B-2016-1908 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT O:B-2016-1908
10673 CULBERTSON DR;;CUPERTINO,CA 95014-3554(375 36 032) HOMEOWNER/BUILD
ER
OWNER'S NAME: RADISIC DESIMIR C AND JASNA DATE ISSUED;05/09/2016
OWNER'S PHONE:408-252-1466 PHONE N
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor HOMEOWNER/BUILDERDate XBLDG —ELECT XPLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL OMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
GAS LINE REPLACEMENT
I hereby affirm under penalty of perjury one of the following two declarations:
1. 1 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.
z. 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:$500.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
information is correct.I agree to comply with all city and county ordinances ATN Number: Occupanc i Type:
and state laws relating to building construction,and hereby authorize 375 36 032
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES Hf WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS 9F PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 5/9/2016 Issued by:ABBY AYENDE
Date:05/09/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
CN compensation,will do the work,and the structure is not intended or offered for spection.
sale(Sec.7044,Business&Professions Code)
/ z.' I;as owner of the property,am exclusively contracting with licensed Signature of Applicant:
v contractors to construct the project(Sec.7044,Business&Professions Code). Date: /95 /2016
i hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERING$TO BE CLASS"A"OR BETTER
1. 1 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. HAZARDOUS M14TERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Cod ,Sections 25505,25533,and 25534. 1 will
maintain compliance with the Cup rfino Municipal Code,Chapter 9.12 and the
permit is issued.
a. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section$ 532(a)should I store or handle hazardous
material. Additionally,should I us equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25-1 54.
—
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. . Owner or authorized agent:
APPLICANT CERTIFICATION Date:5/9/2016
1 certify that I have read this application and state that the above information is CONSTRUCTIIDN LENDING AGENCY
correct.1 agree to comply with all city and county ordinances and state laws I hereby affirm that there is a cons ruction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is is 3ued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
I understand my plans shall be us d as public records.
Code,Section 9.18.
� Licensed
Signatu� Date5/9/2016Professional
GENERAL PERMIT APPLICATION
MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 �.
(408)777-3228 FAX(408)777-3333 building(aDcupertino.org misc
CUPER'TINO
LUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISC.,LLANEOUS
PROJECT ADDRESS Io3 Cell-AS E R7S* O ! O R. APN# '504 ' 6 3
OWNERNAME
Z)2sri»ir R,q,D/S/C P"'409-2.S2-144,6
HONE4o8,2s2-l46,6 5-MAIL� �8 �4iltd�y
STREET ADDRESS R►�D�SIC CIT ,STAT ,Z„I�P FAX CZ14& *TSoA( Dr. CuD�InZ,N/O
CONTACT NAME rE-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
.
❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME �^ LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME 0 tel/ �l E-MAII FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WHALAND EIYES PROJECT II+T ElYES IS THE.BLDG AN 0 YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK /
✓h sous�e G/he
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col. Pers E w #7f5 C it'v ihs ,ee-W^
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TOTAL VALUATION:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property, a . I have read this
application.and the information I have provided is correct. I have red the Description of Work and verify it is accurate. I agT e Yo comply with all applicable local
ordinances and state laws relating to�building connstructs I aut orize re sentatives of Cupertino to enter the above-identified proerty for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED s
CaU -kR
Fes" � EJ�TRFSS
- �N'c.7k STAI�TD ARD -
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LARGE[
lYI.4JOR
MEPMiscApp 2011.doc revised 06/21/11
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION
LrAw10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
+OUPEFtTtFIO' (408)777-3228• FAX(408)777-3333•building na cupertino.or4 -
f� Dear Property Owner(s):
/ An application for a building permit has been submitted in your name listing yourself as tie builder of the property
improvements specified at:
1 SITE ADDRESS _ APN..
t� }b67, GtILB'eRTS0R )R.
OWNER NAME„ QWNERADDRESS-
�1=:SIMR 4�0e+�TS0�1 A • Ct�PQT/A/0
1:0673-C&
d�scovdreds�rr � QS dire. Job is Fix -O
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DESCRIPTION OF WORK: Pyr ,�
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 you 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 ca not 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.)
e 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner-
Builder"building permitthat erroneously implies that the property owner is providin 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
j provide coverage for those injuries.I am willfully acting as an Owner-Builder and ain aware of the limits of my
insurance coverage for injuries to workers on my property.
odS 2. 1 understand building permits are not required to be signed by property ow ers unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibi ity.
f
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 haviiig,the permit filed in his or her
i name instead of my own.
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
num ers on permits and contracts.
5. 1 understand if I employ or otherwise engage any persons, other than Calif rnia licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
7 considered an"employer"under state and federal law.
lt6. 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 tc abide by these laws may subject
me to serious financial risk.
f
PTYIL-
7. I understand under California Contractors' State License Law, an Owner- uilder who builds single-family
structures cannot legally build them with the intent to offer them for sal, unless all work is performed by
I :residential
licensed subcontractors and the number of structures does not exceed,four within any calendar year, or all of the work
Ij is performed under contract with a licensed general building Contractor.
C�"�8. 1 understand as an Owner-Builder if I sell the property for which this permi is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s)that resu t from any latent construction
defects in the workmanship or materials.
nerBuilderForm 20IO.doc revised 04/14/10
5
o� 9. 1 understand I may obtain more information regarding m obligations as an "employer" from the Internal
Y g g Y
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 th California Contractors' State
License Board(CSLB) at 1-800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed
contractors.
Ak-10. 1 am aware of and consent to an Owner-Builder building permit applied for i II my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
11. I 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.
yers.
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 contractors are regulated by-laws designed to protect.the.public. If .
you contract with someone who does not have a license, the Contractors' State Lice se 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. it is also important for.you-to understand that if anunlicensed Contractor or
employee of that individual or firm is injured.while working on your property,you mai be held liable for damages. If
you obtain a perrhit 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' compensatic n 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 ork 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 Eby the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the pro�erty 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 Signaturey, ,-<0 l Date:: ,5•mq-
---- --------- ---------------- -------------------------------------------------------- -------- ----------------------------------
(NOTE:
------ ---- ---------------------
(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 ab ve 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 1,c sued to verify the property owner's
signature.
Property Owner's Signature: Date:
0wr erBuilderForm 2010.doc revised 04114110
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/SUBCONTRACTOR LIST
JOB ADDRESS: 10G75 Cul,6Qrfisov) ).Cu 2rt(v)0 PERMIT# 'S--aa IC--I c)8
OWNER'S NAME: -Z)a-9 im%r 'IZAa 151G PHONE# 4o8 a 2512, 1466
GENERAL CONTRACTOR: BUSINESS LICENSE# tr/A
ADDRESS: %4,/#, CITY/ZIPCODE: %V6,
*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 any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
V 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