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11110009 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10895 SWEET OAK ST CONTRACTOR:RICHARD FORD PERMITNO: 11110009 OWNER'S NAME: RICHARD FORD 10895 SWEET OAK ST DATE ISSUED: 11/02/2011 OWNER'S PHONE: CUPERTINO,CA 95014-0122 PIONE NO: LICENSED CONTRACT'OR'S DECLARATION I— (— (— BUILDING PERMIT INFO: BLDG BIJ:C'IPLUMB License Class Lic.4 r r r NIECII RESIDENTIAL. COMMERCIAL Contractor Date 1 hereby affirm that t am licensed under the provisions of Chapter 9 JOBDESCRIPTION REPLACE WATER IIEATER IN SAME LOCATION (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 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. Sq.Ft Floor Area: Valuation:$1000 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 APN Number:32651041.00 Occupancy Type: permit is issued. APPLICANT CER'T'IFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 1 0 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY M LAST CALLED INSPE T ON. indenonly and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the /� 2 granting of this permit. Additionally,the applicant understands and will comply Issued by: '�/ Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date 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. OWNER-BUILDER DECLARATION Signature of Applicant. Date: hereby affirm that t am exempt from the Contractor's License Law for one of the following two reasons: ALI,ROOF COVERINGS TO BE CLASS"A"OR BEYFE:R 1,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) 1,as owner of the property,am exclusively contracting with licensed contracto I IAZARDOUS MATERIA S DISCLOSURE construct the project(Sec.7044,Business&Professions Code). t have read the hazardous materials requirements under Chapter 6.95 of the California Ilealth&Safety Code,Sections 25505,25533,and 25534. 1 will hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Cade,Section 25532(x)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as delined by the Bay Area Air Quality Management District performance of the work for which this permit is issued. will maintain compliance with the Cupertino Man' at liter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety Code,Sections W05, 5531,11 4 Section 3700 of the Labor Code,for the performance of the work for which this ! Owner or authorizW xgenC Date: / permit is issued. / I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,1 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked, work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep hamnless the City of Cupertino against liabilities,judgments, ARCIIITECT'S DECLARATION Ws.,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. Ling of this permit.Additionally,the applicant understands and will comply ,n all non-point source regulations per the gupenino Municipal Code,Section Licensed Professional y.18. k SignatureDate �� CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION • ADDRESS: 10895 Sweet Oak DATE: 11102/2011 REVIEWED BY: gs APN: 1 BP#: "VALUATION: $1,000 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY SFD or Duplex PENTAMATION PRWHEATR USE: PERMITTYPE: WORK a lace water heater located in garage. SCOPE APPLIANCE EQUIP TYPE FEE ID QTY UNITS BP FEES Water Heater 1PRWHEATR 1 # $26 TOTALS: $26.00 tfe,^h. i;'7a r Check Plumb. Plan Check 0.0 hrs $0.00 Of?''Plein Check rWeoh. Venwi Fee: Plumb.Permit Fee: IPPERMITT:7ac, 3'erniii Pee: • UJ0.0 44. hei ,iferh.lust'. Other Plumb Insp. hrs $ 00 Other h7er.. inq>. ddn.A.Inmp. Pee: !'hash. Indp. 1ce; ["Ie"'Imp. Fen: NOTE: This estimate does not include fees due to other Departments(La Planning,Public Warks,Fire,Sanitary Sewer District,School District,etc.). Thesefees are based on the orelinina information available and are only an estimate. Contact the De t or addn7 inla. FEE ITEMS Lee Resolution 11-053 E8' 7i1/lU FEE QTY/FEE MISC ITEMS Plan Checl, Fee: Suppl. PC]"Ce PME Plan Check: $0.00 Pea-mit Fee: Suppl, blsl>Fee PME Unit Fee: $26.00 PME Permit Fee: $44.00 Cnuftrrri'fiun Tae Administrative Fee: (ADMIN $41.00 Work Without Permit? O Yes 0 No $0.00 :1Jrnrrce:d/'/arming Fees: Travel Documentation Fee: ITPA VDOC $44.00 Stront;Motion Fee: IB_SEISM_1CR $0.50. Select an Administrative Item • Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $156.50 $0.00 TOTAL FEE: 1 $156.50 Revised: 10/01/2011 CITY OF CUPERTINO • 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 32651041 . 00 DATE ISSUED. . . . . . . : 11/02/2011 RECEIPT # . . . . . . . . . : BS000015216 REFERENCE ID # . . . : 11110009 SITE ADDRESS . . . . . : 10895 SWEET OAK ST SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : RICHARD FORD ADDRESS . . . . . . . . . . : 10895 SWEET OAK ST CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-0122 RECEIVED FROM . . . . : RICHARD FORD CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : RICHARD FORD ADDRESS . . . . . . . . . . : 10895 SWEET OAK ST CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-0122 TELEPHONE . . . . . . . . : . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- -ADMIN HOURS 1 . 00 41 . 00 0 . 00 41 . 00 0 . 00 1BCBSC VALUATION 1, 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 1, 000 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1PPERMITFE FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 1PRWHEATR UNITS 1 . 00 26 . 00 0 . 00 26 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 44 . 00 0 . 00 44 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 156 . 50 0 . 00 156 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 156 . 50 418 --------------- TOTAL RECEIPT 156 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 518 WATER HEATER • L GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO. CA 95014-3255 M ' sc •GUPERTINO (408)777-3228• FAX(408)777-3333• buildina(cDcuoertino.org I lf�ING EINIECHAMCAL ELECTRICAL r o MISCELLANEOUS PROJECT ADDRESS �✓ !!/ /� �» 21 SSI V t '/V OWNER N ' / /Qr` /' ✓ J PHONE E-MAIL STREET D % / ✓ /� moi( y� CITY,STATE,ZD' _ J^FAX' CONTACT NAMP / ON r� E.MAM STAEETADORS,JS.S� CRY,STATE, ZIP FAX Y/DWNEII-BUMDER ❑ OWNER AGENT ❑ coNDIACIOR ❑CONTRA=RAGFM ❑ ARCHITECT ❑ENGWEER ❑ DEVELOPER ❑TENANT CO AN / IICENSENUMBER LICFNSTYPB BUS.LIC# d COMPANY NAME E-MAIL FAX STREET AIDRE59��S l 7 A CITY,STATA-W yG� i PHONE ry AACFDTECTIENOINEFR NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY.STATE.III, PHONE E OF ASM.DUPLEx ❑ MULTI•FA Y PROJECTIN WEDtAND ❑ YES PROJECT IN ❑YES Is TREBLDOAN ❑YES BUILDING: [3mm?szRCLAL URBAN INTERFACE AREA NO FLOODZONE 0 N IICHLERHOM 0 N DESCRIPTION OF WORK TOTAL VALUATION: IL206 �� RECEIVED BY: 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. have read thagascription of Work and verify it is accurate. I agree m comply with all applicable local ordinances and state laws relating to buVing mps on. au 'ze enmtives of Cupertino to enter the above-ideadf! ddpm�per�y f inspection puf�'oses. Signature ofApplicanVAgrnt Dare. 777 / SUPPLEMENTAL INFO TION REQUIRED OFFICE USE ONLY d OYER-THE-COUNTER 6 ❑ EXPRESS M U Y ❑ STANDARD X u ❑ LARGE 6 ❑ MAJOR MHPMvcApp_1011.doc revised 06/11/11 OWNER-BUILDER DISCLOSURE FORM • COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228- FAX(408)777-3333-buildina(a)cuoertino.oro 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 O APN BP# OWNER NAM OWNER ADDRESS /jam pp - J DESCRIPTION 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 (DIREC IONS:Please read and initial each statement below to signify you understand or verify this information.) i I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- • ilder' 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 ins'7/'��n—ce coverage for injuries to workers on my property. �2. I understand building permits are not required to be signed by property owners unless they are responsible for e c struction 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 tett myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her T tead of my own. understand Contractors are required by law to be licensed and bonded in California and to list their license on permits and contracts. ///5* 1 understand if I employ or otherwise engage any persons,other than California licensed Contractors, and the tal value of my construction is at least five hundred dollars ($500), including labor and materials, I may be Tederal red an "employer"under state and federal law. 1 understand if I am considered an"employer" under state and federal law, I must register with the state and 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 MaIp serious financial risk. 7. I understand under California Contractors'State License Law, an Owner-Builder who builds single-family r 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 • /ny rformed under contract with a licensed general building Contractor. 8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for inancial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. OwnerBuilderFonn 10J0.doc revised 04//4/70 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 (CSLB)at 1-800-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed contract rs. I10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I 4;M t 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 ��y all icable laws and requirements that govern Owner-Builders as well as employers. agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the formation 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 r ui ed to be presented when the permit is issued to verify the property owner's si natu 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 owners 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: OwnerBuilderFonn 2010.doc remised 04/14/10