15110117U,
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19090 MEIGGS LN
CONTRACTOR: KEITH A COLFER
PERMIT NO: 15110117
OWNER'S NAME: KEITH A COLFER
19090 MEIGGS LN
DATE ISSUED: 11/17/2015
OWNER'S PHONE: 4086806817
CUPERTINO, CA 95014
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
DEMOLISH FIRE DAMAGED CARPORT (319 SQ FT) AND
License Class Lic. #
COVERED PATIO (120 SQ FT).
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: $2500
performance of the w6rk for which this permit is issued.
1 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: 37535049.00
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 180 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 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Date:
Issued b �G`l� �/ Gf'l �� Z 7
granting of this permit. Additionally, the applicant understands and will comply
Y�g
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,
usiness & Professions Code)
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.
ection 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date:
,fermit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
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
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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
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
U
DEMOLITION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildinggcupertino org -�f 4 j j
7
.11
PROJECT ADDRESS
f
APN # - 3:5 O Ll
t i Q G
-37-5
OWNER NAME %Q 1 1� �v Ter
PHONE �jv� , / _ 1 Q J�
E-MAIL e A w(4 r o e. co AA
STREET YSS{ r ��
CITY, S/TATE, �) f;• �� i� /
U
FAX /
CONTACT NAME
PHONE
E -MA
STREET ADD SS
CITY, TATE, ZIP FAX
D4 OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONrRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK �
rti o I; , VA C4 ex ;J,4 r S ,or aj Sfr �c ire:
�Ua+o cc XLAA& el m y0,re 2e f-Vre- Z Ga - cemq e- 4-o be- Gxsfr\,,,c
( (.4 co d S Q ( /CF/'
, n e
RESIDENTIAL
# DWELLING
OFFICE USE ONLY
�ryss�
FLOOR AREA
UNITS //
USE
OCC. TYPE
SO. FT.
VALIJATION
� _
COMMERCIAL
` ,
3
FLOOR AREA
0��
y �_
— _
TYPE OF CONSTRUCTION # STORIES
AQMD JOB NUMBER
J#:�
RECEIVED BY!��q
TO ' J UATI N
tD�
By my signature below, I certify to each of the following: 1 am the property owner or authorized agent to act on the properly wvvner's behalf. 1 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 appiicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date: C 17 S
SUPPLEMENTAL INFORMATION REQUIRED PRIOR TO ISSUANCE OF DEMOLITION PERMIT
OFFICE USE ONLY
_ Provide Job Number from Bay Area Air Quality Management District www.baagmd.org @ 415-749-4762.
PLAN CHECK TYPE
EXPRESS
Provide three copies of a site plan showing protection for any trees 10" in diameter or more at 3' above grade.
_ Provide letter from PG&E (408-725-3325) stating all gas and electric has been disconnected.
❑ STANDARD
Provide a letter of inspection, tests, and abatement of any Hazardous Materials. Letter to be initiated by person(s)
❑ LARGE
certified in asbestos, mercury and/or hazardous material examination.
❑ MAJOR
Planning Dept clearance to verify building is not considered an historical landmark. Allow 10 business days.
Provide letter of clearance of all vermin from a licensed pest control contractor.
Applicant shall call the Public Works Department at 408-777-3104 and schedule a "habitable dwelling" inspection.
Provide signed Debris Bin and Recyclable Materials form.
Commercial Buildings Only: Provide Fire Dept clearance for fire suppression / alarm system review.
DemoApp_2011.doc revised 03/161171
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 19090 Meiggs Lane DATE: 11/17/2015 REVIEWED BY: Sean
APN: I BP#: "VALUATION: 1$2,500
*PERMIT TYPE: Demolition Permit PLAN ('.'I-[L,-Ck TYPE:
PRIMARY SFD or Duplex PENTAMATION 1 SFDWL-DEM
USE: PERMIT TYPE:
WORK Demolish fire damaged carport (319 sq ft) and covered patio (120 sq ft).
SCOPE
FEE ID FLR AREA
(S.L)
1DEMORES 439
NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public works, rise, January 3eweruistrict, 3cnooi
noriv;,lif mf,, I 'rlpar,7 faac "ra h"cod n" fiso nralimimiry 1"nntart the Dent for adds 'l info.
FEE ITEMS (Fee Resolution 11-053 7/1%131
FEE
QTY/FEE
MISC ITEMS
F111. ech,
Fliumb,
l�l(""'e. Perm -1 I f 1",ee:
Oche r.kfech.his yv,
Oflerflhmd) A�sp.
Other Eke. hisp.—=
Afech. IMP.
In p. Fee:
NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public works, rise, January 3eweruistrict, 3cnooi
noriv;,lif mf,, I 'rlpar,7 faac "ra h"cod n" fiso nralimimiry 1"nntart the Dent for adds 'l info.
FEE ITEMS (Fee Resolution 11-053 7/1%131
FEE
QTY/FEE
MISC ITEMS
Phin ( Vieck Tee,,
suppl. P(`.flee
Permit Fee:
$574.00
Suppl. Insp. Feer Reg. 0 OTFO.01
hrs
$0.00
C"(.-nisiruclioll 7 �IA
.Atirninisli-alive Flee.,
lf'w-k If"ithout Peifit "
Advaticed PhinnitN), filees:
Strom _Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
7
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$575.501
$0.00 TOTAL FEE:
$575.50
Revised: 10/01/2015
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - b0dinana cunertino.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/
a 9 o int � �
- / /
� L.a/` e- Cu tr4--%n0 C4 7%*�
APN..
B P #
OWNER N�YIEOWNER
c Cc
ADDRESS-...
/ yo ..d <;, ,* f. L�� e �� f; o C o/
DESCRIPTION OF WORK:
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1� a �''�o v e�(i,f f. �1 �� a n VPfe d . Crar ol` c2 I'� c o�ve �» rl re afa •�_ r_
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We are providing you with an POT 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 nofice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGtJfENT 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 -
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 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.
/24'�2. 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.
I 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,
understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
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.
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.
#5e,7. 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 o��er them for sale, unless all work is per,'ormed 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.
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 2010.doc revised 04/14/10
9. 1 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 vrnw.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
am 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
y all applicable laws and requirements that govern Owner -Builders as well as employers.
2. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information l 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 maybe in civil court. Itis 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 ownei'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 verilry the property owner's si natu .
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:
Address of Authorized Agent:
Tel No
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 2010.doc revised 04/14/10
RECEIVED
Owner Name: Keith Colfer
Address: 19090 Meiggs Lane, Cupertino, CA 95014 I.11
Scope of Work: Remove existing converted carport/garage due to fire damage,
319 square feet. Future 2 car garage to be constructed. All CA 2013 Building
Codes apply. /Zv stvar'e feet 4 Paf-; v 66ve t
COMMUNry nr,mi f1DVr:NT r)FpARTMENT
BUILDING DIVISION - CUPERTINO
/ PPrrf %OVED
This Set of nlar+s and
specifications MUST be kept at the
' c' const~ uction. It is unlawful to make any
or alterations on same, or to deviate
l` 'jr;_ ►°==�� without approval from the Building Official.
f this plan and
o � specifications SHALL NOT
or to be an approval of the violation
v, �.f ry i' ^�\!icing
of a �y City C !' finance or State Law.
/V-
7 , 5
1.51 Gij.
FFICE COPY
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS: .10
PERMIT # 1'5-11c C( 7
-44
OWNER'S NAME: �-
r ''rO/ PHONE # '(0 S _ U
GENERAL CONTRACTOR:
BUSINESS LICENSE #
ADDRESS:
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) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using an subcontractors:
Y
Signatu Date
Please check applicable subcontractors and complete the following information:
Owner / Contractor Signature
Date
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
Owner / Contractor Signature
Date