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16010004Ria CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18750 BARNHART AVE CONTRACTOR: SMITH JAMES H AND PERMIT NO: 16010004 FRANCES L TRUSTEE OWNER'S NAME: SMITH JAMES H AND FRANCES L TRUSTEE 18750 BARNHART AVE DATE ISSUED: 01/04/2016 OWNER'S PHONE: 4082456229 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL CONIMERCIAL E] INSTALL (N) WALL FURNACE (PREVIOUSLY REMOVED License Class Lie. # IN FEBRUARY 2015 TO ACCOMODATE WHEELCHAIR Contractor Date ACCESS) 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 tinder 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: $350 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 till's APN Number 17 oq,� ; 0(3 Occupancy Type: permit is issued. ��j�d� 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 D YS FROM LAST CALLED INSPEC I N. 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 �� Issued by: LULU ��'� 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: Signatur 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. t OWNER -BUILDER DECLARATION Signature of Applicant: Date: ereby 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 1, 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) q1, 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 1 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, Se tions 25505, and 5534. Section 3700 of the Labor Code, for the performance of the work for which this `� 740'VADat,: permit is issued.Owner or authorized a ent: g 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 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 1 understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all nonnt source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. ow, v Signature 11�Date '4 _1 d )b A L h CUPERTINO GENE2AL PERMIT APPLICATION 160 ICWq COMMUNITY DEVELOPNiEN T DEPARTMENT - BUILDING DIVISION 10300 T ORRE AVENUE • CUPERTIN0, CA 01501 A-3255 (408) 777-3228 - FAX (4-08) 777-3333 • buildina(a)cuoerino.org ❑PLUI BP",G �.'�' CHAMCAL ❑ELECTRICALI—]A�iISCELLp��OUS PROJrCT ADDFES 13;6e?`� 4a / vcr 1 -A16l -i-TII1<OI 4P>\ , 375 � 049�, "Z C' OCvTiR]� �Jt PHONE (0ZZ �3 E•Ni=1Z `�14,15i-N,' STREETADDRESS 1rr--YuNb1Y11A Q CITY, STAT -,ZIP �L'�Udlil�LJ �� FAX C'TT Thl✓E PHO�� E•?�L4IL _ _ //�� STPEETA.DDP- Sw Ci CITY, STATE, ZIP FAX 3 Owl ER f3V 1.`? -3U TiD ❑ OVRrA�t AGENT ❑ CMN ,',CTOR ❑ CONTP.ACTOR AGES T ❑kRC:LrCT ❑ ENGL\=:.R ❑ DEVELOP ❑ TENSh7 COJACTOR1;A.lurE I LICDgSE?N7U),SER I LIC~�SET�YE I BUS. LIC- COI✓.P.4NY NAIa I E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE .A RCHITECT/EnGLK_ER NAMBE LICENSE NU?,=R BUS. LIC COI✓,P 2W NA.1v,E--- E -?JL Z I RAY — STREET.4DDRESS I CITY, STATE, Zip I I PHONE USE OF ❑ SFD orDUPL:J. ❑ muLTI-FAI,GZY PRarCT LN ArE DLAND ❑ Y';S PROTECT IN ❑ YES IS = BLDG .4N ❑ ti Es B=N10: ❑ COI'!M CIA—1 URBA INTTERFA.CF AREA ❑ 2,10 FLOOD ZO?? ❑ Np EICi LER HOI✓.E7 (] 1T0 DHSCP.IPTION OF WORK �G CFD („) ,4L lzNA�t Tz/ 5 7-v ACU M k D I)ATF w j4&W C4JoJ4 jZ A,ccJ?rSA.5 TOTA? G 4LUAT10?N:.ti n. s I R C�IZ D�1'J.. ' S ~ By my signature below, I certify to each of the following: Ian the prope ty owner or authorized agent to act on the ope. y owner's behalf. I have read this application and the information I have provided is correct. I have r ad the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relat rQ ` building construction. I -uth r presentat\yes o Cupertino to enter ` above-identti i propel �y for inspection purposes. v Signature of, pplican /Agent: Date: T O PLEMENTAL L\T'ORMA ION REQUIRED OVEi:Tii1 COLTrR J _ va £ X ; k. K cs . ` 1=�REa S-..... rs,,..,=.c -._., I ..,, ...,. 'C l `st :. `3 -' ❑ i.4" yU SCS V.G yl�. � 10 hrEP fisc ipp_2011.doe remised 06/21/11 CITY OF CUPERTINO RM FEE ESTIMATOR -BUILDING DIVISION ik ADDRESS: 18750 Barnhart Ave DATE: 01/04/2016 REVIEWED BY: PAUL UNITS APN: 375 27 042 BP#: *VALUATION: $350 ^PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY USE: SFD or Duplex 7PERMIT PENTAMATION TYPE: FURN/A WORK Install N wall furnace (Previously removed in February 2015 to accomodate wheelchair access SCOPE 'sp Fee APPLIANCE / EQUIP TYPE FEE ID QTY/FEE QTY UNITS BP FEES Heater, Recessed Wall 1 MRSUSHTR i:;%.:E:.t�r>s�,Ll 1 # $72 'sp Fee PME Unit Fee: $72.00 PME Permit Fee: $48.00 Administrative Fee: (ADMIN $45.00 Work Without Permit? 0 Yes (@ No $0.00 TOTALS: a Travel Documentation Fee: 1TRAVDOC $72.00 Strong Motion Fee: IBSEISMICR NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dept for addn'1 into. FEE ITEMS (Fee.Resolution 1.1-053.Ef. 7/11.132 Mech. Plan Check 0.0 hrs $0.00 QTY/FEE MISC ITEMS Mech. Permit Fee: I MPERMIT ee: Ltler Mech. Insp. 0.0 hrs $48.00 �7#q��,;.."r'"rrr,rh i ;,,_,.>;t.�f>: i:;%.:E:.t�r>s�,Ll . .; i't,i7i. I'c'r." .f"�s t'i:1ii. iitj!:, i`c=. L:trC'.C:..•';4j:%. �'£'.£:; NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dept for addn'1 into. FEE ITEMS (Fee.Resolution 1.1-053.Ef. 7/11.132 FEE QTY/FEE MISC ITEMS f PME Plan Check: $0.00 'sp Fee PME Unit Fee: $72.00 PME Permit Fee: $48.00 Administrative Fee: (ADMIN $45.00 Work Without Permit? 0 Yes (@ No $0.00 a Travel Documentation Fee: 1TRAVDOC $48.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bld, Stds Commission Fee: IBCBSC $1.00 SUBTOTALS:: $214.50 $0.00 TOTAL FE $214.50 Revi d: 10/0112 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 c1cupertino.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: SITE ADDPRESBR%v/lnn�✓ C�... :......AP r 73,4 T ldv N..3 I✓ LLq �� ^, OVYNERN OWNERADDRESS: DESCRIPTION OF WORK: j SLAB-� GU LL �t1 fU1Q79P. tom` wotj l is=-3�✓, 2�7� We are providing you with an Owner -Builder Ackhowledgment 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.) �. I 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 >nally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by ilicensed person and his or her employees while working on my property. My homeowner's insurance may not de coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my ance coverage for injuries to workers on my property. 2. I understand building permits are not required to be signed by property owners unless they are responsible for ie construction and are not hiring a licensed Contractor to assume this responsibility. '3. 1 understand as an Owner -Builder I am the responsible party of record on the permit. I understand that I may rotect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her Me instead of my own. 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license u{{ bers on permits and contracts. "T5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the �t I value of my construction is at least five hundred dollars ($500), including labor and materials, I may be cAsidered 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 ral government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to nployment compensation for each "employee." I also understand my failure to abide by these laws may subject o serious financial risk. ,P� F174 understand under California Contractors' State License Law, an Owner -Builder who builds single-family esidential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by liaeised 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 riTinancial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwneYBuilderForm 2010.doc revised 04/14/10 s,. I understand I may obtain more information regarding my obligations as an "employer" from the Internal we Service, the United States Small Business Administration, the California Department of Benefit Payments, e California Division of Industrial Accidents. I also understand I may contact the California Contractors' State se Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed ctors. ' 0. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I party legally and financially responsible for proposed construction activity at the site address listed above. 1. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will alstde 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 iation l have -provided on this form. Licensed contractors are regulated by.Iaws 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. If 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 maybe held liable for damages. If you'obtaih a perr-hit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or note 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 verify the property owner's signature. 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 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: OwneYBuilderForm 2010.doc revised 04/14/10