12110128CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1052 WEST HILL CT I CONTRACTOR: BG CONSTRUCTION INC I PERMIT NO: 12110128 I
OWNER'S NAME: MADHU & LAXMI ALUR
850 W SUNSET BLVD ) DATE ISSUED: 11/21/2012
OWNER'S PHONE: 4082482509 I HAYWARD, CA 94541 I PHONE NO: (510) 432 -6249
❑ LICENSED CONTRACTOR'S DECLARATION
License Class RR_ � Lic. 9 6 O -S 7
Contractor l.>G7. r1 y.J (&Ak L1-- Mk+Bate //—
I hereby affirm that 1 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.
1 hereby affirm under penalty of perjury one of the following two declarations:
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.
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
permit is issued.
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above information is
correct. 1 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,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit Additionally, the applicant understands and will comply
with non -porn source regulations per the Cupertino Municipal Code, Section
9.18.
Signature 2 Date
❑ OWNER - BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following three
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, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
I certify that in the performance of the work for which this permit is issued,) 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, 1
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.
APPLICANT CERTIFICATION
1 certify that 1 have read this application and state that the above information is
correct. 1 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,
costs, and expenses which may accrue against said City in consequence of the
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.
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
MECH r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: KITCHEN REMODEL 200 SQ FT
Sq. Ft Floor Area: I Valuation: $25000
APN Number: 36227043.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: \Jl Date: 146
RE- ROOFS:
All roofs shall be inspected prior to any roofing material berg installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
"B 0 T11Z113 X0111 DI91M I9tCll:io[mWI:VRWI:Y[Ot71311 IIYII 7
HAZARDOUS MATERIALS DISCLOSURE
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should 1 store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
r zed agen• Opff V10oo" 1, - Ct'
Date- (^ 2 E+'" 2tA Z_
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 1052 WEST HILL CT
CO,NTRACI'OR: MADHU K LAXMI ALUR
PERMITNO: 12110128
OWNER'S NAME: MADHU R LAXMI ALUR
1052 W IiILL CT
DA'Z'E ISSUED: 11212012
OWNER'S PIIONE: 4082482509
CUPERTINO, CA 95014
PIIONE NO:
❑
JOR DESCRIPTION: RF,SIDE\ 1'LAI, 0
COMMERCIAL❑
LICENSED CON`VRACfOR'S DECLARATION
License Class Lic.4
KITCHEN REMODEL 200 SQ FT
Contactor Date
hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business S professions
Code and that my license is in full force and effect.
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
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
permit is issued.
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 and state Imes 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,
costs, and expenses which may accrue against said City in consequence of the
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,
Date
U OWNER - BUILDER DECLARATION
J
hereby affirm that I am exempt front the Contractor's License Law for one of
the following two reasons:
1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and die structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project(Sec.7044, Business R Professions Code),
hereby affirm under penalty of perjury one of the following three
declarations:
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.
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.
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
become subject to the p'orker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CER'rIFICA'1'ION
I certify that I have read this application and state that the above information is
torten. 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,
costs, and expenses which may accrue against said City in consequence of the
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.
I.
Sq. Ft Floor Area: I Valuation: $25000
AI.N Number: 36227043.00 1 Occupancy'I'ype:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN JPO DAYS OF PERMIT ISSUANCE OR
180 DAY F/1(/6M LAST CALLED INSPECTION.
Issued by: IL14LL
RE- ROOFS:
NI roofs shall he inspected prior to may Tooling material being installed Ira roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
,ALI, ROOF COVF,RINGS TO BE CLASS "A" OR BE I'fER
ILA %.ARDOUS MATERIALS DISCLOSURE
have read the hazardous materials requirements under Chapter 6.95 of the
California health S Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health S Safety Code, Section 25532(a) should I store or handle hazardous
m:ucrial. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area ,Air Qualitv \lanagement District
will maintain compliance with the Cupertino Municipaf Code, Chapter 9.12 and
the health S Safety Code. Sections 25505. 25533. and 25534.
11 � ,� I�. I
Oa tier or authorized agent: ^,91 Q 1 w_, . nQi „ Dater
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCUrrECI "S DECLARATION
I understand my plans shall be used as public records.
Licensed
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 • buildinclocupertino.oro
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❑ NEW CONSTRUCTION El ADDITION ❑AI.TERATION /TI ❑ REVIS ION I DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS 105 2 IkfCL-T H I LI C-r 11 y p "-r r �D
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OWNER ❑ OWNER-BUILDER Cl OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRA ORNAINIE 114
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ARCHTTF.CTASNGMEER NAAIE
LICENSE NUMBER
BUS. LIC b
COSIPANY NAME
E -NTAIL
FAX
STREET ADDRESS
CRY, STATE• ZIP
PHONE
DESCRIPTION OF WORT:
EXISTING USE
PROPOSED USE
CONSTR.TYPE
1UES
USE
TYPE
OCC.
SQ.PT.
VALUATION (S)
EKS-rG
NEW FLOOR
DENIO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROONI KITCHEN OTHER
MINIODELAREA RE \IODI..L AREA RHN10DEL AREA
PORCH AREA DECK AREA
TOTAL DECKA'ORCH AM
GARAGEAREA: LIDUACH
ATTACH
HDWELLINGUNITS:
ISASECOND11NIT ❑YES
SF.CONDSTORY []YES
aEIN'G ADDED' [] NO
,UIDrnom ENO
PRE - APPLICATION DYES IF YES. PROVIDE COPI.OF
IS To F. aLDGAN L] Yes
RECEIVED B \':
/F577t. VALUATION:
PLANNTNGAPPLF ❑NO PLANNING APPROVAL. LETTER
EICHLER IIONIEe [] NO
By my signature below, 1 certify to each of the following: I am the propeny owner or authorized agent to act on the property owner) behalf. l have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate, 1 agree to comply- witkaHVp)Sf`atile —local
ordinances and stale laws relating to building onSIMenon. I autho of Cupenino to enter the above-identified property for inspection purposes,
Were
a
Signature of Applicam/Agent: O/K A A II_ Date:
SUPPLEMENTAL INFORMATION REQUIRED
ANCHECKTYPI;
I<OU]INCSLIP
O \'I:x= I'IIF.- COUNTPat
BUILDING PLAN REVIEW
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is requimd prior to issuance of building
permit for new building.
❑ EXPRESS
❑ rl.\N:ar.c PL,w'xe\•IEW
— Commercial Bldgs: Provide a completed I- lazardous Materials Disclosure
71 STANDARD
❑ PUBLIC WORKS
form if any Hazardous Materials are being used as pan of this project.
❑ Iw\xcE
❑ FIUF: m:rr
_ Copy Of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application.
❑ m \JON
❑ S. NI'I'ARY SEWER DIS'URICT
❑ FN\•m0NNIKNrc LBK,%Lrn
BleigApp_2011.doc revised 06121111
I 1011 29
CITY OF CUPERTINO r^P&-"r'wk
FEE ESTIMATOR- BUILDING DIVISION
NOTE: This estinuae aloes not include jeev (tide to other Departments (i.e. Planning, Public Works, Fire, Sanitary Setter District, School
District, etc). These %ev are based on the prelhnhmn, information available and are onh, an estimate. Contact Cite Dept for adds 7 info.
FEE ITEMS (Fee Resohition 11 -053 E/f 711112)
ADDRESS: 1052 West Hill Ct
DATE: 11/21/2012
REVIEWED BY: A. Salvador
Mech. Permit Fee:
APN: �� Z 1 3
BP #:
'VALUATION:
ISO
'PERMITTYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex
USE:
rlec. Insp. Fee:
PF,NTAMATION IR3SFDREM
PERMITTYPE: A
WORK
PME Plan Check:
SCOPE
$0.00
NOTE: This estinuae aloes not include jeev (tide to other Departments (i.e. Planning, Public Works, Fire, Sanitary Setter District, School
District, etc). These %ev are based on the prelhnhmn, information available and are onh, an estimate. Contact Cite Dept for adds 7 info.
FEE ITEMS (Fee Resohition 11 -053 E/f 711112)
Mech. Plan Check
Phunh. Phan Cheek
Elec. Plan Check
Mech. Permit Fee:
Phanth. Permit Fee:
Elec. Permit Fee.,
Other Mech. Inep.
Other Plamh Insp.
Other Elee. brig.
.Vech. In y. Fec:
Phmrb. hasp. Fee:
rlec. Insp. Fee:
NOTE: This estinuae aloes not include jeev (tide to other Departments (i.e. Planning, Public Works, Fire, Sanitary Setter District, School
District, etc). These %ev are based on the prelhnhmn, information available and are onh, an estimate. Contact Cite Dept for adds 7 info.
FEE ITEMS (Fee Resohition 11 -053 E/f 711112)
FEE
QTY /FEE
MISC ITEMS
Plan Check Fee:
$0.00
200 s.f.
$600.00
Remodel, Kitchen (< =300 so
IRE,tIRESKIT
Suppl. PC Fee: (F) Reg. Q OT
FO .0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee0 Reg. Q OT
0.0
1 hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Conatrticiion Tar:
Adminisa-mive Fee:
O
Work Without Permit? O Yes Q No
$0.00
Advanced Planning Fee:
$0.00
Select Non - Residential
Building or Structure
0
i
Travel Docwnenlation Fees:
Strome Motion Fee:
$0.00
Select an Administrative Item
Bldg Stds Commission Fee:
$0.00
SUBTOTALS:
$0.001
$600.001
TOTAL FEE:
$600.00
Revised: 10/01/2012
ADDITIONAL CODE REQUIRMENTS
Energy code mandatory lighting measures: '
1. All permanently installed high efficacy luminaires shall be switched separately from low efficacy
luminaires. (150(k)(7))
2. Permanently installed lighting in Kitchens shall be high efficacy luminaires. Up to 50% of the
wattage of permanently installed lighting in kitchens may be in lights that are not high efficacy.
(I 50(k)(8))
3. Permanently installed luminaires in bathrooms, garages, laundry rooms and utility rooms shall be
high efficacy luminaires OR are controlled by an occupant sensor(s) certified to comply with Section
119 that does not turn on automatically or have an always on option. (150(k)(10))
Plumbing plan notes:
4. Water closets shall have an average water consumption of not more than 128 gallons per flush. (CPC
402.2)
5. Shower heads shall have a water flow not to exceed 2.5 gallons per minute. (CPC 402.1.1)
6. Faucets in kitchens, wet bars, lavatories, laundry sinks, etc shall have a water flow not to exceed 22
gallons per minute. (CPC 402.1.2)
7. Shower stalls shall have a clear interior finish area of 7.1 sq. ft. and be able to accommodate a
minimum 30 inch circle at the threshold level. These clearances shall be maintained up to a height of
70 inches above shower drain. (CPC 411.7)
S. Shower compartments and walls above bathtubs with installed shower heads shall be finished with a
smooth, nonabsorbent surface to a height not less than 72 inches (6 ft). (CRC R307.2)
9. The maximum hot water temperature discharging from the bathtub, shower and whirlpool bathtub
filler shall be limited to 120 degrees Fahrenheit. The water heater thermostat shall not be considered
a control for meeting this provision. (CPC 4145 R 418.0)
10. A 30 -inch clear width for water closet compartment and 24 inch clearance in front of water closet.
(CPC 407.5)
Electrical Plan Notes:
11. The installation of smoke alarms in all of the following areas shall be provided: (R314.3)
a. On the ceiling or wall outside of each separate sleeping area in the immediate vicinity of
bedrooms.
b. In each room used for sleeping purposes.
12. The installation of carbon monoxide alarms in the following areas shall be provided: (R315.1)
a. Approved carbon monoxide alarms shall be installed outside of each separate sleeping area in
the immediate vicinity of the bedrooms and on every level including basements in dwelling
units that have fuel -fired appliances or attached garages.
13. A minimum of two 20 amp small appliance branch circuits shall be provided for all receptacle outlets
in the kitchen, dining room, pantry, or other similar areas. (CEC 210.11(C)(1))
14. At least one 20 amp branch circuit shall be provided to supply bathroom receptacle outlets. Such
circuits shall have no other outlets. (CEC 210.11(C)(3))
15. In every dwelling unit, fixed appliances such as food waste grinders, dishwashers, washing machines,
dryers, laundry tray locations, built -in refrigerators or freezers, furnaces, AC units, built -in heaters or
any other fixed appliance with a motor of '/4 h.p. or larger shall be on a separate 20 amp. branch
circuit.
16. All receptacles in bathrooms, garages, accessory buildings, outdoors, crawl spaces, unfinished
basements, kitchens (where receptacles serve counter top surfaces), laundry, utility, wet bar sinks
(within 6 feet of the edge of the sink), shall have ground -fault circuit interrupter (GFCI) protection.
,(CEC 210.8)
17. In all areas specified in 210.52, all 125 -volt. 15- and 20- ampere receptacles shall be listed tamper -
resistant receptacles. (CEC 406.11)
ResKhHathPo1icy_2011.doc revised 09101111
CUPERTINO
OWNER- BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO. CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 • buildinorc)cuDenino.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 i OS.2
1. e_r HI LL Cr C,t/)'
VVG,
APN
BPN
OWNER'NAME
LAW
AL P.
OWNER ADDRESS
osz wasr HILL cr b_9DeRr173v
DESCRIPTION OF WORK:
kl7euc -9.)
v -b6cuAj-c .
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.)
ft I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
" 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.
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.
SL3. 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.
tJJL_4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
n ISibers on permits and contracts.
UJL5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
%tat 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.
I understand if I am considered an "employer" under state and federal law, I must register with the state and
fe eral 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.
tLLI understand under California Contractors' State License Law, an Owner - Builder who builds single - family
r sires ial 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.
WA-8. I understand as an Owner - Builder if I sell the property for which this permit is issued, I may be held liable for
any Tnancial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
O %,nerBtlilderFornl 2010.doc revised 04 114110
I understand I may obtain more information regarding my obligations as an "employer" from the Internal
'ue Service, the United Slates 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 www.cslb.ca.gov for more information about licensed
contractors.
l) 10. 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.
1. 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.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
formation 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 propert owner's si nature.
Property Owner's Signature: Date: 'I Y-ZI
............... ..
(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:
OirnerBuilderFa-m ?010.doc revised 04114110
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