11070109 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10010 PHAR LAP DR CONTRACTOR:KLINKOWSKI KENNETH PERMIT NO: 11070109
AND MARIANN
OWNER'S NAME: KLINKOWSKI KENNETH AND MARIANN 10010 PHAR LAP DR DATE ISSUED:07/18/2011
c 2R'S PHONE: 4084460604 CUPERTINO,CA 95014-1112 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION F f—
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH F RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE EXISTING FRONT ENTRANCE DOOR&
(commencing with Section 7000)of Division 3 of the Business&Professions REPLACE WITH
Code and that my license is in full force and effect. NEW.EXISTING ROUGH OPENIGN SIZE WILL REMAIN THE
SAME
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
permit is issued. Sq.Ft Floor Area: Valuation:$7000
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:32618035.00 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: .�,��✓ � ate
L OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for 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
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code)
1,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. I 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. 1 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 contaminants as 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 with the Cupertino nicipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Se 'ons 25 ,25 3,and 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 r iz gen
Dat . Q
v ;
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the performance of work'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
it' nnify and keep harmless the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the Lender's Address
gimaing of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18.
I understand my plans shall be used as public records.
Signatu Date 4&av t
Licensed Professional
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32618035. 00
DATE ISSUED. . . . . . . : 07/18/2011
RECEIPT #. . . . . . . . . : BS000014075
REFERENCE ID # . . . : 11070109
SITE ADDRESS . . . . . : 10010 PHAR LAP DR
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : KLINKOWSKI KENNETH AND MARIANN
ADDRESS . . . . . . . . . . : 10010 PHAR LAP DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-1112
RECEIVED FROM . . . . : KENNETH J KLINKOWSK
CONTRACTOR . . . . . . . . LIC # *OWNER*
COMPANY . . . . . . . . . . : KLINKOWSKI KENNETH AND MARIANN
ADDRESS . . . . . . . . . . : 10010 PHAR LAP DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-1112
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 7, 000 . 00 1. 00 0. 00 1 .00 0. 00
1BSEISMICR VALUATION 7, 000 .00 0. 70 0 . 00 0 .70 0. 00
1DOORSTRUC EACH 1 .00 392 . 00 0 . 00 392 .00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 393 . 70 0. 00 393 .70 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 393 . 70 AMEX
---------------
TOTAL RECEIPT 393 . 70
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10010 phar lap dr DATE: 07/18/2011 REVIEWED BY: larry s
APN: T_
BP#: '"VALUATION: 1$7,000
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Repair
PRIMARY SFD or Duplex 2nd Unit? Yes E No PENTAMATION 1 R3SFDREM
USE: OTC. 0 Yes E)No PERMIT TYPE:
WORK remove existing front door and replace with new, rough opening size will remain the same
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 0 $0.00 $0.00
TOTALS: 0 $0.00 $0.00
MECH,HOURLY 0 Yes 0 No PLUMB,HOURLY Q Yes Q No ELEC,HOURLY Q Yes Q No
_T7
Lj
NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info.
FEE ITEMS (f'ee Resolution 11-053 Ifff.' 7.111) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Select a Misc Bldg/Structure
Suppl. PC Fee: (2) Reg. 0 OT 0.0 hrs $0.00 or Element of a Building
PME Plan Check: $0.00 0 # New Door Opening
Permit Fee: $0.00 $392.00 IDOORSTRUC Shearwall/Masonry
Suppl. Insp. Fee-0 Reg. 0 OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Acoustical Fee: 0 Yes G No $0.00 0
Work Without Permit? 0 Yes E) No $0.00 G
Planning Fee: $0.00 Select a Non-Residential E)
Building or Structure 0
Strong Motion Fee: IBSEISMICR $0.70 Select an Administrative Item
Bldg, Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $1.70 $392.00 TOTAL FEE: 1 $393.70
Revised: 07/04/2011
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 ancupertino.orq
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:
SIT DDRE
VIN
� � � APN BP#
—1190 10
NER N E KL j OW OADDR �
DESCRIPTION OF WORK: („Gt (_
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.)
<_1
. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Bul er' building permit that erroneously implies that the property owner its 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.
n
2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
th truction and are not hiring a licensed Contractor to assume this responsibility.
jg3,.Iunderstand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
yseIf from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
I
instead of my own.
. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
ers on permits and contracts.
. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
alue of my construction is at least five hundred dollars ($500), including labor and materials, I may be
ered an"employer'under state and federal law.
Qin. 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
me to serious financial risk.
tz riderstand 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.
. 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.
OivnerBuilderForm 2010.doc revised 04/14/10
e
I 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
contractors.
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.
. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all al&plicable laws and requirements that govern Owner-Builders as well as employers.
e12I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
.
ma ' ve 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.)
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 o the property owner's driver's license,
form notarization, or other verification a cept ble fo city may be re be presented when the permit is issued
to verify the property owner's s' re
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:
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:
GYvnerBuilderFonn 2010.doc revised 04/14/10
I ( c)-7 0 (
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTIAlO (408)777-3228• FAX(408)777-3333 • building akupertino.oro
❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS / QL A-)777 /
OWNER NAME j/ �k P ON "G}! 13-MAIL
STREET ADDRESS C ST TE, f GL FAX
Irio a r Lq P/' tri
CONTACT NAME PHONE E-MAIL
STREET ADDRESS 7 CITY,STATE, ZIP FAX
"OWNER 13 OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME PI / Aler4 orr, C4 ) LICENSE NUMBER LICENSE TYPE BUS.LIC#
c 1z f
COMPANY NAME E-MAIL FAX
Cly CC fu L_(
STREET ADDRESS 1CITY,STA ,ZIP PHONE
R7 -YF S _ CA ` G .Zqz
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK ;'MOvIr V� ST)r-f�- ef'-OeT V^'ri-o-tw i-Ar boo 4ivo 1LO.PL#cr
t T}i n/tSN • ��X T'�^� 1Z��,G�/ C��,� ,� �Rn
� �� s�rritS'
EXISTSE PROPQSED USE CO'j$TJi.TYPE #STO S
7J� USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET.AREA 3 ✓� ��' �/�.�^
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA ELARF+
W,
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH
❑ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES
BEING ADDED? []NO ADDITION? [:]NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES _RE C D Y: TOTAL VALUATION:
PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? []NO ✓V V - -
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the pr_pperty 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 bu�' ing cons tion. I a ze represent of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent:
SUPPLEMENTAL TWFORMATION REQUIREb PLAN CHECK TYPE ROUTING SLIP
_New SFD or Multifamily dwellings: Apply for demolition permit forVER-THE-COUNTER El BUILDING 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 ❑ STANDARD ❑ PUBLIC WORKS
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
submittal of Building Permit application. ❑ MAJOR ❑ SANITARY SEWER DISTRICT
❑ ENVIRONMENTAL HEALTH
BIdgApp_2011.doc revised 06/21/11