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12090008CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1195 YORKSHIRE CP CONTRACTOR: JAIN PUNIT/MEGIIANA PERMITNO: 12090008 OWNER'S NAME: JAIN PUNIT/MEGHANA 1195 YORKSHIRE CT DATE ISSUED: 09/04/2012 OWNER'S PHONE: 4087181862 CUPERTINO, CA 95014 PDONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION r G (J BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lie. tl r (- "" DIECII RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm tint l am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE AND REPLACE (6) LIGHTS AND INSTALL (3) (commencing with Section 7000) of Division 3 of the Business & Professions NEW LIGHT FIXTURES 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 die work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance, as provided for by Sq. Ft Floor Area: Valuation: $2390 Section 3700 of the Labor Code, for the performance of Ute work for which this permit is issued. APN Number: 36211009.00 Occupancy Type: APPLIC,N'r C1:Rq'IFICVTION 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 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. �}/ Q Issued by: Date: /�/� �/g% G I • y'��. Signature Date ❑ OWNER -BUILDER DECLARATION RE -ROOFS: hereby affirm that I am exempt from the Contractor's License Low 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 newmaterials 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: 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sce.7044, Business & Professions Code). AL1, ROOF COVERINGSTO BE CLASS "A" OR BETTER 1 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 DAZARDOUS 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 the performance of the work for which this permit is issued. California Ilealth & 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 CupertinoMunicipal Code: Chapter 9.12 and the Health & Section 3700 of the Labor Code I for the performance of the work. for which this SafetyCode. Section 25532(a) should 1 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 forwhich this permit is issued, l shallmaintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the not employ any person in my manner so as to become subject to the Worker's Health & Safety Code, Sectio s 255051 255331 and 25534. Compensation laws of California. If, after making this certificate of exemption, 1 become subject to the Worker's Compensation provisions of the Labor Code, I must Owner or authn zedage V" forthwith comply with such provisions or this permit shall be deemed revoked. Date: Arr1,11 ,\NT CERTIFICATION CONISrFRUCI'ION 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 cored. 1 agree to comply with u11 cit)' and county ordinances and stale 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 indemnify 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 all non -point source regulalions per the Cupertino Municipal Code, Section ARCIII'1'IiCI"S DECLARATION 9.18. 1 understand my plans shall be used as public records. ^ I I4 I )Y Signature `�I w" Date Licensed Professional GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT DIEM •BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTf NO (408) 777-3228 • FAX (4.08) r r -3333 • building c(�. cugerino.ora ❑ u6ING ❑!.RC1-*1NC.4L ELECTRC?t F1iEscat reorr.�DRss / Y Q I� I< Sf7/ R C L t` owr+ERNAA. vnJ t % S /� 1 �/ J (>-`n,: r• Da' 7/9.JJ8.6(/2I E-MAFi ��/^ E' ct STA1=t ADDR-SS "T -= Y. ,., c vnc--7 ,neo I FAX CONTACT NAA. HONE MAIL S -RM TA DRESS Cr", STATI; iW FAX 4 R OWWM- ❑ OWNER -131.)= ❑ OWNER AG -vi 11 CONiMCiOR ❑MO. C70RAG?ri ❑ ARCr= ❑ NG:I ❑ DEV�*_.OPZ Lam] T -J CONTRACTOR NAME 1 L'C-'.__.__.___ _ LICENSE -,'PE COMPANY NAA. E-MAIL I Bus. iIC4 I FAX S7R�� •______ _ __ __ _ I L7TY-_.—.-••__ - I � ARCST i?IG.T �i NAA. I LICENSE NUA107 I PHONE ^ I BVS. LIC 4 COAOANY, NAME E-MAIL FAX STREET ADDRESS I COY, STAT; ZZ PHONE USE. OF 577) m DU7LJt❑ MUL, rFAACLY BUILDING ❑ COM cEac::AL I PROT...CC N WIL IAND❑ S b-A',BAN FACE ARTA NO PRO.0 21 11 YES FLOOD ZONE !r`T••[.0 I Is THE BLDG AN 11 YES Eic-= HoM . NO DESC=,,ON OF WORK G IZL-CESS L/6,�t7S iL F-r'A 4f roc rw(7,qrc 3 rvE0 Ft,� 7 o s T OTAL VALILATION: 1` Sj 5 O I RECEIVED BY: By my sig:ta^_re be)ow, I c-'zi:y to each of Lhe fellewiDg: 1 an the ptnpeny owner or anthorizcd agent to act on the propcy owner's behalf. I have r -_ad :his application and the iafomacan I have prow ed is cer:ect 'ave :rad Lhe Descintion of Work and verity it is acne t I agree to comply wiCh al] applicable local ordinance and sate laws rt!arrg m buildi consavcdq I h:hor':� r-_pmsemm4ves of Cuperdnc _ ^_ter the a! ove.idc/p'Se /yorepe.-1 for inspection ou:vesu. $igaan.2 o`AppEcant/Agan \ Dz: 9 / �f / / y SUPPLEMENTAL IN; OR-kATiON REQLZZED OFFICE USE ONLY t, U G U < OVER-THE-COUNTER ❑ ETPRESS ❑ STANDARD ❑ LARGE ❑ owoR MEP.Vf c9pD_:Ol l.doc revised 06/21/II co+v � CITY OF CUPERTINO I►1'//I FEE ESTIMATOR—BUILDING DIVISION J&DI)RESS: 1195 Yorkshire Ct DATE: 09/04/2012 REVIEWED BY: Sean UNITS PN; BP#: 'VALUATION: $2,390 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: $67 PENTAMATION 1REAP11 PERMIT TYPE: WORK Remove and replace 6 lights and install 3 new light fixtures. SCOPE APPLIANCE/ EQUIP TYPE FEE ID Phanh. Plan Check QTY UNITS BP FEES Elec. Permit Fee: IEPERMIT Fixtures, Lighting 1BREMFIXT Other Elec. Insp. 0.0 hrs $45.00 11 # $67 Permit Fee: Supp/, Insp Fee PME Unit Fee: $67.00 PME Permit Pee: $45.00 Construction Tae: Administrative Fee: IADMhv $42.00 Work Without Permit? C) Yes Q No $0.00 TOTALS: F Travel Documentation Fee: ITRAVDOC $67.00 Strong Motion Fee: IBSEISMICR A'OTE: This estimate does not include fees due to other Departments (i.e. Planning, Public (Parks, Fire, Sanitary Sewer District, School Dicrrirt etr.). Those fres are haled an it,,, nrelimivary informalion available and are anti, an estimate. Contact the Dept for atddn'I info. FEE ITEMS (Fee Resolution 11-053 Eff 7/l/Il1 Xlech. Plan Check Phanh. Plan Check Elec. Plan Check 1 0.0 1 hrs $0.00 ,Llech. Pencil Fee: Plumb. Permit Fee: Elec. Permit Fee: IEPERMIT OJnm ,tlech. Insp. Other Plumb /nsp.Li Other Elec. Insp. 0.0 hrs $45.00 .Ilach. lay. Fee: Plumb. h,sp. Fee: rice. Insp. Fee: A'OTE: This estimate does not include fees due to other Departments (i.e. Planning, Public (Parks, Fire, Sanitary Sewer District, School Dicrrirt etr.). Those fres are haled an it,,, nrelimivary informalion available and are anti, an estimate. Contact the Dept for atddn'I info. FEE ITEMS (Fee Resolution 11-053 Eff 7/l/Il1 FEE QTY/FEE MISC ITEMS Plzen Check Fee: Suppl. PC Fee PME Plan Check: $0.00 Permit Fee: Supp/, Insp Fee PME Unit Fee: $67.00 PME Permit Pee: $45.00 Construction Tae: Administrative Fee: IADMhv $42.00 Work Without Permit? C) Yes Q No $0.00 Advanced Planning Fees: Travel Documentation Fee: ITRAVDOC $45.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IRCBSC $1.00 SUBTOTALS: 1 $200.501 $0.001 TOTAL FEE: $200.50 Revised: 07/01/2012 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinara)cuoerilno.ara 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' j qYQ��fNt�� C� APN OWNER NAME 19, n t' I A I ,,LBP# �+ /� OWNER ADDRE� o `- yo1(k S 14I R ClI `ul�-ri'm 11 l7 DESCRIPTION OF WORK: L G 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.) P1. 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. 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 homeowners 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. f2. 1 understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. ,P A, 3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 0 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. PA -5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total 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. f'_6. 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." I also understand my failure to abide by these laws may subject me to serious financial risk. P -L7. I 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. P�_& I 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. OwnerBuilderForm ?010.doc revised 04//4//0 A I _Ll. 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. H10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. P7 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. E12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be Issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verificatio cceptable o the city may be required to be presented when the permit is issued to verify the propertyowner's s0at e. Property Owner's Signature: Date: ,% L --------------------------------------------------------------------------------------------------------------------- (NOTE. The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner -Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: Tel No I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderForm 1010.doc revised 04114110