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11090064 CITY OF CUPERTINO BUILDING PERMIT BOLDING ADDRESS: 10450 SERRA ST CONTRACTOR:ADZICH ROBERT TRUSTEE PERMIT NO: 11090064 &ET AL OWNER'S NAME: ADZICH ROBERT TRUSTEE&.ET AL 10164 CARMEN RD DATE ISSUED:02/07/2012 OWNER'S PHONE: 4084384413 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.4 MECH RESIDENTIAL f COMMERCIAL ' Contractor Date hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:CONSTRUCT l STORY WITH BASEMENT,4497 SF,NEW (commencing with Section 7000)of Division 3 of the Business&Professions ATTACHED GARAGE,705 SF,AND NEW PORCH,1301 SF. Code and that my license is in full force and effect. TOTAL=6503 SF I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain it 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 pertnit is issued, I have and will maintain Workers Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$1500000 permit is issued. APPLICANT CERTIFICATION APN Number:34259013.00 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 consuuction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF `FORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 1$0 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Sectiotm i$® D.. � FR® ` � CALLED INSPECTION. Issued by- Date: Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: 1 hereby affirm that 1 am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining arm inspection,I agree to remove all new materials for 1,as owner of the property,or nmy employees with wages as their sole compensation, inspection. will tto the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to constnict the project(See.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I 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 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(tie performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I 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 3 700 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. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this pemut is issued,l shall maintain mpliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health afety ode,Sections 25505,25533,grid 25534. 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 trust Own nth i e as 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 I hereby affirm that there is a construction Iending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnill and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which m v accrue against said City in consequence of the granting of this ermft.Add it pally,time applicant understands and will comply ARCHITECT'S DECLARATION with all non-p in - urce reg , ions per the Cupertino Mutmidp Co e,Section 9.18. I understand my plans shaft be used as public records. Signature Date L Licensed Professional 1 CITY OF CUPERTINO BUILDING PERbAfE 2 BUILDING ADDRESS: 10450 SERRA ST CONTRACTOR:ADZICH ROBERT TRUSTEE PERMIT NO: 11090064 &ET AL OWNER'S NAME: ADZICH ROBERT TRUSTEE&ET AL 10164 CARMEN RD DATE ISSUED:02/07/2012 OWNER'S PHONE: 4084384413 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION { FF_ 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:CONSTRUCT 1 STORY WITH BASEMENT,4497 SF,NEW (commencing with Section 7000)of Division 3 of the Business&Professions ATTACHED GARAGE,705 SF,AND NEW PORCH,1301 SF. Code and that my license is in full force and effect. TOTAL=6503 SF -5/9/2012-DEF#1-DEFERRED HAMBRO FLOOR SYSTEM WITH STRUCTURAL CALCULATIONS-5/23/2012 DEF#1 ISS'D I 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. 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. Sq.Ft Floor Area: Valuation:$1500000 APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above information is APN Number:342590I3.00 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 by: Date: 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 wil I 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 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. 1 have read the 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. I 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& 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 contaminantss 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 w th the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Health&Sad' Code, eons 25505,25533,an 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. Owner or a rize Date: )) C_- i , i APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that 1 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 Hork'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 harmless the City of Cupertino against liabilities,judgments, costs,and expensesAich may accrue against said City in consequence of the Lender's Address granting of this pe iy.Additiohally,the applicant understands a d will comply with all non- o t sbdree regulalh s per the Cupertino Municip Code, ection ARCHITECT'S DECLARATION 9.18. I understand my plans shall be used as public records. Signature Date i Licensed Professional CITY OF CUPERTINO BUILDING PERMIT DATE BUILDING ADDRESS: 10450 SERRA ST CONTRACTOR:ADZICH ROBERT TRUSTEE PERMIT NO: 11090064 &ET AL OWNER'S NAME: ADZICH ROBERT TRUSTEE&ET AL 10164 CARMEN RD DATE ISSUED:02/07/2012 OWNER'S PHONE: 4084384413 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATIONr BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lie.# MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:CONSTRUCT 1 STORY WITH BASEMENT,4497 SF,NEW (commencing with Section 7000)of Division 3 of the Business&Professions ATTACHED GARAGE,705 SF,AND NEW PORCH,1301 SF. Code and that my license is in full force and effect. TOTAL=6503 SF 10/22/12-DEF#2-TRUSS CALCS-10/29/12-DEF#2 ISS'D 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 Sq.Ft Floor Area: Valuation:$1500000 permit is issued. APPLICANT CERTIFICATION APN Number:34259013.00 Occupancy Type: 1 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Signature Date Issued by: Date: OWNER-BUILDER DECLARATION RE-ROOFS: Xlhcreby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material beiig installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 1 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(x)should I store or handle hazardous material. Additionally,should 1 use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&Safe C e,Sectipns 25505,25533,and 2 534. 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 Owner or auth agent:, forthwith comply with such provisions or this permit shall be deemed revoked. \ Date:— APPLICANT ate:APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned pr erty for inspection purposes.(We)agree to save indemnify and keep hanless�the City of Cupertino against liabilities,judgments, Lender's Address costs,and expense ;wh1ch m y accrue against said City in consequence of the granting of this peit. ddi tonally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-poi nt7urcreulations per the Cupertino Municipaf Code,Section 9J8 I understand my plans shall be used as public records. i2 Z Signature r, `� Date l ' Licensed Professional DEFERRED# CONSTRUCTION PERMIT APPLICAT6AYE COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228• FAX(408)777-3333• build ing(ftupertino.org ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI REVISIONDEFERRED` ORIGINAL PERMIT# 1.' PROJECT ADDRESS - a APN k OWNER NAMEr \ PHONE E-MAIL . ii , rn STREET ADDRESS CITY, STATE,ZIP , 1 FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-M AIL FAX STREETADDRESS CIT ZIP PHONE ARCHITECTIENGINEER NAME LICENSE LM w 16. BUS.LIC k COMPANY NAME E-M-AIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR.TYPE R STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECKAREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ATTACH k DWELLING UNITS: Is A SECOND UNIT ❑YES SECOND STORY ❑YES BELNGADDED? []NO ADDITION? ❑NO PRE-APPLICATION ❑YFS IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES TOTAL VALUATION: PLANNL*1G ADPL ❑NO PLANNING APPROVAL LETTER EICHLER HOT, ? ❑NO 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 provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply With all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFOR-,4ATION REQUIRED IicjurlNGSLir New SFD or Multifamily dwellings: Apply for demolition permit for oVERTJi)<Coul\TER s ❑ BUILDu.GPLAN REviE« existing building(s). Demolition permit is required prior to issuance of building permit for new building. �~EIPRESS ❑ PLP.NNII\GPLANREVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ sTANDARn° ❑ PUBLICS ORLS 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 ❑ sAIQITARY sERERDISTRICT Y, submittal of Building Permit application. ❑ nzAJOR ❑,'ENVIRONMENTAL HEALTH., CONSTRUCTION PERMIT APPLICATION -` COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION, 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 \ (408)777-3228 •FAX(408)777-3333•building4cupertino.org CUPERTINO NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION I TI ❑ REVISION t DEFERRED ORIGINAL PERMIT N PROJECT ADDRESS 1045-c? 56$t f T mer/P0 A APN# 2�n ra O OWNER NAME /fg. 1f„�i�e/ An��•C u PHONE ,q _ 430 /�1�I�j E-MAILp„�scGitr@ Ap2�Crl �{. cu STREET ADDRESS-` C�iJW�c 1 -0. `I CI Y.CU (L rt MO C14 15-0j.+J�++ FAX CONTACT NAME ,or c�FFEL PHONE _ 3(�-Gq-q?j E-MAIL!`f1i6 C/�NVEt APA STREET A D E PY,o '- ��. CI �v1b ZIP Y � I i� FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME O� LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME F-MAIL FAX STREET ADDRESS CITY,STATE.ZIP PHONE ARCH ITECT:ENGINE m(6 5Tznar-L_ LICENSENUMBER G-- 2OC 9 BUS-LIC# COMPANYI AltA tj pe_A n' } pEsjb� E-MAIL K0) �NPCAI17l� STREETADDRES4�O �. IZrJ/ CITY, E, l PHPN -�'�` D � DESCRIPTION OF WORK G.. t e7' (/JCC rAM fLY jr_ s IP JEtJ CC EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES / CC ' p`;s IV-g I USE TYPE OCC. SQ FT VALUATION(S) EXISTAREAGF�f/7� PEA G.)IZ O? TOTAL DEMO �,I� NET AR£�A`�2G2 REMODEL AREA �y/ REMODELAAEAA/ REMODELAREA PORCH AREA `DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: DETACH I/7O' _1O�- TTACH N DWELLING UNITS IS A SECOND UNIT YES SECOND STORY YES BEING ADDED' Nrlo ADDITION' ;WO PRE-APPLICATION YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: TO AL VALUATION: PLANNING APPL# []NO PLANNIN APPROVAL LETTER EICHLER HOME' {VIVO f 100600 By my signature below,1 certify to each oft a71ro. g: l am thz operty owner or authorized agent to act on the property owner's be f. 17.7c rmif this application and the information I have provideI have the Description of Work and verify it is accurate. 1 agrc to c ply with all applicable local ordinances and start laws relating to buildi> c l auth a representatives of Cupertino to enter the above-idcntif d pr Of for inspection purposes. Signature of ApplicantJAgcnc I Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER 0-1M[.DING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building ,,,.�^ permit for new building. 13ExPRESS Cf PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ZL-0ANDARD 2-1-UB—LIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE Lt_I+IRE DEPT Copy of Planning Approval Letter or Meeting with Planning prior to /` su ittal of Building Permit application. ❑ 1►tAJOR s� ANriARY SEWER DISTRICT ❑ ENVIRONMENTAL HEALTH BldgApp_201 Ldoc revised 06121111 CONSTRUCTION PERMIT APPLICATIOImEFERRED# [Sl COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 DATE (408)777-3228• FAX(408)777-3333• buildinq(@cupertino.org CUPERTINO q N ❑ ADDITION ❑ ALTERATION/TI REVISION/DEFERRED ORIGINAL PERMIT# d (OCA C9 y PROJECT ADDRESS /0 '-/5-0 1� APN# OWNER NAME ' \ 7 �) 21 \\ PHONE `r��- G(_�/�` EMAIL J c�1 d `1�c ^�c< STREET ADDRESS "7 n5 r CITY, STQ E�I C� I ICJ' -0111 (� JFAXv , C3 CONTACT NAME � n�� �,L. _\\ PHONE o-�y_ t,� � EMAIL STREET ADDRESS CITY,STATE,ZIP T D FAX A d ❑ OWNER OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITFCTIENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OFWORK /�Jl{� �/ —, D� -,�#C �S EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA AREA NET.AREA - BATHROOM KITCHEN OTTER REMODEL AREA REMODEL AREA REMODEL AREA PORCHAREA DECKAREA TOTAL DECK/PORCH AREA GARAGE AREA: LJ DETACH []ATTACH #DWELLING UNITS: IS A SECOND UNIT [-]YES SECOND STORY []YES -7 BEUYG ADDED? []NO ADDITION? []NO PRF-APPLICATION El YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: TOTAL VALUATION: PLANNING ADPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO D By my signature below,I certify to each of the followi : I am the property owner or authorized agent to act on the pr_nperty owner's behalf. I have read this application and the information I have provi d is o ct I have read the scription of Work and verify it is accurate. agree to comply with all applicable local ordinances and state laws relating to buildin con on. I authorize rept ntatives of Cupertino to enter the above-id rifle property for inspection purposes. Signature of Applicant/Agent: Date: 2— SUPPLEMENTAL INFO TION REQUIRED PLAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit fory� �1—s .. PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building , permit for new building. �❑ EXPRESS ❑ PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure L- STANDARD ❑ PUBLIC WORM form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FM DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_2 011.do c revised 06/21/11 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228- FAX(408)777-3333- building(&-cupertino.org CUPERTINO `c ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/-n REVISION/DEFERRED ORIGINAL PERMIT# v �O 0 1 PROJECT ADDRESS 5-0 S ---J-)— APN# OWNER NAME PHONE! E MAII. GL's STREET ADDRE J C/'6 ( C w ��` CITY,STA Zl?p FAx CONTACT NAME �] , PEONS E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX ❑OWNER 'KWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARC C-r ❑ENGWEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE.ZIP PHONE AR=C(ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MALL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO 7TN16ETAT AREA AREA AREA T AREA - BATHROOM KITCHEN OTIiEEt REMCDELAREA REMODELARE4 REMODELAREA PORCHARES DECK AREA TOTAL DEC'KlPORCH AREA GARAGE AREA: DETACH , ❑ATTACH #DWELLING UNrfS: LSA SECOND UNFIT ❑YES SECOPN"DVORY ❑YES -7 BEING ADDED? []-NO ADDITION? []'NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY. TOTAL VALUATION: PLANNINGAPPL# (]NO PLANNING APPROVAL LETTER EICHLERHOME? []NO By my signature below,I certify to each o foll g. I ja2hori he operty owner or authorized agent to act on the pr;perty,owneri s behalf. I have read this application and the information I have vided's c ct I rea the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to bni 'ng c s tion. I resentatives of Cupertino to eater the above-id fled perry for inspection purposes. Signature of Applicant/Agent: Date: STJPPLEM=AL INF RMATION REQUIRED PIAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER ❑ Bva.DINGPLAN REVaw existing building(s). Demolition permit is required prior to issuance of building ,� � permit for new building. :L Y-M- RESS ❑ PLANN]NG PLAN REVIE r`I' _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PaBT.ICWORKS form if any Hazardous Materials are beim used as part of this project ❑ LARGE ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ tKAroR ❑ SANITARY sEwER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp 1011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION \�61 ADDRESS: 10450 serra st. DATE: 09/09/2011 REVIEWED BY: bobs. APN: BP#: `'VALUATION: 1$1,500,000 'PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY SFD or Duplex 2nd Unit? 0 Yes • No PENTAMATION 1 R3SFDW USE: PERMIT TYPE: WORK construct new 1 story with basement=4497 s.f, new attached garage= 705 s.f. new porch 1301 s.f. SCOPE OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. s.f. R-3 (Custom) II-B,111-B,IV,V-B 6,503 $3,422.10 1R3PLNCK $4,622.62 1R3INSP TOTALS: 6,503 $3,422.10 $4,622.62 E3 El Lj NOTE: This estimate does not include fees due to other Depts(i.e.Public Works,Sanitary Sewer District,School District,etc.). Thesefees are based on the preliminary in ormation available and are only an estimate. Contact the Dept-for addn 7 info, FEE ITEMS (F'ee Resolution 11-053 Etf 71/11 FEE QTY/FEE MISC ITEMS Plan Check Fee: $3,422.10 Select a Misc Bldg/Structure Suppl.PC Fee: E) Reg. Q OT 0.0 hrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: $4,622.62 Suppl. Insp.Feer Reg. ®OT T 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Constr.Tax: IBCONSTAXR # $579.61 units 0 Work Without Permit? Q Yes (j) No $0.00 G Advanced Planning Fce: PLLONGRNGR $845.39 Select a Non-Residential Building or Structure Q Strong Motion Fee: IBSEISMICR $150.00 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $60.00 SUBTOTALS: $9,679.721 $0.00 TOTAL FEE: 1 $9,679.72 Revised: 09/02/2011 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10450 Serra Street DATE: 10/22/2012 REVIEWED BY: Sean APN: BP#: 11090064 *VALUATION: Iso *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION 1GENRES USE: PERMIT TYPE: WORK Deferred Submittal #2: Roof truss calculations. SCOPE Li ins h.,rn�r.Ie: 7;irrr�l,. ,1 !� : 1 : __•'rr,c. 1,�.,. NOTE. This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District etc.). Theseees are based on the prelintina information available and are only an estimate. Contact the Dept for addn 7 info. FEE ITEMS(Fee Resolution 11-053 ff. 711'12) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? C)Yes (F) No $0.00 2 hours Plan Check,Hourly Suppl. PC Fee: Q Reg. OT 0.0 hrs $0.00 $266.00 1STPLNCx PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp.Fee:Q Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 C`o�tsrrnc°ti:�rr Tu:a, Work Without Permit? 0 Yes No $0.00 0 Advanced Planning Fee. $0.00 Select a Non-Residential ;'r-<r�°z,1)o' r,1't�'YtLdf (�77 1�rE�s: Building or Structure i Strong Motion Fee: $0.00 Select an Administrative Item Bldy.Stds Commission Fee: $0.00 SUBTOTALS_ $0.00 $266.00 TOTAL FES; $266.00 Revised: 10/01/2012 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10450 serra st. DATE: 05/09/270127REVIEWED BY: bob s. APN: BP#: *VALUATION: $0 %PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION 1GENRES USE: PERMIT TYPE: WORK deffered hambro floors stem with structural caculations. SCOPE . ,, . . NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc . Thesefees are based on the prelimina information available and are only an estimate. Contact the Dept/or addn'1 info. FEE ITEMS (Fee Resolution 11-053 Ef' 71LIIIJ FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? Q Yes 0 No $0.00 4 hours Plan Check,Hourly Suppl. PC Fee: Q Reg. 0 OT 0.0 1 hrs $0.00 $520.00 ISTPLNCK PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-(F) Reg. OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Work Without Permit? Q Yes 0 No $0.00 0 Advanced Planning Fee: $0.00 Select allon-Residential Q q Building or Structure A Strong Motion Fee: $0.00 Select an Administrative Item Bldg Stds Commission Fee: $0.00 SUBTOTALS $0.00 $520.00 TOTAL FEE: $520.00 Revised: 04101/2012 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: DATE: REVIEWED BY: APN: BP#: 'VALUATION: A PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SF© or Duplex 2nd Unit" Yes No PENTAMATION IR3SFDADD USE: OTC.,, 0 Yes QNo PERMIT TYPE: WORK SCOPE OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BPFEE ID CONSTR. (s.f.) R-3(Custom) 11-B,111-B,1V,V-B 0 $0.00 $0.00 TOTALS: 0 $0.00 $0.00 MECH, HOURLY 0 Yes 0 No PLUMB, HOURLY 0 Yes (j) No ELEC,HOURLY 0 Yes 0 No Lj I- NOTE: This estimate does not include fees due to other Departments(le. Planning,Public fVorks,Fire,Sanitary Sewer District,School District,etc.). These Lees are based on the prelininar information available and are only an estimate. Contact the Depifor addnl info. ��/�'r I % FEE ITEMS FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes 0 No $0.00 1 2 1 hours Plan Check,Hourly Suppl.PC Fee: (S) Reg. 0 OT 0.0 hrs $0.00 $260.001 ISTPLIVCK PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-.0 Reg. 0 OT TO-0 T brs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.60 0 Work Without Pen-nit? 0 Yes 0 No $0.00 0 $0.00 Select a.Non-Residential ................. Building or Structure 0 $0.00 Select an Administrative Item ...... $0.00 SUBTOTALS:SUBTOTALS: $0.001 $260.00 TOTAL 260=00 Revised: 1/19/2012 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 C O P E RT I N O Telephone: 408-777-3228 Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: Q%3—o ..5 54,f 51. PERMIT# /0 900 OWNER'S NAME: 'C A PHONE # 40J7 GENERAL CONTRACTOR: 06,a.,' 2k BUSINESS LICENSE# ADDRESS: O CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # ✓ Cabinets & Millwork a/ Cement Finishingrii&A /S' / S) Electrical = 30 97(e Excavation — 2 g Fencing Flooring / Carpeting e74 .33910 I/ Linoleum/Wood ,e / 33950 t/ Glass/ Glazing , ,I �', ,ZQ2.2 6 Heating �� J &/ Insulation AGO Landscaping Lathing Masonry Painting/Wallpaper &AU4 E J ,3 s 0 G Plastering 6--c slay 29q 3Z. ✓ Plumbing ur, 320 Roofing FSeptic Tank ,/ Sheet Metal i9;/Z WOIr 30 I/ Sheet Rock eye v —" Ti �� C eu Rc I 10 G� 6 / Owner/Contractor Signature bate ir l UTILITY RELEASE REQUEST FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL CUPERTINO 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (40B)777-3228•FAX(408)777-3333•building(cDcuaertino.org PURPOSE For residential single family or duplex construction, there are cases where gas and electric utilities are requested to be released prior to the issuance of the certificate of occupancy. Upon approval from the building inspector, the City of Cupertino is allowing both utilities to be released prior to the final sign-off of the building. INSTRUCTIONS 1. Download this form at: http://www.cupertino.org/index.aspx?page=297. 2. Complete the form and obtain signatures from both the owner of the property and the primary contractor. 3. Fax, E-Mail, Mail or hand deliver the original signed form to: City of Cupertino Building Division Attn: Utility Release Request Form 408-777-3228 office 10300 Torre Ave. 408-777-3333 fax Cupertino,CA 95014 building(&cupertino.orQ 4. Schedule a Gas Meter Release inspection(#403) and/or Electric Meter Release inspection(#404). Please note, a Gas Test inspection (#506) is required prior to or at the same time of the Gas Meter Release inspection. BUILDING INFORMATION (Please complete the following information): APN _�1 2_ 59 O 13 BLDG PERMIT#: //0 C1106-6 51 DATE: /Io// y SITE ADDRESS: D y R S OWNER'S NAME: FAHX#: MAILING ADDRESS(if different from site address): I CONTRACTOR: PHONE* FAX#: CONTACT: PHONE#: FAX#: I request the City to release my utilities prior to obtaining a final inspection approval for the building. I fully understand the occupants of the building cannot move into the residence until they receive all of the required final sign-offs and the City has issued a certificate of occupancy for the build' Owner• utld!.�........ ............ .. ... ................................Print:.........\. ....Q' (1-'.... .. ..... .L ..............Date:...f. .��. .�.�......... Contractor:............. ................................................................Print:.........................................................................Date:.............................. UtiliryReleaseForm_2011.doc revised 08/09/11 OWNER-BUILDER NOTICE COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• building(a)cupertino.org Effective January, 1, 2009, Assembly Bill 2335 amends California Health and Safety Code, Section 19825, regarding disclosures and verifications required for all applicants seeking Owner- Builder construction permits. These new application requirements provide an enhanced level of consumer awareness and protection for property owners accepting the risks associated with Owner-Builder construction permits. "The Legislature hereby finds and declares that there is an urgent and statewide public interest in assuring that building contractors comply with the Contractors License Law...and provisions of law relating to Workers' Compensation Insurance for building construction, that property owners are informed about, and protected from, fraudulent representations, liability for worker's injuries, liability for material and labor costs unpaid by contractors, licensing requirements, and employer's tax liabilities when improving their property as owner-builders" Important information you need to know BEFORE pulling your permit! The term "Owner-Builder" can mean three different things: "Owner as Worker", "Owner as Contractor" or "Owner as Employer" Understand each has Benefits or Risk, and it is possible to combine them! Hiring a California Licensed Contractor means you do not personally perform any of the construction work,the pen-nit is not taken out in your name, you are not personally responsible for the construction and you are not an Owner-Builder. Instead,you become a"Customer" and California law provides you the benefit of protection from poor workmanship,failure to finish the job and financial risk due to worker injury. Benefit/Risk: Highest Benefits and the Least amount of Rist: Owner-as-Worker is a type of Owner-Builder where you personally perform the construction work, the permit is taken out in your name and you are personally responsible for the construction management, knowledge, workmanship, and completion of the job. You benefit by not paying others to perform this work for you and your risk depends on your own ability to complete the job successfully. Benefit/Risk: with Lo« Financial Risk Owner-as-Contractor is a type of Owner-Builder where you personally act as your own General Contractor, the pen-nit is taken out in your name and you hire California licensed sub-contractors to perform portions of the construction work. WARNING: The benefit of protection provided by law when you hire only California licensed sub-contractors can tum to serious financial risk if you hire unlicensed contractors to perform any of the work. Benefit/Risk: and Significant Financial Risk Owner-as-Employer is a type of Owner-Builder where you pay any individual to perform any construction work valued at more than $500.00, the permit is taken out in your name and you are personally responsible for their employment requirements, supervision,perfonnance,safety and welfare while on your property. WARNING: Cost savings benefit can turn to serious financial risk if you fail to deduct payroll taxes or provide workers compensation insurance for each worker. Benefit/Risk: - with Significant Financial Risk Over 20,000 consumer complaints are filed each year. Many complaints relate to owner/builder projects and include workmanship and workers' compensation issues Homeowners suffer financial harm due to defective workmanship and injured employees. OwnerBuilder 2010.doc remised 06108/10 Following are alarming examples of what has occurred with Owner-Builder permits: Example 1: Homeowner received insurance money to rebuild burned-down home. ■ Owner/Builder permit pulled to rebuild structure. ■ Unlicensed contractor built substandard structure— must be torn down and replaced. ■ Estimated financial injury is $225,000. ■ Additional financial injury - IRS threatened to tax insurance payout if house not completed by the end of the year. Example 2: Brother-in-law had active license but filed an exemption from Workers Comp. ■ Owner-Builder hires brother-in-law to install a new roof. ■ Employee falls and sustains multiple spinal and extremity fractures as well as a head injury and remains in a coma to this day. ■ The Owner-Builder, who has sold the home, is now a defendant in a lawsuit for reimbursement for benefits paid to the injured worker. Example 3: Employee of contractor without Workers Comp is hired by Owner-Builder to install septic system and suffers injury that results in permanent disability. ■ The Owner-Builder did not have a homeowner's insurance policy on the house against which to submit a claim. ■ The Owner-Builder is now a defendant in a lawsuit for reimbursement for benefits paid to the injured worker. Did you know— unlicensed persons frequently have the property owner obtain an "Owner- Builder" building permit which erroneously implies that the property owner is providing his or her own labor and material personally? Did you know—your homeowner's insurance may not provide coverage for injuries sustained on your property by an unlicensed contractor and his/her employees? Did you know— if you are considered an "employer' under state and federal law, you must register with the state and federal government, withhold payroll taxes, provide workers compensation and disability insurance and contribute to unemployment compensation for each "employee"? Did you know—that if you fail to abide by these laws you may be subjected to serious financial risk? OWNERS BEWARE AND CONSIDER THE RISK BEFORE ACCEPTING FULL RESPONSIBILITY FOR YOUR CONSTRUCTION PERMIT Ow»erBuilder 2010.doc revised 04112110 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• building(d)cupertino.org 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 f'V �y 5-b �rr� �� APN 3V2_5 8P# OWNER NAMEn _ Jl� Z�v OWNER ADDRESS/O / Cyn p ,u J Q ? DESCRIPTION OF WORK: 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 (DI TIONS:Please read and initial each statement below to signify you understand or verify this information.) 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 inurance coverage for injuries to workers on my property. le 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for onstruction 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 pct myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her e instead of my own. n . 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. O5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the t—alvalue of my construction is at least five hundred dollars($500), including labor and materials, I may be nsidered an "employer' under state and federal law. 6. 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 e to serious financial risk. 7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family sidential 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 erformed under contract with a licensed general building Contractor. 8. 1 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. 014,nerBuilderForm 2010.doc remised 04/14110 9. 1 understand I may obtain more information regarding my obligations as an "employer"from the Internal evenue 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 c ntractors. 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I the party legally and financially responsible for proposed 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 Iorall 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 mation 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 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: - ------------------------------------------------------------------------------------------------------------------------------------------ -- (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: 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 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.docrevised04114110 4_ n LANDSCAPE WATIER-EFFICIEN& CHECKLIST Community VVelopment Department 1.0300 Torre Avenue " 408.777,3308/Fax 408.777.3333 Cupertino, CA 95014 u planiling@cupertino.org CUPERTINO 041 'we2http://cupertino.org/plannin w �r>~izrE►�Y Applicant Name: 05 f—� AT14Y Ar>ZI CH Email: 3E 64.4 FDlr' Project Site Address: l o`"f s o ST '� Phone: I • Total Landscape I Q� Landscape area: All the planting areas, turf areas, and water Area (square feet : ` features in a landscape installation. The landscape area does not include footprints of buildings or structures, sidewalks, driveways,parking lots, decks, patios, gravel or stone walks, Turf Area: ( Z Z I �j •�• other pervious or non-pervious hardscapes, and other non- irrigated areas designated for non-development (e.g., open J58+ spaces and existing wildland vegetation). Non-Turf Plant Area: l Turf: A ground cover surface consisting of non-native grass Kecies that is customarily mowed. Annual bluegrass, entucky bluegrass, perennial ryegrass, red fescue, and tall S ecial Landscape Area: fescue are examples of cool-season turf grasses. Bermud�i Water Feature Wet Surface Area- grass, kikuyu grass,seashore paspalum,St. Augustine grass, If>lU%of landscaped area,water budget calcu- ��j3 5•� zoysia grass,and buffalo grass are warm-season turf grasses. lation required with landscape project submittal. See reverse side for other definitions. NOTE: If landscape area exceeds 2,500 sq.ft.,a landscape project submittal shall be required. If no landscaping is proposed,enter "0"above and proceed directly to the signature block at the bottom of this form. Landscape Parameter Requirements Project Compliance Turf < TotaI turf area shall not exceed 25%of the landscape jg Yes ❑ No area,or 1,250 square feet,whichever is lesser in area. (If no, Water budget i�alculalion required with landscape project submittal] All portions of turf areas shall be wider than eight(8)feet. Al Yes Turf(if utilized)is limited to slopes not exceeding 15%. Yes Non-Turf At least 80%of non-turf area shall consist of native or 29 Yes ❑ No 'f low water use plants. no, Wager budget calculation required -with landscape project submittal I 'a Hydrozones Plants with similar water needs shall be grouped within Yes ❑ No hydrozones. Each hydrozone shall be controlled by a I [Plants can be grouped per separate valve. Table Id.15.050(C)] Irrigation System i Systems shall be designed and maintained to minimize Yes ❑ No I water waste(e.g.,runoff,low head drainage,overspray). It Low-volume irrigation shall be utilized in non-turf areas. Irrigation shall only occur between the hours of 8:00 pm j [If no, Provide explanation on hack] and 10:00 am. Soil A minimum of eight(8)inches of non-compacted topsoil I Yes ❑ No shall be available in planted areas. If no, Provide explination on hack] l Soil amendments,such as compost or fertilizer,shall be ] appropriately added according to the soil conditions at Yes J No the project site and based on what is appropriate for the I [if no, Provide explanation on back] selected plants. Mulch A minimum two(2)-inch layer of mulch shall be applied Yes ❑ No on all exposed soil surfaces of planting areas,except in areas of direct seeding application(e.g.hydro-seed). If no, Provide explanation on back] 1 am aware f available informational resources regarding native and low water use plants,irrigation efficiency,and other aspects of water-effic- ands in`g�. ertify that the information provided on this checklist is correct,and the installed landscape complies with Chapt r 14.15. 1 also understand that any changes to the project will necessitate as new checklist. e tv owner or authorized representative Date S �L �� ",! Page 1 of 2 's checklist implements the requirements of Chapter 14.15,Landscape Ordinance,of the Cupertino Municipal Code. to responses provided will be evaluated to determine whether the proposed landscape is generally consistent with the dinance's water-efficiency goals. licant Comments ditional paper if necessary iff Evaluation Staff Comments Approved At Not Approved Signature Date elect Definitions Hydrozone: A portion of the landscaped area having plants with similar water needs. A hydrozone may be irrigated or non-irrigated. Low-volume irrigation: The application of irrigation water through a system of tubing or lateral lines and low-volume emitters such as drip and bubblers. Certain rotary emitters designed for highly efficient water distribution,and situated to irrigate low water use plants,may also be included in this definition at the discretion of the Planning Office. Low water use plant: A plant species whose demonstrated water needs are compatible with local climate and soil conditions such that regular supplemental irrigation is not required to sustain the plant after it has be- come established. Any species classified as"very low water use" and"low water use" by WUCOLS,having a regionally adjusted plant factor of 0.0 through 0.3,shall be categorically deemed a low water use plant. Native plant: A plant indigenous to a specific area of consideration. For the purpose of this division, the term will refer to plants indigenous to the coastal ranles of Central and Northern California, and more specifical- ly to such plants that are suited to the ecology orthe present or historic natural community of the project's vicinity. Special landscape area: An area of the landscape dedicated solely to edible plants, areas irrigated with re- cycled water, water features using recycled water and areas dedicated to active play such as parks,sports fields, golf courses,and where turf provides a playing surface. Turf: A ground cover surface consisting of non-native grass species that is customarily mowed. Annual blue- grass, Kentucky bluegrass, perennial ryegrass,red fescue,and tall fescue are examples of cool-season turf grasses. Bermuda grass,kikuyu grass,seashore paspalum,St, Augustine grass, zoysia grass, and buffalo grass are warm-season turf grasses. Water feature: A landscape design element where open water performs an aesthetic or recreational function. Water features include ponds, fountains, waterfalls and artificial streams. Also includes spas and swim- ming pools that are ancillary to single-family, two-family and multi-family residential uses. Wet surface area: The surface area of that portion of a water feature that functions to contain water,such as the water surface of a swimming pool,spa,or garden pond. For a fountain or other feature with flowing water, wet surface area shall be measured as a two dimensional plane bounded by the perimeter of the area where water has been designed to flow.