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12020065 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21141 GRENOLA DR CONTRACTOR:DMITRI GARANOV PERMIT NO: 12020065 OWNER'S NAME: DMITRI GARANOV 21141 GRENOLA DR DATE ISSUED:02/14/2012 OWNER'S PHONE: 4082184072 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATIONI—BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lie.# f-MECH RESIDENTIAL COMMERCIAL Contractor Date JOB DESCRIPTION: INSTALL SELF CLOSING/LATCHING GATE,FOR SFDWL I hereby affirm that I am licensed under the provisions of Chapter 9 POOL. (commencing with Section 7000)of Division 3 of the Business&Professions ENCLOSURE 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. Sq.Ft Floor Area: Valuation:$0 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:32628014.00 Occupancy"Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN ,40 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 OM LAST C D INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the , li 1-1-12, Lid . 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. RF,-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: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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) 1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will 1 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 Code,Section 25532(a)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 defined by the Bay Area Air Quality Management District 1 performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the health&Safety Code,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this � �,� �1/ permit is issued. Owner or authorized agent: lY'�,v Date: 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,1 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 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 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, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section licensed Professional 9.18. L� Signatur Date CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 32628014 . 00 DATE ISSUED. . . . . . . : 02/14/2012 RECEIPT # . . . . . . . . . BS000016011 REFERENCE ID # . . . : 12020065 SITE ADDRESS . . . . . : 21141 GRENOLA DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : DMITRI GARANOV ADDRESS . . . . . . . . . . : 21141 GRENOLA DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : MINXUE QIAN CONTRACTOR LIC # *OWNER* COMPANY DMITRI GARANOV ADDRESS 21141 GRENOLA DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 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 0 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 0 . 00 0 . 50 0 . 00 0 . 50 0 . 00 1STINSP UNITS 1 . 00 130 . 00 0 . 00 130 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 172 . 50 0 . 00 172 . 50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 172 . 50 131 --------------- TOTAL RECEIPT 172 . 50 DocuSign Envelope ID:049DF950-1 D54-4AOA-952C-C4AOFB72E807 To City of Cupertino From Owner of 21141 Grenola Dr,Cupertino,CA 95014 Dmitri Garanov I Regarding Renew the permit for Pool&Spa I, Dmitri Garanov, hereby giving my Real Estate Agent Catherine Qian authorization to sign all necessary papers and open doors to renew our house pool&spa permit since I am currently in Russia. - y. �-DocuSigned by. wl�d�t.b Dmitri Garanov V.,i " Date 14.02.2012 PT 3FD9DNIDF8F431... f 1 i i i DocuSign Envelope ID:049DF950-1D54-4AOA-952C-C4AOFB72E807 cj OWNER-BUILDER DISCLOSURE FORM �°�dr_ COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228•FAX(408)777-3333•buiidinaecupertino.ora CUPERTINO t. , Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builde�orope� improvements specified at: SIT` /DSSZ3►•enal A �f ? APN BP# OWNER NAME / OWNER AD E G1 ' ` P111 tri, G y4 � .- DESCRIPTION OF WORK: sLe& 4c , 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 (Dl 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- 01 er"building permit that erroneously implies that the property owner Is providing his or her own labor and material personally. 1,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 Trance coverage for injuries to workers on my property. 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for nstruction and are not hiring a licensed Contractor to assume this responsibility. i 3 c . 1 understand as an"Owner-Builder"I am the responsible party of record on the permit. I understand that I may ins t myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her e instead of my own. 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license bers on permits and contracts. 5. 1 understand if I employ or otherwise engage any persons,other than California licensed Contractors,and the I value of my construction is at least five hundred dollars($500), including labor and materials, I may be Tider6ed 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 federal government,withhold payroll taxes, provide workers'compensation disability insurance,and contribute to unemployment compensation.for each"employee.' l also understand my failure to abide by these laws may subject ZLential o serious financial risk. 7. 1 understand under California Contractors'State License Law, an Owner-Builder who builds single-family structures cannot legally build them with the intent to offer them for sale, unless all worts Is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year,or all of the work performed under contract with a licensed general building Contractor. 8. 1 understand as an Owner-Builder if 1 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. OwnerBuilderForm 2010.doc revised 04/14/10 DocuSign Envelope ID:049DF950-lD54-4AOA-952C-C4AOFB72E807 DS 9. 1 understand I may obtain more information regarding my obligations as an"employer"from the Internal nue 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 j License Board(CSLB)at 1-800-321-CSLB (2752)or www.csib.ca.gov for more information about licensed nantractors. 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I he party legally and financially responsible for proposed construction activity at the site address listed above. i 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide � I applicable laws and requirements that govern Owner-Builders as well as employers. i 12. l agree to notify the Issuer of this form immediately of any additions,deletions,or changes to any of the rmation 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 I 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: I 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 s nature. Docusigned by.. Property Owner's Signature: te: 3FD9D9F1DFBF431... ------------------------ (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 i 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: 62)/*1 Name of Authorized Agent: l�j �.Yurl ���%�Yi/ (i Tel No 40. �. Address of Authorized Agent: 10275- A/ Z)e 14,724 b1 pd- doeetho, 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 properly owner's j signature. Docu5igned by. /C;Rjoperty Owner's Signature: CZdYAlA&k Date: 14.02.2012 PT 3FDM F1 DFSF431... OwnerBuilderForm_2010.doc revised 04114110 j i CITY OF C;UPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 21141 granola dr. DATE: 02/14/2012 REVIEWED BY: bob s. I VALUATION: $0 APN: BP#: PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Repair PRIMARY PE+NTAMATION I.JSE• SFD or DuplexT PERMIT TYPE: WORK install self closing/latching ate for sfd pool enclosure. SCOPE NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . These.Les are,based on the relinsna information available and are only an estimate. Contact the De, t or addn 7 in o. FEE ITEMS FEE [SC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure Suppl. PC Fee: Q Reg. Q OT ELI hrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: Hourly Only? 0 Yes d No $0.00 Suppl. Insp. Fee:Q Reg. Q OT Eil hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: — F-1 $0.40 0 Work Without Permit? 0 Yes Q No $0.00 0 iar :._ .._. I£ , �� l_' W_ $0.00 C� hours Inspections $130.00ISTINSP Inspection,Hourly $0.00 0.5 hrs Admin./Clerical Fee Blcg 1,tds {oivin,�ssion Fee: $0.00 $41.00 ]ADMIN SUBTOTALS: $0.00 $171.00 TOTAL FEE: $171.00 Revised: 1/19/2012 I DocuSign Envelope ID:049DF950-1 D54-4AOA-952C-C4AOFB72E807 ! Ua U U Lo S CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTiNO (408).777-3228•FAX(408)777-3333•buildin cu p.ertino.org ❑NEW CONSTRUCTION ❑ ADDITION lr ALTERATION/TI ❑ REVISION/DEFERRED OWGINAL PERMIT# PROJECT ADDRESS *�)1 l Q P r e APN OWNER NAME PHONE �+. E-MAIL STREET ADDRESS- I1, 1 /1 �0/Q CITY.STATE,ZIP FAX CONTACT NAME(�J }ft$�� alb., PHONE � �(J� E-MAIL Mevm� Q/(,/4&2,fwA��CG��(� / v� t STREETADDX3 , 1Oeen©la OrC1TY.STATE.ZIP �r yF FAX ❑OWNER ❑ OWNER-BUILDER AOWNER AGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT 11 ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME (P'{ /� LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME `6e !� E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITEC•r/ENG24EER NAME LICENSE NUMBER BUS.LTC# I COMPANY NAME E-MAIL FAX STREET ADDRESS CITY.STATE,ZIP PHONE DESCRIPTION OF WORK Y�ICv/1 wr/l I i EXISTING USE PROPOSED USE CONSTR TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NETAREA 2 2.- d BATHROOM KITCHEN OTHER REMODELAREA REMODELAREA REMODEL AREA PORCHAREA J.DECKAREA TOTALDECKIPORCHAREA I GAPAGEZEC771DETACH ATTACH #DWELLING UNITS: LSA SECOND DMT ❑YES SECOND STORY OYES BEING ADDED? ONO ADDITION? ONO PRE-APPLICATION OYES tF YES,PROVIDE COPY OF IS THE BLDG AN I]YES I ( IVED BY: TOTAL VALUATION: PLANNING ADPL# ❑NO PLANNING APPROVAL LETTER EICELER HOME? ❑NO / / ry By my signature below,[certify to each of the following: I am the property owner or authorized agent to act on the✓prppJerty 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. 1 agree to comply with all applicable local ordinances and state laws relating to building cors truction. I authorize representatives of Cupertino to enter the abov -id tified property for inspection purposes. Signature of Applicant/Agent:— oJiL+�� _ Date; SUPPLEMENTAL INFORMATION REQUIRED PLAN CHS TYPE !2MG SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for COvnT'ER BUH,DING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ mawss ❑ PLANN NG PLAN REvMW _Commercial Bldgs: Provide a completed Hazardous Materials Dis foclosure ❑ STANDARD ❑ PUBLIcwoRxs rm if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ IrtE nm _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ s.1NITARY sitwER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH. Bldg,4pp 2011.doc revised 06121111