10100092 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1149 HUNTERSTON PL CO VTRACTOR:RAJESH BALASA PERMIT NO: 10100092
OWNER'S NAME: RAJESH BALASA 114')HUNTERSTON PL DATE ISSUED: 10/13/2010
YER'S PHONE: 2487056142 CUl'ERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB .
License Class Lic.#
MECH r- RESIDENTIAL[_ COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOII DESCRIPTION:8 REPLACEMENT WINDOWS(INCLUDING SLIDING
(commencing with Section 7000)of Division 3 of the Business&Professions DOOR)
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 Sq. 't Floor Area: Valuation:$3274
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION APP Number:36221015.00 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 and state laws relating
to building construction,and hereby authorize representatives of this city to enter ;HERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: ----Date:
Signature Date —
OWNER-BUILDER DECLARATION RE-ROOFS:
All n)ofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of insta led without first obtaining an inspection,I agree to remove all new materials for
the following two reasons:
inspection.
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(�0�4 Sign,&ure of Applicant: Date:
Business&Professions Code) _
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&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 I har a read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the Calif Drnia 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 I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. cont,minants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Heal 7—Ni a Code,Sections 25505,25533,and 25534.
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 Ow th izd agent: 2
become subject to the Worker's Compensation provisions of the Labor Code,I must 1w Date: l 4 1
forthwith comply with such provisions or this permit shall be deemed revq�aGl.,
(` �J�i' CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I here by affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for w rich this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lend er's Address
ins'--unify and keep harmless the City of Cupertino against liabilities,judgments,
ind expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
g,.._..mg of this permit.Additionally,the applicant understands and will comply
with all non- t rce regulations per the Cupertino Municipal Code,Section I und(xstand my plans shall be used as public records.
9.18.
Signature Date d 0 Licen sed Professional
CITY OF CLPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: FIATE: REVIEWED BY:
APN: BP#: `VALUATION: 1$3,274
RPERMIT TYPE: Building Permit PLAN C HECK TYPE: Addition
PRIMARY PENTAMATION
USE: SFD or Duplex 1.1 PERMIT TYPE: 1 GENRES
WORK
SCOPE
r 3 t r
NOTE: Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info,
FEE ITEMS (Fee Resolution 09-051 Eff. 7,.,"1.1'10) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 ETI # Window/Sliding Glass Door
Suppl. PC Fee: Reg. OT 0.0 hrs $0.00 $380.00 1 WINREP Replacement
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Feer Reg. 0OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
C rJtts�7°t{<'�tC��7 a ct.t
Acoustical Fee: 0 Yes (F) No $0.00 0
Work Without Permit? 0 Yes E) No $0.00 E)
Planning Fee: $0.00 Select a Non-Residential Q
Building or Structure
i
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.50 $380.00 TOTALFEET: $381.50
Revised: 9/29/2010
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 36221015 . 00
DATE ISSUED. . . . . . . . 10/13/2010
RECEIPT #. . . . . . . . . : BS000011723
REFERENCE ID # . . . : 10100092
SITE ADDRESS 1149 HUNTERSTON PL
SUBDIVISION
CITY CUPERPINO
IMPACT AREA . . . . . .
OWNER RAJESA BALASA
ADDRESS 1149 :iUNTERSTON PL
CITY/STATE/ZIP . . . : CUPERCINO, CA 95014
RECEIVED FROM RAJES:i N BALASA
CONTRACTOR LIQ: # *OWNER*
COMPANY . . . . . . . . . . : RAJES11 BALASA
ADDRESS . . . . . . . . . . : 1149 HUNTERSTON PL
CITY/STATE/ZIP . . . : CUPER'7INO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---- ------------- ---------- ----------- ---------- ---------- ----------
1BCBSC VALUATION 3, 274 . 00 1 . 00 0. 00 1. 00 0 . 00
1BSEISMICR VALUATION 3, 274 . 00 0 .50 0 . 00 0 .50 0 .00
1WINREP EACH 8 1. 00 ;;80 . 00 0. 00 380. 00 0 . 00
----- ----- ---------- ---------- ----------
TOTAL PERMIT _.81 .50 0. 00 381. 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- -- ------------------
CREDIT CARD 381 . 50 MIEX
---------------
TOTAL RECEIPT 381 .50
1� if ki - �r
x5� 49x�7
Window
—� --��-- Sliding Door
Bedroom-1 Bedroom-2
Bathroom
111 tt.
X Master Bathroom
EKil:chen
IN 4;
� +
Master Bedroom C.uhi
SIGNH)
phis s(�t,)f plansa annus MUST
e h It all h- ->.,ind it i�
,nlav<rfui to make fir atterations
n carne without vvntten permission from
the tluilding Depi '
{;ity of C;upHrtino
Tht,stamping of it r,pt, I' 'Ir"d�;pec:ification,,
LIVIn ROOM "1Al 1. NOI b,,F��1 to bernxt of to bs ar
g atrn al of the I-Oviloun Garage
'IxS� '`X��r"
eels 9 C�C
Cc�p�'Inc)y 9
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMEN'r-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
(408)777-3228-FAX(408)777-3333- building ancupertino.ora
CUPERTINO
Dear Property Owner(s):
An application for a building permit has been submitted in your r ame listing yourself as the builder of the property
improvements specified at:
SITE AD ES
APN BP#
OWNER NAMER,),,,, OWNER ADDREB S �,�� VA W*, c��011 fit'
CSS if �S p 1�1�v ff
DESCRIPTION OF WORK: ,R�O Ob e C`1e
We are providing you with an Owner-Builder Acknowledgment,ind Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having :his 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. f,n 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 Ih FORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
'. I understand a frequent practice of unlicensed pers)ns 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. 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 work ing on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as 3n Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
k2. 1 understand building permits are not required to bo signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
6(�&�3.
I understand as an"Owner-Builder" I am the respo-isible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licen Sed Contractor and having the permit filed in his or her
name instead of my own.
1% '� 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.
�k5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
value of my construction is at least five hundred dollz rs($500), including labor and materials, I may be
onsidered 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
federal government,withhold payroll taxes, provide workE rs' 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.
96 - I understand under California Contractors' State License Law, an Owner-Builder who builds single-family
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 docs not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general build ng Contractor.
�j 8. 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 subse auent owner(s)that result from any latent construction
defects in the workmanship or materials.
OivnerBuilderForm_2010.doc revised 04/14/10
4ku . I understand I may obtain more information regardinc 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 and:rstand I may contact the California Contractors'State
License Board (CSLB)at 1-800-321-CSLB (2752)or www.c,,;Ib.ca.gov for more information about licensed
contractors.
(k�10. 1 am aware of and consent to an Owner-Builder bui ding permit applied for in my name, and understand that
am the party legally and financially responsible for proposed construction activity at the site address listed above.
�l11. 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-3uilders as well as employers.
��12. 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 contractc rs are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, th: 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 c n your property, you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contactors, 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-he performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name:
Lender Ac dress:
Before a building permit can be issued,this form must be --ompleted 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 verifica ceptable to the city m�y be required to be presented when the permit is issued
to verifythe property owner's si t
Property Owner's Signature: Date:
-------------------------------------- -------------------------------------------------------------------
(NOTE: The following Authorization Form is required to be co,npleted by the property owner only when designating an
agent of the property owner to apply for a construction permit J or the Owner-Builder).
AUTHORIZATION OF AGENT TO ACf 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 owne^for the address listed above and I personally filled out the
above information and certify its accuracy. Note:A copy of thy;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:
Owi7erBuildei-Fo1'p1_2010.doc revised 04/14/10
carr aF
CITY OF CLFERTINO
CUPS TINO GENERAL BUILDING
PERNUT APPLICATION FORM
APN# / `� r Date:
1'-� 4�2 � A
Building Address:
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this pr)ject? Yes E No
HOA: (Exterior work only) Yes ❑ No If es, rovide letter from HOA
Owner's Name: Phone#:
R:'SES �
Contractor: Phone:
Fax:
Contractor License#:
Cupertino Business License#:
Contact: / Phone:
1--- Fax:
Residential ` Commercial
Job Description:
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ II/III/V-A ❑ II/VI B, IV-HT, -V-B [ f =
Valuation: Square Footage:
Project Size: Express Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it
to the application or if applicable, include in plan set& the sheet index.
'Ooints Achieved:
For help, contact Build it Green at www.builditzreen.o,
Revised 07/14/09