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12060162 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10605N WOLFE RD CONTRACTOR:MARCHESE CHRIS PERMIT NO: 12060162 TRUSTEE&ET AL OWNER'SNAMF.: MARCIIESE CHRIS TRUSTEE&ET AL IMARRIOTT DR DATE ISSUED:06272012 OWNER'S PHONE: 4082529100 WASHINGTON,DC 20058 PHONENO: ❑ LICENSED CONTRACTOR'S DECLARATION r r r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.N MEC" RESIDENTIAL COMMERCIAL Contractor Date 1 hereby affirm that I am licensed under the provisions of Chapter JOB DESCRIPTION:COURTYARD BY MARRIOTT-REPLACEMENT OF (commencing with Section 7000)of Division 3 of the Business&Professions EXISTING Code and Ihe1 m}•license is in full forte and effect. SEWER PI UI:FOR LIKE)GOING TO THE GREASE TRAP OF IN FRONT OF BUILDING 1 hereby affirmunder penalty of perjury one the following declarations: w I have and willllmaintain a cenificate of consent to 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 �. Section 3700 of the Labor Code,for the performance of the work for which this "1 permit is issued. Sq.FI Floor Area: (P+.� '�, Yelualion:$3993 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:316471H9,00 X115 •, v Occupancy Type: 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 S , indemnity and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. 'L Signature Date Issued by: "J��/✓ �LCRTI/// Date: 1p'L71-7•/a— ❑ OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for one of RF:ROOF'S: the following two reasons: All roofs shall be inspected prior to any roofing material beteg installed.Ira roof is I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection.I agree to remove all new materials for will do the work,and the structure is not intended or offered for sale(See.7044, inspection. Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contmctors to Signature of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). 1 hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER declarations: I have and rill maintain a Certificate of Consent to self-insure for Worker's IIA'/..\RDOIIS hl,\TF.RL\LS DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 1 have read the hazardous materials requirements under Chapler 6.95 of the I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safely Code,Section 25532(x)should I store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of Cali fomia. If,after making this certificate of exemption,1 Health&Safely Code,Sections 25505,25533,and 25534. become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. f Owner or ihorizeJ agent• - 7 Dale: —7-1 IX APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of work's to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Lender's Address granting of this permit. ditionally,the applicant understands and will comply with all non-point so�c regul tions per the upcninregul tions per the o Municipal Code,Section ARCHITECT'S DECLARATION 9.18. i I understand my plans shall be used as public records. Signature Date �Z �� License)Professional OWNER-BUILDER,DISCLOSURE FORM COMMUNITY,DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408),777-3228•FAX(408)777-3333• buildinQCa)cuoertinc.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 (� VA APN BPN ER MEC' {Q/ iNE (3E!ES?) n� I/t DESCRIP OFWOP2 : r CJ Cl Li tom) `"1 5 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`phor 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.) �1. 1 understand afrequent 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, maybe 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. 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. Q63. 1 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. (�)_4. 1 understand Contractorsrare required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. 5. 1 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 (TS. an"employer"undei state and federal law. (T6. I understand if I am considered an"employer" under state and federal law, I must register with the state and federal government,withhold:payroll takes, 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 K7.serious financial risk. 1 understand under California Contractors'Stale 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 performed under contract with a licensed general building Contractor. _8. 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. OionerBuilder-Form 2010.doc revised 04114/10 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 1-500-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed contractors. L10. I 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. Cb11. 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. all12. 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 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: (� A— 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 si nat e. ' Property Owner's Signat r 7 Date: f — - ----- -- ----- --- -- -- ------- ------ -- — - - — (NOTE: The following Authori- zation Form is required to be completed by the property owner only when designating an agent of the property owner to apply fora construction permit for the Owner-Builder). AUTHORIZATION_OF-AGENT_TO ACT ON PROPERTY OWNEWSBEHALF 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): T lA ktb L," UkT �n lzaiE7J�VU Project Location or Address: j�G� i 4 / J \ Name of Authorized Agent: -,' Tel N��k� Address of Authorized Agent: 1010 WA& CV 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: On nerBiedderForm 2010416c revised 04/14/10 GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 950143255 M I CUPERTINO (408)77'7 3226 •FAX(408)7'7'7-3333•buildinO(c�cuoertinO.orO SC �/uhmING ❑MECHANICAL ❑�rnuCAc ❑NOSCELLANEOUS PROJECT ADDRESS V 60S- oS- AJI �I.rnO AZPlW p-Zifg//d1,0 ' O lei I l OWNER NAME 1 WTe— � PHONEO E-MAIL STREET ADDRESS C . TATE,Z1 p]�/ yD6p{ (' / I CONTACT NAME eJ F„AxV L.,pI Ap r2rvS1.2,r�Y�'C�i3 Co ry� PHONE2/ .7 G U/ EMAD'JI , CIO Y I Ni4 .f r STREETADDRESS �o I < ncmTE.srAC� FAX o63 Z ❑OWNER WNER-BUILDER ❑ OWNERAGENT ❑ LDNTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINE'FR ❑ DEVEIDFER ❑ TENANT CONTRALTO NAME LICENSENUMBER LICENSE TYPE BUS.LIC I (- (� _ Qn C K — ®s 1 G Z COMPANY NAME ) / E.MAQ. �Qn STREET ADDRESS / CITY,STATE,ffi PHONE 2- Cli r4er cu 17rIVf CQ YSJ 3 40 �7S- 3� ARl7RTECDENGWFER NAME N/A LICENSE NUMBER Bus.LICA CO%1PANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or OUPI F V ❑ MULTI-FAMa.Y PROJECT IN W aD-kND ❑ YES PROJECT INYFS is THE BLDG AN ❑ YES BDrLDWG: MHERCIAL IIRBAIJ INTERFACE AREA NO FLOOD ZONE NO MCH10t HOME' aNO DES At cr 5Cwvr �oCk 5,fra ro u'- nA n TOTALVALUATION: 3 '9 :�c n t7 RECEIVED BY: By my signature below,I certify to each of the fallowing: I am the pmparty owner or autharlr<d agent to act on the property owner'/s behalf. I have read this application and the information I have provided is comct I have read th Description of Work and verify it is accurate. I agree m comply with all applicable local ordinances and stale Taws relating to buildi cons an. I ao riTe res auttives of Cuperdnc'o cnmr the above-ideatifiedproperc; ;or inspection purposes. Signature of Appilcant/Agent Date: -Z7—/ Z– SUPOCEMENTAL INFORMA -REQUIRED rte{ OFFICE USE ONLY OVER-THE-COUNTER ❑ EXPREss 1 u m ❑ STANDARD U J ❑ LARGE ` ❑ MAJOR MEPMucApp_3011.doc revised 06/21/11 -