N I understand my plans shall be used as public records. Licensed CITY OF CU TIN BUILDING PERMIT, 190ATE BUILDING ADDRESS: 10310 BEARDON DR CONTRACTOR: BEN & CHRISTINE ELLIS PERMIT NO: 11080140 OWNER'S NAME: BEN & CHRISTINE ELLIS i 10310 BEARDON DR DATE ISSUED: 11/07/2011 OWNER'S PHONE: 4088597210 CUPERTINO, CA 95014 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH r RESIDENTIAL F COMMERCLkL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ADD 783 SQ FT TO GREAT ROOM AND M. SUITE, (commencing with Section 7000) of Division 3 of the Business & Professions REMODEL LIVING KITCHEN 160 SQ, CONVERT LIVING ROOM TO OFFICE 100 Code and that my license is in full force and effect. SQ FT, REPLACING A/C I hereby affirm under penalty of perjury one of the following two declarations: 1/10/12 DEFERRED 41-TRUSS CALCS-2/28/2012 DEFERRED#1 ISS'D 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 die work for which this Permit is issued. Sq. Ft Floor Area: Valuation: $100000 APPLICANT CERTIFICATION APN Number: 32633020.00 Occupancy Type: 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 indemnity 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 (lie 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 T\,Iutiicipal Code, Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. Signature Date Issued by: Date—z— 2 OWNER-BUILDER DECLARATION hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: he following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is [, 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) 1, as owner of the property, an exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project (Sec.7044, Business & Professions Code). 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 performance of the work for which this permit is issued. I have read tire hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance, as provided for by California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain Section 3700 of the Labor Code, for the performance of the work for which this compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & ut e. Safety Code, Section 25532(a) should I store or handle hazardous material. permit is issued. Additionally, should I use equipment oi• 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 become subject to the Worker's Compensation provisions of the Labor Code, I must Healt Safety Code Sections 25505, 25533, and 255 Ow t da forthwith comply with such provisions or this permit shall be deemed revoked. Date: 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 indemnify and keep harraless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the Lender's Address granting of this perm it. rt Additionally the applicant understands and will comply with all non- Mit . urc re ti , 2cr the Cupertino Municipal Code, Sectio 9.18. ARCHITECT'S DECLARATION 1 understand my plans shall be used as public records. Signatur. Date Licensed Professional CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION 1AADDRESS: 10310 beardon dr. FEE DATE: 01/10/2012 REVIEWED BY: bobs. APN: 1)2(%j BP #: v "VALUATION: $0 *PERMIT TYPE: Building Permit ® hours Plan Check, Hourly $520.00 ISTPLNCK PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: hrs 2nd Unit? % Yes 0 No OTC. 0 Yes E)No TPERMIT PENTAMATION 1 DSR3 TYPE: WORK truss submittal. SCOPE �tdeferred $0.00 Suppl. Insp. Fee:G Reg. Q OT OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. s.f. Deferred Submittal (R -3) II- B,111- B,IV,V -B 0 $0.00 1 1 $0.00 TOTALS: Sf7 Gn Check •t1,,Ch..firi:c;' i'f -"e', $0.00 ET NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School U[Strtct, etc.). 1 hese fees are based on the preummary information available and are only an estimate. C;'ontact the Uept_tor aaan'l into. FEE ITEMS (Fee Resolution 11 -0i3 I , 711111) FEE QTY/FEE I MISC ITEMS Plan Check Fee: Hourly Only? Q Yes 0 No $0.00 ® hours Plan Check, Hourly $520.00 ISTPLNCK Suppl. PC Fee: Q Reg. Q OT LLJ hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:G Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 E) Work Without Permit? 0 Yes G) No $0.00 Advanced Planning_Fee: $0.00 Select a Non - Residential Building or Structure Q 0 i Strong Fee: $0.00 Select an Administrative Item Bldg Stds Commission Fee: $0.00 SUBT'OTALSi . $0.00 $520.00 T ®TAL, '*EE: $520.00 Revised: 1/01/2012 CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 m FAX (408) 777 -3333 • buildingp_cupertino.org [—]NEW CONSTRUCTION k ADDITION ❑ ALTERATION/ n ❑ REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS APN # 3 33 OWNER NAME h n `� PHONE s 9-2 7 2 I Q E-MAIL f�° STREET ADDRESS �a.:- c ci '� V. CITY, STATE, ZIP 1 Sd' 4 L F to V 2_ 5 U ( 5 CONTACT' NAME • ` \` PHONE �y Z 1 0 E -MAIL \ f STREET ADDRESS CITY, STATE, Z[P X501 FAX - Z55 0J icy a e �r 0$ ❑ OWNER OWNER - BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCIBTECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHH ECFIENGINEER NAME ALL LICENSE NUMBER BUS. LIC # COMPANY NAME \ E MAH ��`� ,^ rj 0 � � 1! 71�+✓�G Cd� STREET ADDRESS C �T' q 5 (a( PHONE 2 3 P cS� J O_ FJ DESCRIPTION OF WORK ahVe,Y� _ o c EXISTING USE OPOSED USE CONSTR TYPE, - 1 a aw `- 1 �J �TOT6AL # STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EMSTG AREA NEW FLOOR AREA DEMO AREA NET AREA ^ 1%1 -79':3 /��1� BATHROOM REMODEL AREA Z KITCHEN REMODEL AREA /% OTHER REMODELAREA /0 D PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: DETACH ATTACH # DWELLING UNIT'S: IS A SECOND UNIT .+ �❑.�^Y.ES BEING ADDED? G SECOND STORY [] YES ADDITION ?O PRE - APPLICATION ❑ YES IF YES, PROVIDE COPY OF PLANNING APPL # �IJO PLANNING APPROVAL LETTER IS THE BLDG AN YES EICHLER HOME? XNO RECEIVED BY TOTAL VALUATION: By my signature below, I certify to h the lowing: la the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I v p vid is Gorr t. I ve read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relatin to d on. orize representatives of Cupertino to enter the abo-i entified -perty for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP El OVER- THF-COUNTER r,�/ Is BUILDING PLAN REVIEW —New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building for new building. ❑ EXPRESS &- PLANNING -PPLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure R--STANDARD 9-1plUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE E,111IRE DEPT Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR I� SAHITARY SEWER DISTRICT submittal ofBuilding Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06121111 CUPERTINO ❑ NEW CONSTRUCTION DEFERRED # CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING PATEN — 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • building(@cupertino.org ❑ ALTERATION / TI , _ _1 11-'M ORIGINAL PERMIT # O 'l ?D 14 O PROTECT ADDRESS APN * 2 / _ 3 3)� 02- 0 OWNER NAME l (- PHONE E MAII tj `➢ n CI7 Y. SATE ZIPS STREET ADDRESS 16310 /ZS5t at— a � 1 V4C h� / S CONTACT NAME PHONE' STREET ADDRESS t AA CITY, STATE ZIP ❑ OWNER 4 OWNER - BUILDER ❑ OWNERAGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER �1 � u I bQ LICENSE TYPE BUS. LIC # �Alrv\d e j0 S %_L COMPANY NAME T� I T�v�.v Vj E -MAIL �o FAX . �® STREET ADDRESS ��` CITY, STATE, ZIP S�S� PHONE / lkz _r.�m.' o e a C ZoZ a.37, ARCHITECT/ENGINEER NAME � LICENSE NUMBER ^� MIA BUS. TIC # COMPANY NAME E -MAIL - FAX STREET ADDRESS L CITY, STATE, ZIP PHO Z 9 f9 ®` �� L� ` U J DESCRIPTION OF WORK ..r o EXISTING USE PROPOSED USE CONSTR. TYPE # STORIES USE TYPE OTC. SQFT. VALUATION (S) EXLSTG AREA NEW FLOOR AREA DEMO AREA TOTAL NETAREA X-7—.f1 it A .t3 �/�� /?'3 BATHROOM KrrCHEN OTHER REMODEL AREA REMODELAREA REMODEL AREA PORCHAREA DECK AREA TOTALDECKIPORCHAREA GARAGEAREA: DETACH ❑ ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? ❑NO ADDITION? []NO PRE - APPLICATION []YES IF YES, PROVIDE COPY OF PLANNING APPL # []NO PLANNING APPROVAL LETTER IS THE BLDG AN ❑ YES EICHLER HOME? []NO RECEIVED BY �, TOTAL VAL ON: C�/6fLJ� By my signature below, I certify to each of the following:,,I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have proved 's correc� have read the Description of Work and verify it is accurate. I agree to comply with all applicable local laws building '6n I Cupertino 'fled for inspection ordinances and state relating to onstruc a � on resentatives of to enter the above -iden property purposes. Signature of Applicant/Agent: Date: / �i SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECICTYPE SLIP El oVER- THE- couNTR G�ROUTING L�l�E4iiDING PLAN REVIEW _ New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ mREss ❑ PLANNINGPLANREVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure SIS TANDARD ❑ PuBLIcwomcs 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 ❑ El SANITARY submittal of Building Permit application. MAJOR SEWER DISTRICT ❑ ENVIRONMENTAL HEALTH BldgApp j011.doc revised 06/21/11 BUILDING ADDRESS: 10310 BEARDON DR OWNER'S NAME: BEN & CHRISTINE ELLIS CITY OF CUPERTINO BUILDING PERMIT CONTRACTOR: BEN & CHRISTINE ELLIS I PERMIT NO: 11080140 10310 BEARDON DR DATE ISSUED: 11/07/2011 OWNER'S PHONE: 4088597210 I CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic.# 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. 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. 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 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, 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 9.18. Signature Date OWNER - BUILDER DECLARATION I hereby -affirm that I am exempt from the Contractor's License Law for one of the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation, 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 construct the project (Sec.7044, Business & Professions Code). I bereby affirm under penalty of perjury one of the following three 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. 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 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. 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 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, 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- oin souce regyti s er the Cupertino Municipal Code, Section 9.18. �� // // / / BUILDING PERMIT INFO: BLDG r, ELECT r PLUMB MECH RESIDENTIAL COMMERCIAL JOB DESCRIPTION: ADD 783 SQ FT TO GREAT ROOM AND M. SUITE, REMODEL KITCHEN 160 SQ, CONVERT LIVING ROOM TO OFFICE 100 SQ FT, REPLACING A/C Sq. Ft Floor Area: I Valuation: $100000 APN Number: 32633020.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: 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 inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,. Chapter 9.12 and the Health & Safety Code, Sections 25505, 255339 and 25534. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional 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)cupertino.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 ADRES:S�, o qtr r- APN BP# a� NeR game ., X 1EA `1 S: Y1� D ° , fON OF WORK: ` IQ v cL �- &a 14-f d ✓1 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.) I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Buil 'er" 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 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 pro t myself from potential financial risk by hiring a licensed Contractor and having the permit fled in his or her name instead of my own. 1 understand Contractors are required by law to be licensed and bonded in California and to`list their license numbe s on permits and contracts. 1 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total Walue of my construction is at least five hundred dollars ($500), including labor and materials, I may be it��nsation considered an "employer" under state and federal law. if I am considered an "employer" under state and federal law, I must register with the state and withhold payroll taxes, provide workers' compensation disability insurance, and contribute to ensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. �.�I understand under California Contractors' State License Law, an Owner - Builder who builds single - family reside tial 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. U4I understand as an Owner - Builder if I sell the property for which this permit is issued, I may be held liable for any yancial 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 04114110 9. I 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 (CSCB) at 1- 800 - 321 -CSLB (2752) or www.csib.ca.gov for more information about licensed contactors. . (b1r0. I 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. Z1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all4applicable laws and requirements that govern Owner - Builders as well as employers. AM. 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 issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verlficatio a ceptable to t e it ay be required to be presented when the permit is issued to verify the property owner's sign Property Owner's Signat g : Date: � --------------------------------------------------------------------------------------------------------------------------------------------- (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: 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: OwnerBuilderForm 2010.doc revised 04114110 FM__7 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION 1AADDRESS: 10310 beardon dr. OCCUPANCY TYPE: DATE: 08/18/2011 REVIEWED BY: bobs. APN: BP #: *VALUATION: $100,000 *PERMIT TYPE: Building Permit R -3 (Custom) PLAN CHECK TYPE: Addition PRIMARY SFD or Duplex USE: 1 PLNCK 2nd Unit? Yes No OTC? 0 Yes (E) No PENTAMATION 1 R3SFDADD PERMIT TYPE: WORK sfd add master suite and great room remodel kitchen and living. SCOPE $1,519.00 Suppl. Insp. Fee.e Reg. 0 OT 0.0 Mech. Plan Check 0.0 1 hrs $0.00��rsr Mech. Permit Fee: 1 MPERMIT Other Mech. Insp. 0.0 hrs .j+i'X :i1. 1r,:-q), Fll?..E. tVOTF. ThP.QP fps QPP hase_d on the nrolim1nary information QVQ1lahlP and QPP nn1v an pvti ate- Contart the Dpnt for addn �l into- FEE ITEMS (Fee Resolution 11- 05313' '. 7'1..'11) OCCUPANCY TYPE: TYPE OF CONSTR FLR AREA s.f. PC FEES PC F E H) BP FEES BP FEE ID R -3 (Custom) II- B,111- B,IV,V -B 783 $2,420.00 1 PLNCK $1,519.00 1R3INSP $0.00 = s.f. Remodel, Other $392.00 IREMMISOTx Permit Fee: $1,519.00 Suppl. Insp. Fee.e Reg. 0 OT 0.0 hrs $0.00 = # Mechanical $65.00 1BREMAIR A/C Units ( < =10K cfm) PME Unit Fee: $0.00 PME Permit Fee: $44.00 _T_T TOTALS: 783 $2,420.00 $1,519.00 Q E) Mech. Plan Check 0.0 1 hrs $0.00��rsr Mech. Permit Fee: 1 MPERMIT Other Mech. Insp. 0.0 hrs .j+i'X :i1. 1r,:-q), Fll?..E. tVOTF. ThP.QP fps QPP hase_d on the nrolim1nary information QVQ1lahlP and QPP nn1v an pvti ate- Contart the Dpnt for addn �l into- FEE ITEMS (Fee Resolution 11- 05313' '. 7'1..'11) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,420.00 160 s.f. $588.00 Remodel, Kitchen (< =300 sf) 1REMRESKIT Suppl. PC Fee: G Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 = s.f. Remodel, Other $392.00 IREMMISOTx Permit Fee: $1,519.00 Suppl. Insp. Fee.e Reg. 0 OT 0.0 hrs $0.00 = # Mechanical $65.00 1BREMAIR A/C Units ( < =10K cfm) PME Unit Fee: $0.00 PME Permit Fee: $44.00 _T_T Acoustical Fee: 0 Yes °% No $0.00 Q E) Work Without Permit? 0 Yes G No $0.00 Planning Fee: PLLONGRNGR $101.79 Select a Non - Residential Building or Structure Q 0 Travel Documentation Fee: 1TRAVDOC $44.00 Strong Motion Fee: 1BSEISMICR $10.00 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $4.00 SUBTOTALS: " $4,142.79 $1,045.00 T®TA,L FEE: ' $5,187.79 Revised: 07/04/2011 DSA File # INSPECTIONS DSAAppl. #_ 690 SUNOL STREET, BUILDING H • SAN JOSE, CA 95126 OSHPD # (408) 288 -8460 • FAx:(408) 271 -0902 — ANCHOR INSTALLATION INSPECTION REPORT City of: /C !! r7;vo Date: 2- / — / Z Project Name: LL /s ,t%ES40E1VGr,-7 Project# r420 —6Y-7 Address: 10310 5E19-2-boA/ PR-1 VC— Permit# ��GU�i� /`-10 Inspectors Name: L! -,92Ay CAT %RGNGE ID# / ----------- — — — — — — — — — — — — — — — — — — — — — — — — — — — — — Installation Inspection of: GEpmied- Rein� leel we MEpoxied Allthread Anchors ❑Expansion - Anchors ❑Witnessed the drilling of the holes and verified proper diameter and depth. ( °r) FILE inspected predrilled holes and verified proper diameter and depth. /Observed the cleaning of the holes and the in flee o / insertiefI,- - ^^%-150^/ SE T %X? eji y / epoxy capsules / grout, ICC ER # Z S (%S Expiration Date % C-21 -3 "tnessed the proper insertion of- (No.) (No.) �D diameter all read ahors / reinfarciag.steeLdowels eexpansiopancboL% inches in length, embedded Z /t inches, at the following location Abld 1>-LA% 4Yt /&.0 % AT` GQ /� L //yr= /T Z, .4AICffaZ /NsTi�tcEy) �.�i7sra�2 rl! /3u /L/� /A/� SLfi-i3 inches in diameter allthread a i nchors / reinforcing steel dowels / expansion anchors bedded I inches, at the following location: (No.) diameter allthread anchors / reinforcing steel inches in length, embedded I inches, at the Iitllowing location: anchors ----------------------------------------- �—�z / 07 Notes: 4- G /?' t 11-7-11 -----------------=----------------------- To the best of my knowledge, work inspected was in laccordance with the building department approved design drawings, specifications and applicable workrsarZ ip p visi s of the C. BC. except as noted above: Inspectors' signature: wY�1