13100028CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10185 LOCKWOOD DR
CONTRACTOR: MICHAEL SZELONG
PERMIT NO: 13100028
OWNER'S NAME: MICHAEL SZELONG
10185 LOCKWOOD DR
DATE ISSUED: 10/03/2013
OWNER'S PHONE: 408913675
CUPERTINO, CA 95014 -2613
PHONE NO:
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIALE]
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
KITCHEN REMODEL 126 SQ FT TO INCLUDE M,E,P'S
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
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
Sq. Ft Floor Area:
Valuation: $7000
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
APN Number: 34214033.00
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 1 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 M LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
IVB113
costs, and expenses which may accrue against said City in consequence of the
Issued by: Date:
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.
RE- 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)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I 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 I
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
Owner or authorized agent: Date: 3
permit is issued.
��
I certify that in the performance of the work for which this permit is issued, I shall
Inot 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, I 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 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
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
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.
Signature Date ���
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 \'n
(408) 777 -3228 FAX (408) 777 -3333 • buildingta�cupertino.org
CUPERTINO
❑ NEW CONSTRUCTION ❑ ADDITION Rr ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS 10185 Lockwood Drive, Cupertino CA 95014
APN # � ✓
OWNER NAME Michael Szelong
PHONE 408 - 891 -3675
E -MAIL mszelong @yahoo.com
STREET ADDRESS 10185 Lockwood Drive
CITY, STATE, ZIP Cupertino, CA 95014
FAX
CONTACT NAME Same as above
PHONE
E -MAIL
STREET ADDRESS
CITY, STATE, ZIP
FAX
IM OWNER OWNER- BUILDER -- ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRA OR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NAME
E -MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E -MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK Replace cabinets and countertops in my kitchen; I will be building the cabinets. The layout of
the kitchen will remain the same with the exception that the oven will be built into the range instead of two
seperate units. Original kitchen was installed in 1982 with permits.
EXISTING USE
PROPOSED USE CONSTR.
TYPE
I # STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
AREA
NEW FLOOR
AREA
DEMO
AREA
TOTAL
NET AREA
Cabinets
$3500.00
REMODEOL AREA
I
REMODEL KITCHEN AREA 126 S ft
q
OTHER
MODEL AREA 0
Countertop
$3500.00
PORCH AREA
DECK AREA
TOTAL DECKIPORCH AREA
GARAGE AREA: LIDETACH
[]ATTACH
I
# DWELLING UNITS:
IS A SECOND UNIT OYES
SECOND STORY []YES
BEINGADDED? []NO
ADDITION? []NO
PRE- APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES TOTAL VALUATION:
PLANNING APPL # []NO PLANNINGAPPROVAL LETTER EICHLER HOME? ❑ NO - $'7000.00
w
By my signature below, I certify to each of the following: I am the property owner or authorized age t to on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and veri t is accurate. I agree to comply with all applicable local
ordinances and state laws relating to ing c tf�ltction. I authorize representatives of Cupertino to enter the above -- identified property for inspection purposes.
*
AzoSignature
of Applicant/Ag s Date:
SUPPLEMENTAL INFORMAIM REQUIRED
`
New SFD or Multifamily dwellings: Apply for demolition permit forte
"'
v
B
existing building(s). Demolition permit is required prior to issuance of building'
permit for new building.INiI~rcrl
a,v
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
form if any Hazardous Materials are being used as part of this project.
tlili,
Copy of Planning Approval Letter or Meeting with Planning prior to
t h
_
submittal of Building Permit application.
BldgApp_2011.doe revised 06121111
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
{
ADDRESS: 10185 lockwood dr
DATE: 10/03/2013
REVIEWED BY: Mendez
APN:
BP #:
*VALUATION: 1$7,000
xEERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY
USE: SFD or Duplex
0:0
PENTAMATION
PERMIT TYPE: 1 R3SFDRE i
WORK
kitchen remodel 126 sq ft to include M E P's
SCOPE
$0.00
NOTE: This estimate does not include fees due to other Departments (La Planning, Public Works, Fire, Sanitary Sewer District, School
Dictrirt otr )_ Thoco foot aro hacod not tho nroliminary information available and are anly an ectimnle_ Contact the Dent for addn'l info.
FEE ITEMS (Fee Resolution 11 -053 E . 711113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
126 s.f. Remodel, Kitchen (< =300 sfl
$626.00 IREA MESKIT
Suppl. PC Fee: 0 Reg. ® OT
0:0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee :Q Reg. ® OT
00
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction .Tax:
Administrative Fee:
Work Without Permit? ® Yes (E) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non- Residential
Building or Structure
E)
i
Travel Documentation Fees:
Strong Motion Fee: IBSEISMICR
$0.70
Select an Administrative Item
Bl.da Stds Commission Fee: IBCBSC
$1.00
Maw
$1.70
$626.00 �tiy'OTA1
$627.70
Revised: 08/01/2013
CUPERTINO
OWNER- BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 • building Qcupertino.org
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
d, Lawn oo -Tie k 4lam O' Uetw
APN
BP#
Olt
NAME
G-
OWNER ADDRESS
5-LoCKW o ,D � 2. V%;: Jv R�T� RSA
DESCRIPTION OF WORK: ym rf
'ib Cc*%. C2P+ -t- 6Ve51-J
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.)
071.
1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
er" 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.
I understand building permits are not required to be signed by property owners unless they are responsible for
t e construction and are not hiring a licensed Contractor to assume this responsibility.
I understand as an "Owner- Builder" I am the responsible party of record on the permit. I understand that I may
)t-
t myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
- I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
t 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
tal 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.
V6. 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.
l7. 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.
W8. 1 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.
Owner&ilderFonn 2010:doc revised 04114110
*9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal
Rvenue 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.
0. 1 am aware of and consent to an Owner - Builder building permit applied for in my name, and understand that I
a the parry 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 all applicable laws and requirements that govern Owner - Builders as well as employers.
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 P ublic. 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 verifv the property owner's signature
Property Owner's Signature: Date: /0/3 /2oi'3
---------------------------------------------------------------------------------------------------------------------------------------------
(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:
OWne7BuildelFOrn1 2010. doe revised 04114110
Address
ASS. 7 9 S
W.; 0'
•
SMOKE / CARBON MONOXIDE ALARMS
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 • building aacupertino.org
�- FILa
9z�
/310000-9
PURPOSE
This affidavit is a self - certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2013 CRC Section R314,2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for
inspections are required.
GENERAL INFORMATION
Existing single - family and multi- family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds
$1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and /or Carbon
Monoxide Alarms be installed in the following locations:
AREA
SMOKE ALARM
CO ALARM
Outside of each separate sleeping area in the immediate vicinity of the
bedroom(s)
X
X
On every level of a dwelling unit including basements
X
X
Within each sleeping room
X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel- burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated.
In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access by means of attic, basement or crawl
space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for
alarms which must be connected to the building wiring.
As owner of the above - referenced property, I hereby certify that the alarm(s) referenced above has/have been
installed in accordance with the manufacturer's instructions and in compliance with the California Building
and California Residential Codes. The alarms have been tested and are operational, as of the date signed
below.
I have read and agree to comply with the terms and conditions of this statement
Own�er (or Agent's) Name:
cOwner
/„`
/t% or C 5?CL<DAJ(� -
Signature .................... ...... .............. .. ............................... .......................... Date: ........(i�
Contractor Name:
Signature.................................... ............................... Lic.# ....... ............................... Date: ...................
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