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12020099 CITE' OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 888 BLAZINGWOOD AVE CONTRACTOR:BARCZI KENNETH A AND PERMIT NO: 12020099 JOANNE B OWNER'S NAME: BARCZI KENNETH A AND JOANNE B 888 BLAZ[NGWOOD AVE DATE ISSUED:02/22/2012 OWNERS PHONE: 4082575543 CUPERTINO,CA 95014-4619 PHONE NO: f- 0 Q LICENSED C'ONTRAC_'TOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB ' License Class Lic.# MECH f RESIDENTIAL COMMERCIAL Contractor Date JOB DESCRIPTION:TWO LIGHT FIXTURES,REPLACE TUB IN GUEST BATH, I hereby affirm that I am licensed under the provisions of Chapter 9 REPLACE SHOWER PAN IN ROASTER BATH,NEW GAS (commencing with Section 7000)of Division 3 of the Business&Professions FIREPLACE INSERT,REPLACE SLIDING DOOR WITH FRENCH 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 3 700 of the Labor Code,for the performance of die work for which this Sq.Ft Floor Area: Valuation:$45000 permit is issued. APPLICANT CERTIFICATION APN Number:36917018.00 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 acrd 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 `'YORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN YS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply 180 DAB'S, M LAST CAI:LED INSPECTION. with all non-point source regulat.ictis per the Cupertino Municipal Code,Section 9.18• .� Date: Issued by: Signature Date 4 OWNER-BUILDER DECLARATION RE-ROOFS I herebv affirm that I 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 an inspection,I agree to remove all new materials for I,as owner of the property,or illy employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Date: Business&Professions Code) Signature of Applicant: 1,as owner of the property, in,exclusively contracting with licensed contractors to construct the prckiect(Sec.7044,Business&c 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 [have read the hazardous materials requirements under Chapter 695 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should l store or handle hazardous material. Section 3700 of the Labor Code,for(lie performance of the work for which this 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(fie performance of the work for which this pennit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the not employ anv person in any rrianner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,I Own or authori ed age become subject to the Worker's Compensation provisions of the Labor Code,I must Date: Z �L forthwith comply with such provisions or this pen-nit shall be deemed revoked. �J CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION l 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 aril 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 Narne upon the above mentioned property for inspection purposes.(We)agree to save indemnih and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. Signature C7t Date L Z2 ��/ Licensed Professional Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 CUPERTINO CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: 88 -BL A.1-1)G uj oo�) PERMIT# OWNER'S NAME: KEN j3AIZC t l PHONE# GENERAL CONTRACTOR: 0 E BUSINESS LICENSE# ADDRESS: X7°1 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)HAVE OBTAINED AHCITY OF CU ERTINO UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum/Wood Glass /Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Date Owner/Co tractor S nature CITY OF CUPERTINO 71APNFEE ESTIMATOR-BUILDING DIVISION : ADDRESS: 888 blazing wood DATE: 02/22/2012 REVIEWED BY: A. Salvador I BP#: VALUATION: $35,000 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Repair PRIMARY PENTAMATION 1 GENRES USE SFD or Duplex PERMIT TYPE: woRK Two light fixtures replace tub in quest bath replace shower pan in mstr bath new gas fireplace insert SCOPE replace sliding door with french door; add wet bar in existing family room. Mech.Plan Check 0.0 hrs $4.00 Plumb.Plan Check 0.0 hrs $Q.00 Elec. Plan Check 0.0 his $4.00 klech.Permit Fee: I tIPERMIT Plumb.Permit Fee: IPPERMIT Elec.Permit Fee: IEPERIflT Other Mech.Insp. 0.4 �hrs $44.00 Other Plumb Insp. 0.0 hrs $44A0 Other Elec. Insp. 4.0 �hrs $44-00 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 relinina in ormation available and are onl an estimate. Contact the De t or addno. 'l info. FEE ITEMS 's 3 f= ;;: ; ;.' t:>. '_` ''°1 i FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure hrs or Element of a Building Suppl. PC Fee: 0 Reg. Q OT 0.0 $4.00 E= PME Plan Check: $4.40 F 1 # Mechanical Permit Fee: $4.00 $65.00 IBAPPLOT Other Appliance/Equip Scrppl. Insp. Fee-0 Reg. Q OT O,Q hrs $0.00 1 # Windom-/Sliding Glass Door PME Unit Fee: $0.00 $392.00 IWINREP Replacement PME Permit Fee: $132.00 = # Plumbing $27.00 IBPFILIRE Fixture or Trap Administrative Fee: IAD-WIN $41.40 2 # Electrical Q Work `'Without Permit? Q Yes Q No $0.00 $44.00 IBREMRECEP Recep/SwiteWOutlets `d + o __,' P 11nim I c..._. $0.00 = # Electrical d Travel Documentation Fee: ITRA VDOC $44.00 $65.00 IBREMFLXT Fixtures,Lighting 9 �; �ioli"g;n F 1=11: IBSEISMIc_'R $3.50 Select an Administrative Item _. ':..'"__.. ..C.om-isneIBCBSC $2.00 SUBTOTALS: $222.50 $593.00 TOTAL FEE: $815.50 Revised: 1/19/2012 CITY OF CUPERTINO 12 ITEMS OF 12 PERMIT RECEIPT OPERATOR: patg COPY # Sec: Twp: Rigg: Sub: Blk: Lot: APN . . . . . . . . 36917018.00 DATE ISSUED. . . . . . . ; 02/22/2012 RECEIPT #. . . . . . . . . : BS000016082 REFERENCE ID # . . . 12020099 SITE ADDRESS . . . . . 888 BLAZINGWOOD AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . BARCZI KENNETH A AND JOANNE B ADDRESS . . . . . . . . . . 888 BLAZINGWOOD AVE CITY/STATE/ZIP . . . CUPERTINO, CA 95014-4619 RECEIVED FROM . . . . KENNETH A BARCZI CONTRACTOR . . . . . . . LIC # *OWNER* COMPANY . . . . . . . . . . BARCZI KENNETH A AND JOANNE B ADDRESS . . . . . . . . . . 888 BLAZINGWOOD AVE CITY/STATE/ZIP . . . CUPERTINO, CA 95014-4619 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1ADMIN HOURS 1 .00 41.00 0. 00 41.00 0.00 1BAPPLOTHE NO OF APPLIAN 1. 00 65 . 00 0 .00 65 .00 0 .00 1BCBSC VALUATION 45, 000 -00 2 . 00 0 .00 2 .00 0 . 00 1BPFIXTURE NO OF FIXTURE 3 .00 27.00 0 . 00 27 .00 0 . 00 1BREMFIXT NO. FIXTURES 1 .00 65 .00 0 . 00 65 .00 0 .00 1BREMRECEP NO. OUTLETS 1.00 44 .00 0 .00 44 .00 0.00 JBSEISMICR VALUATION 45, 000 .00 4 . 50 0 .00 4 .50 0 .00 1EPERMITFE FLAT RATE 1 .00 44 . 00 0 . 00 44 .00 0 . 00 1MPERMITFE FLAT RATE 1.00 44 .00 0 . 00 44 .00 0 .00 IPPERMITFE FLAT RATE 1.00 44 .00 0 .00 44 .00 0 . 00 ITRAVDOC FLAT RATE 1 .00 44 . 00 0 .00 44 .00 0.00 1WINREP EACH 8 1 .00 392 . 00 0 . 00 ---- ------ 392 .00 0 .00 ---------- ---------- ------ ---- TOTAL PERMIT 816 .50 0 .00 816 .50 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 816 . 50 MC --------------- TOTAL RECEIPT 816 .50 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228- FAX(408)777-3333- buildinQ(a�cuper ino.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 ADDRESS APN 13P# OWNE NAME OWNER ADDRESS L'�� 9` s o c��// DESCRIPTION OF WORK: tm l 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.) Cider" 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- B 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. 2. I understand building permits are not required to be signed by property owners unless they are responsible for th construction and are not hiring a licensed Contractor to assume this responsibility. A. 3. 1 understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may pro ct myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license n0mbers on permits and contracts. 4' 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the totll value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer' under state and federal law. 6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and eral government,withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. �7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. -4�18. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for a financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction de ects in the workmanship or materials. OianerBuilderForm 2010.doc revised 04/14/10 �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 contractors. �10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I an 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 by II applicable laws and requirements that govern Owner-Builders as well as employers. 12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the infohmation 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: j Date: �a --------------------------------------------------------------------------------------------------------------------------------------------- (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: 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: OwnerBuilderForns 2010.doc revised 04/14/10 RESIDENTIAL PROJECT COVER SHEET Assessor's Parcel Number: Name of owner. i� ti C- o -�l Y) Project address. tS L q 1"3 Ci W 00D' 61 V L U P5(ZT 11v o CA `3 Y Contacterson. �� Phone. p Fax. Net square footage of lot. Iwo- Existina Proposed Square footage: First floor: - Second floor: Garage: TOTAL: Are there at least two 10 foot by 20 foot clear spaces inside the garage? N Is privacy protection planting required for theproject? N\ Build it Green Total Points On what floor(s) is work being done? Brief description of work. 7-w,:, Lc k xus rfgiteY4 1,a Ce,J2 a c2. ver �j�Y) 01 r„ m- R ��-4-1.. � u - h �- _ a c.Q � n•, -I-,� Ja,:r� iGrer.i[ Code editions: 2010 CBCg�)N)2010 CFC N)2010 CMC N) i( 2010 CPC -N)2010 NEC Californim BUiLDI Code 2010 APPROVED Effective 1/01/11Thts set of plans and specifications MUST be kept at the site during construction. It is unlawful to deviate(�any changes or aiterations on sarnova from the Buiiding'C' ici<I. therefrom,without app ^ { �t �n, of this plan and specifications�Fi yl The .arnp 9 rfzrovai cf be h�:I to permit or to be'ri �.�. of any pions of any city ordinance or S`� By—L--A pErMIT NO. Plan Review Process Work Book Page-8- Revised 12/21/10 rn N O 7 A Itn Ln 3� Ln N N O cD d i t f E � b m WO r1 K y t� ��.�►nr.� --t(a Cl n►n w O c � r N C O N S Q C.0 Q V M W T� D cy r r COW, C:l a� ch r+ 03 7" 0 N 0 b 3' N A 3 V� CONSTRUCTION PERMIT APPLICATION PWT pLA WS COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION CBECKW By 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 D�AT>l� -r�. — ��- (408)777-3228• FAX(408)777-3333• building6a cupertino.org CUPERTINO ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED �� _ APN# DATE 11 PROJECT ADDRESS 1111 A 7v PHONE '/ L �. 1j Z i 1�,, cot t Y i ! OWNER NAME �L'� (� • FAX STREET ADDRESS CITY, STATE ZIP \0 cf,cl<'_1C1L PHONE E- IL PCONTACT7NANffi •�tY� CITY,STATE, ZIP FAX �`� L ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ APCFIITECr ❑ENGINEER ❑ DEVELOPER ❑TENANT ❑OBER ❑ OWNER-BUILDER ❑ OWNER AGENT LICENSE NUMB EEL LICENSE TYPE BUS.LIC# CONTRACTOR NAME O�� FAX E-MAIL COMPANY NAME CITY,STATE,ZIP PHONE STREET ADDRESS /� LICENSE NUMBER BUS.LIC# ARCHTI'ECT/ENGINEERRNRME IO 7 /�. FAX E-MAII. COMPANY NAME CITY,STATE,ZIP PHONE STREET ADDRESS 1XV At PS, rf1 DESCRIPTION OF WORK t EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES USE TYPE OCC. SQ FT. VALUATION(S) TOTAL NEW FLOOR DEMO EXLSTGA AREA NST AREA AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA DETACH ' PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: []ATTACH #DWELLING UNITS: ISA SECOND UI\Tr ❑YES SECOND STORY ❑YES BEING ADDED? []NOADDITIOf�? [:]NO YES RECEIVED BY: TOT VALUATION: PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN C] S( PLANNING ADPL# []NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO �� -U a By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on owner's behalf.'I have read this the prrperty 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 tion. I authorize representatives of Cupertino to enter the above-identifiedii property for inspection purposes. ordinances and state laws relating to building construc Date:�?; �Z Signature of Applicant/Agent SUPPLEMENTALinRMATION QUIlZED PLAN CHECK TYPE �ROUTINGLIP _New SFD or Multifamily dwellings: Apply for demolition permit for R-TM7C N BUII DING PIAN R�viER' existing building(s). Demolition permit is required prior to issuance of building ❑ EXPRESS ❑ PLANNING PLAN REVIEW permit for new building. ❑ PUBLIC WORKS _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ FDS DEPT form if any Hazardous Materials are being used as part of this project. ❑ TARGE _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJ oR ❑ SAMTARY SEWER DTSTRICr submittal of Building Permit application. ❑ ENV1RONMENTAL HEALTH BldgApp_z011.doc revised 06/21/11