Loading...
12070228 CITY OF CUPERTINO 13UILDING PERMIT BUILDINGADDRESS: 21736COLLINGSWORTI3ST CONI'RACI'OR:QUALITY ROOFING CO PERM ITNO: 12070228 O\\'NER'SNAdIE: CIIIANG,rINGCIIUCK 1041.5 NEW AVE DATE ISSUED:07/30P_012 OWNER'S PRONE: 4088021987 GILROY,CA 95020 PI[ONE NO:(408)461-0484 PCj LICENSED CON I'RACI'OR'S DECLARATION � r— r7 q ,.� BUILDING PERMIT INFO: BLDG - ELEcr PLUNIR License Class C,3� Lic.H �a-:1-216g � x `v 11ECF1 r RESIDENTIAL(- COMMERCIAL r Contractor ( MG,,`. ae h Date 7—3.) 12 hereby affirm that I am licensed under the provisions ur Chapter 9 ,1013 DESCRIPTION:SINGLE FAMILY DWELLING TE\R OFF SHAKE,INSTALL (commencing s%ilh Section 7000)of Division 3 of the Ilusiness S Professions NEW Code and that my license is in full force and effect. ASPHALT SHINGLES 13 SQFTCLASS A hereby affirm under penalty of perjun'one of the fullun'ing 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 performance of the work for which this permit is.issued. I have and will maintain Worker's Compensation Insurance,:w provided for by Section 3700 of the labor Code,for the performance of die work for which this permit is issued. Sq. Ft Floor Area: , Valuation:$9200 A I'I'LIC.\\I'CICR'I'll'IG\"TION I certify that I have read[his application and state that the above infomnation is APN Number:35617051.00 Occupancy T pe: correct.I agree to comply with all city and cowuy ordinances and state laws relating to building construction,mid hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save indemnity and keephannlcssthe City ol'Cupertinoagainst liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said Cit1•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//� Signaturc���al.l� 4LS "'7G Dau —3d 'IZ Issued b •• Date: ❑ OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt front the Contractor's License Law frolic of RE-ROOFS: the following rvo reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is I,as owner of the properly,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all nese materials for will do the work,and the snmeture is not intended or offered for sale(Sec.7044, inspection. Business d Professions Code) lI I,as owner of the properly,am exclusively contracting with licensed contractors to Signature of Appli©�s-O r` A•YlIS MNL- $Dau: construct the project(Sec.7044,Business fi Professions Code). 7_j -I Z hereby affirm under penally of perjury line of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BE17ER declarations: I have and will limitation Certificate of Consent to self-insure for Worker's IIA'/.ARDOIIS\I,\9'ISRIALS DISCLOSURE 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 read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance,as provided for by California I lealth S Safety Code.Sections 25505,'_5533.and 25534. 1 will maintain Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cuperlino Municipal Code.Chapter 9.12 and the I lealth S Safety Code,Section 25532(0)should 1 store or handle hazardous material. permit is issued. Additionally.should I use equipment or devices which emit hazardous air I cenifx•that in the performance of tine work for which this pemnit is issued,1 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 Calif irrim. If,after making this certificate of exemption,I health S Safety Code,Sections 25505,25533,and 25534. become subject to the Worker's Compensation provisions of the Labor Code,I mus[ forthwith comply with such provisions or this permit shall be deenned revoked (srner ur au mry'red age 1 Date. ��V z \I'I'LIC,\NI'CIsR'I'I PIC,1l'IfIN ,f CON41RUCIJON 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 thm 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 hamilcss the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence o(the Lender's Address graining of[his permit.Additionally,the applicant understands and will comply with all non-point source regulatiau per the Cupertino Municipal Code,Section ARCHITECT"S DECLARATION 9.18, I understand my plans shall be used as public records. Signature Date Licensed Professional -- f \ ` REROOF TEAR-OFF POLICY COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION ALBERT SALVADOR. P.E., C.B.O.. BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333•buildinci(Mcupertino.orD PROI T ADO It ANN# L 0B 'ER I`ME � + PHO-NEJE �- E-MAIL T� O STREET ADDRESS// �1 CITY STATE,ZIP FAX 1, b :� S W O F R"�1�' C .. c 1 • ku a. CONTRA AME ORNLICE.NSENUMBER LICENSETYPE BUS.LIC.P � IJ 6C(L1 611 COMPA U''A �!t ` E-MAIL FAC O STREETA® DDRESS CITY'.STATE.21P �q` 562 PHONE V 1 �( U 1 UNDERSTAND AND AGREE TO THE FOLLOWING: 1. The re-roof project shall comply with all applicable provisions of the 2010 California Codes. 2. An inspection request can be scheduled up to the day before the inspection date. Please call (408)777- 3228 from 7:30 - 3:30pm (Mon-Thurs) or 7:30 - 2:30pm (Friday) to schedule the next day inspection. For Tear-Off and Nailing Inspections, you must also call on the day of the inspection only after that phase of the work is completed. The building inspector will be available within one hour. Progress and Final Inspections will be given a two hour window. 3. Tear-Off Inspection is required. Any and all dry-rotted wood shall be replaced prior to this inspection. Unless new plywood roof sheathing is proposed throughout, all the nails/fasteners shall be either completely knocked-down or removed prior to this inspection. 4. If plywood is installed, a plywood Nailing Inspection is required. 5. Roofing shall not be applied without first obtaining all prior inspection and written approvals from the building inspector. Any roofing which is applied without first obtaining an approved inspection will require the removal of all new material down to the sheathing so a proper inspection can be performed. 6. Progress Inspection is required when approximately 50% of roof covering is installed. 7. A Final Inspection and approval shall be obtained from the building inspector when the re-roofing is completed. To receive a final sign-off. the following items will be verified: a. Flat roofs shall have a minimum of%" per foot of slope and demonstrate there is no ponding. b. Listings from approved testing agencies for all pre-manufactured products used shall be available on-site to review at the time of the inspection. c. Proper spark arrestor installation, vents painted, gutter/downspouts installed, debris removed. 8. NOTE: If you call for a tear-off or plywood nailing inspection and the work is not complete, you will be charged a re-inspection fee of$126.00. The re-inspection fee shall be paid before another inspection can be scheduled. By my signing below, I certify each of the following is true: I am the property owner or authorized agent to act on the property owner's behalf. 1 understand and agree to comply with the re-roof policy stated above. I also understand that smoke detectors and carbon monoxide detectors are required to be installed in accordance with Sections R314 and R315 of the 2010 California Residential Code. Signature of Applicant/Agent: q Date:_ -30 RefonfPolicv 201 Ldoc revised 02/16/ll CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION 2s ADDRESS: 21736 collingsworth ave. DATE: 07/30/2012 REVIEWED BY: bobs. ,CPN: BPH: -VALUATION: 1$9,200 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY PENTANIATION USE: SFD or Duplex PER 1119"I'1'pFc 1SFDWLR00 NVORK sfd tear off skake install new asphalt shingles. SCOPE blech. Plan Check Plumb.Plan Check Flee.Plan Check Mech.Permit Fee: . Plumb.Permit Fee Elec. Permit Fee: Other Much.Insp. Other Plumb Insp. Ll I Other Elec.Insp. ,1lech,lisp.Fee: - Plumb. bnp.rue: face.Insp.Fee: NOTE: This estimate does not includejees clue to other Departments(i.e. Planning, Public Narks, Fire,Sanitary Sneer District,School District,etc.). These fees are based on the prelintinat3v information available and are onh•an estimate. Contact the De t or addn'I info. FEE ITEMS (Fee Resolution 11-053 1i B: 7/111 F FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 2,300 s.f.. Re roof SuppL PC Fee: Q Reg. 0 OTFO-0-1hrs $0.00 $345.00 IREROOFREs PMH Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee@ Reg. Q OT 0.0 hrs $0.00 PML' Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tnc: Administrative Fee: Q Work Without Permit? O Yes (j) No $0.00 G Advanced Planning Fee: $0.00 Select a Non-Residential 0 T tire/Documenlmion Fees: Building or Structure 0 Soong Motion Fee: IBSE/SMICR $0.92 Select an Administrative Item Bldg Stds Conunissi on Fee: IBCBSC $1.00 SUBTOTALS: $1.92 $345.00 TOTAL FEE: $346.92 Revised: 07/01/2012 REROOF PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228 • FAX(408)777-3333 •buiidinoQfcupertino.oro PROJECT ADDRESS, \ o • APNu -7 �- � (Pa ,��. 5�U r vQ � OWNER NAME G ; O ;HONE) 807 k E-MAIL STREETADDRESS / \ k W4 L .CITY`.•TATE,ZIPIP ; �`� FAX 11 CONTACT NAME PHONE ` E-MAIL STREET ADDRESS `�/"�17�✓ICY CRY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BURGER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHnEcT ❑ENGINEER ❑ DEVFIOPER ❑TENANT CONTRACTO�NAM1IE LICENSE NUMBER LICENSE TYPE BUS.LIC.M N R 6 C•3 COMPANY NAME E-AZAR FAX V a LUQ STREET ADDRESS CITY,S .ATE,ZIP 0 ( G(M1.! V — 4- J ARCHITEC(ENGINEER NAME LICENSE NUMBER BUS.LIC.M COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF FD or Duplex ❑ Multl-Fanily, ROOF AREA: VALUATION: 06 STRUCTURE. ❑ Convnercial add LO 6 J EXISTING ROOF TYPE: ❑BUILT-UP ROOF yyASPHALT SHINGLES ❑WOOD SHAKES ❑WOODpSHHrINGLES C2 OTHER(SPECIFY, REMOVEIREPLACE YES IF NO, PLYWOOD 13A- ClPLriVD fa)sB PITCH: ROOF 0N df. YERS -K c.. ❑ SB' TYP ❑f X �:12 `a 1 CLASS PROPOSED ROOF TYPE; ❑BUILT-UP ROOF XASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER ICC-ES REPORT N DESCmP�A OF ���; \ I \ _I r 'Cod I v-S \ OSJ 6 I,Gj T v, A `mss e By my signature below,(certify touch of the following: I am the property owner orauthorized agent to act on the property owner's behalf. 1 have read this application and die information I have provided is correct. I have read the Description of Work and verify it is accurate. 1 agree to comply with all applicable local ordinances and state laws relatine to building con (syy ti n. I authori representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicam/Agen' Date: SUPPLEMENTAL INFORMATION REQUIRED OFFICE BSE ONLY _If bui Wing.is associated with a Home Owners Association•provide letter PLAN CHECK TYPE. - ROHITNGSLIP , of approval from HOA. ER-THE-COUNTERINC PUN REVIEW Provide Planing approval to verify if there any restrictions. ❑ EXPRESS ❑ PL�NT:INCeun REVIEW Provi opy of Mawfacurrer's Installation Specifications. ❑ STANDARD ❑-ETRE DEPT rovlde signed copy Gf CuN. r ino's Tem,-Off Policy. ❑ OTRER: • Reroojdpp_2011.docrevised O3Q6/ll CITY OF CUPERTINO BUILDI,NC PER,ti1IT BUILDING ADDRESS: 10458 BONNY UIt CON'TRACI.01t:-/.f1U FDWARD ANDCHEN PF101ITSO: 12070226 T%U-I IUI OWNI.R'SNAMF.: %IIUI:DWARDANI)CllI'.N'f%U-IiU1 10458 BONNY UR DATE ISSUED:0 7/3 02 0 1 2 OWNER'S PHONE: 4085180889 CUPERTINOXA 95014 PIIONF SO: ❑ LICI.N'SED COQ fRACfO1d'S DECLARATION Run.DINc rE1c,\n'r lNl=o: Rl,uc r el.6;cr r Fl.uau; r License Class Lie.b alr:cn r REsn)ENTLu. r COMM Elacl,u, r Contactor Date I hercby affirm that I not licensed under the provisions of Chapter 9 JOB DESCRI FHON: RECONNEO'EXISTING GAS AND ELL•CIRICAL MISIIiRS (commencing with Section 7000)of Division 3 of Business& Profession., TI IAT Code arld that me license is in full force and effcel. WERE REMOVED 13Y PG&E.PERMIT IS A RI:QUE•S'r FROM PG&E'I'O INSPI:CI'S YSTEMS PRIOR'1'0 RECONNECHNG. 1 hereby affirm under penalty of perjury one of the fullmvim!Iwo declarations: I have and will maintain a certificate of consent Int self-insue Rn Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work f'or which this permit is issued. I have and will maintain Worker's Compensation insurance,as provided for by Section 3700 of the LabocCode.for the perlornlauce of the work for e'hich this pcnmit is issued, Sq.PI Floor Arca: Valuation:$250 APPLICANT CERTIFICATION I certify than have read this application and state that the above inRmnalion is AI'N Number:35914036.00 Occupancr'I)'pe: correct. I agree to comply with all city and county ordinances:end state laws relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property Jim inspection purposes. (We)agree to save indemnify and keep harmless the City ofCuperlinnagainstliabilities.judgments, PERA7LI LXPIIt1:SIF NVORK IS NO-I- S-LAR-I ED costs,and expenses which may accmc against said City in consequence of the 180 p p 1 I ) granting Of this pl'rnit. Add11alnulIy,the applicant understands lands and will comply WITHIN DAYS OI' I'ERIMI I ISSUANCE Oil with all non-point Source regulations per the Cupertino Municipal Code.Section 9.18. ISI) DAYS FRO,,\'I LASTCALLED INSPECTION. Signature Dalc Issued 1)y: A N , �/_,:�l Date: 7.30' /,9' ❑ OWNEIt-RIIILDRIt IgSCI.:\It:\'f10N I hercbyaffirm that I am exempt front the Comrarlor's License Lao forone of RP;ROOFS: the following two reasons: All roofs shall be inspected prior to toy roofing material being installed.If a roof is I,as owner of the property or my employees with wages as their sole compensation, installed without first obtaining;in inspection.I agree to remove all nest nacrials for will do the work,and the stmcture is not intended or offered for sale(Sec.70-14, inspection. Business&Professions Code) I,as owner of the property,nal exclusively contracting with licensed contractors to Signature of Applicant- Date: construct the project(Sce.70d4•Business&Prolessions Code). I.hereby affirm under penalty of perjury one of the follimina three ALL ROOF COVIIR NGS TO BE CLASS"A" OR BE 1-EER deefinations: I have and will maintain a Certificate of Consent In sell'-insure for Wokcr's 11:\%,\ItDO11S)LV1'6;121:\LS I1ISCLOSIi It I: Compensation•as provided for by Section 3700 of the Labor Code,fix the pcdonnance of the work for which this permit is issued, I have rend the hazardous materials requirements under Chapter 615 of the I have and will maintain Worker's Compensation InSmmnCe,as provided for by California Health&Safety Code.Sections 255115.25533,and 25534. d will maintain Section 3700 of the Labor Code,Jim- he performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should 1,lore or handle hazardous material. pcnnil is issued. Additionally,should I use equipment or devices which emit hazardous air I certify than in the performance of the work for which this pernlil is issued,I shall cunlanin:unl,as defined by the Ray Arca Air Qualitx Nlanagcmenl District I .rill 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 California. It,after making this certificate ofexenlption,I Health&Safely Code,Sections 255115.25533,and 25534. become subject to the Worker's Compensation provisions of the labor Code,I must nr n t -. t forthwith eonlph•wish such provisions or this permit shall be ddetailedrevoked. Owner gein:voked. Ila le: 1/73102— A I'I'LI CANT CE RTI FICAT]ON C.ONS'1'It 1ICl'Il)N LENI)INC:AGENCY I certify that I have read this application:end state that the above information is correct.I agree to comply with all city and county ordinances and state lays 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 peril is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(Wt-)agree to save Lender's Name indemnify and keep harmless the City of Cupertino against l iabilhies,judgments, costs,and expenses which may accmc against said City in consequence of the Lender's Address granting of this pemlit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code Section 9.18. ARCI11'1'ICCI"S DECLARATION I/L 1 understand me plans shall be used as public records. Sien;nurc Date Licensed Professional CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10458 Bonny Dr. DATE: 07/30/2012 REVIEWED BY: Sean APN: BP#: lc5zo n�' 'VALUATION: $250 *PERMIT TYPE: Building Permit PIAN CHECK TYPE: Alteration / Repair PRIMARY SFD Of Duplex PENTAM ATI ON USE: pPERMITTYPE: 1REAP A WORK Reconnect existing as and electrical meters that were removed by PG&E. Permit is a re uest'from SCOPE PG&E to inspect systems prior to reconnecting. Mech. Plan Check Phoub.Plan Check Clec.Plan Check Meeh. Permit Fee: Plump.Permit Fec: Clec•. Permit Fee: Other Heck Insp. Other Plumb Insp. Li I Other Cleo.Insp. Mech./esp. Fec: Plumb. h"p. Fee: Elcv Insp.Fec: A'OTE: This evdi n to does not include jeer due to other Departments(i.e. Planning. Public Works, fire,Sanitary Saver District,School District, etc.). Thesefees are baser/on the prelintinart•information available and are onh,an estimate. Contact the De t or addn'I info. FEE ITEMS LEce Resolution 11-053 Ell' 7/1111) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure Suppl. PC Fee: Q Reg. O OT 0.0 hrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: Hourly Only? O 1'es Q No $0.00 Suppl. Insp. Fee@ Reg. Q OT 0.0 [its $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Conswuction Tax: Administrative Fee: Q Work Without Permit? O Yes Q No $0.00 0 Advanced Plannina Fee: $0.00 0 hours Inspections (D Travel Docnnentanon Fees: $133.00 ISTINSP Inspection, Hourly 0 Strong Motion Fee: IBSEISHICR $0.50 Select an Administrative Item Bidg Stds Commission Fee: IRCBSC $1.00 SUBTOTALS: $1.50 $133.00 TOTAL FEE: $134.50 Revised: 07/01/2012 t; OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• buildinormcuoenino.oro 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 . O� APN BP# o K �7Y • qq�� //11 OWNER NAME , OWNER ADDRESS r", r/I C, - DESCRIPTION OF WORK: L i.LL 1(. Ylo q GovlNl=ol' 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.) r,(___ 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- uilder' 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. Ci�< 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. 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. I 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 considered an "employer"under state and federal law. X6. 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. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family l 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. �rj- )(,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. OwnerBuilderForm 2010.doc remised 04/14/10 �t i( �9. I 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 vAvw.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 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 // ,,by all applicable laws and requirements that govern Owner-Builders as well as employers. x,.VLI-- 12. I 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: 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 Property Owner's Signature: Date: b Z ------------------------------------------------------------------------------------------------------------------------------------------ (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: 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: OirnerBuilderForm 2010.doc revised 04/1$/10 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 950143255 I (408)777-3228 • FAX(4C8)7T/-3333 •bukinc0cuoerino.org CUPERTINO SC ��cc I Z7M KPLUfBING ❑NEC---ANiCAL ELECZCAL El"ti PROJECT ADDRESS i o Y' `{3�r n �Y. I ApN# (� 3( OWNER;NAME \ hL�l GhQ,v(� PHONE s-t'� , 1 p$821 E MAR 't2 c. 8 @ NN6i N�• A'n S iREEi ADDRESS o4gg CITY, S;AT-c,-tK) Ua FAX S �'/oil l'� VY. • ILIO CONTACT NAME 13U I u; / 1 _ ) /- � I PF.ONE I i.Sl��7 p_`1) E MAR t'? /e STREET ADDRESS, �1��(p� r�`IINnA `/ =.S7AI-, Z J`'FFAAXX O RO OWNER ❑ OWNER-BUEDEA ❑ 0W AGENT El CONT crca ❑COMRACORAG�l ❑ ARl]i:' r ❑DIGLNEER ❑ DEVELOPER ❑TENANT CONTRAC0R NAME _J L'CENSENUMEER UCENSE TYPE I BUS.LIC# COMPANY NAME E.MAR FAX SREETADDRESS I CITY,STATE.Zr? PHONE ARCHMCi/EIOLNE:-RNAME I LICENSE NL'hfHER I BUS.uC.i COMPANY NAMEE-MAIL FAX STREET ADDRESS CITY,STA,E ZP PHONE USE OF FD w DUP= ❑ MUL--FA' y I PROJECT PN WGDLWD ❑ YES I ?ROIBCT N ❑1'S I a T !H.DG AN YES BUTI-ONG: (]COIW IIIRCLAl. URBAN p+Tc�Ii FA - FACE 0 D]ANE NO E1CFB 1101,(E! O DESCRIPTION OF WORX 1' P67 A TOTAL VALUATION: �J�O I RECEIVED BY: By my signature below,II certify m each of the fallowing: I=the propery owner or authorized agent to act an the property owner's behalf. i have mad chis application and the information I have provided is correct I have rcad the Deseipcion of Work and verify it is accurate. I agree to comply wiIh all applicable local ordinances and sate laws relating m build, s on. I amhorize representatives of Cuperticc's=Ythe e above-ideatifiedpropcay for inspecdou puPbosm Sigaature of Applirarr/Ageae Date: SUPPLEMENTAL F IFORV(ATION REQU ED OFFICE USE ONLY y OVER-TNE-COUNTER r ❑ EXPRFS U ❑ STANDARD V ❑ URGE ❑ mAJOR eVLEP.Wac4pp_2011.doc revised 06/2lllI