12110152 CITY OF CUPERTINO BUILDING PERMIT
`B'OILDING ADDRESS: 10573 GASCOIGNE DR CON'IRACI'OR:HARk11N INVESTMENTS PERMIT NO: 12110152
\
VI 112 LP
OWNER'S NAME: HARMIN INVESTMENTS 112 LP 2162 RINGWOOD AVE DATE ISSIIF,D: 11!18/2012
OWNER'S PHONE: 4088073636 SAN.IOSE,CA 95131 PliONF,NO:
❑ LICFNSFD CONIRACfOR'S DECLARATION BUILDING PERNIIT INFO: BLDG r ELECT r PLUDIB
License Class Lie,q
N1ECF1 RESIDENTIAL — COMMERCIAL J
Contractor Dale
hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALI-TENIP POWER POLE
(commencing with Section 7000)of Di%ision 3 of the Business& Professions
Code and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following too declarations:
I have and will maintain a certificate of consent to sell'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.
Sy.PI Floor Area: Valuation:$500
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. ANN Number:37528009.00 Occupancy7lpe:
APPLICANT CP:RTIFICATION
I certify that I have read this application mid state that the above information is
correct.l agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of this pemnit. Additionally,the applicant understands mid will comply
with all non-point source regulations per the Cupertino Municipal Code,Sectiai Issued
9.18.
Signature Date
RF,-ROOF'S:
❑D(/ O\\'NER-BUILDER DECLARATION All roofs shall be inspected prior to any tooling material beiig installed.If a roof is
1 herebyaffirm that I am installed Without first Obtaining an inspection,I agree to remove all new'materials for
exempt P from the license Lnw for one of inspection.
the following two reasons:
1,as owner o(the property,or my employees with wages as their sole compensation, Signature of Applicant: Dale:
will do the work,and the 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 ALL ROOF COVERINGS TO BE CLASS"A"OR RF,'EI'FR
construct the project(See.7044,Business&Professions Code).
hereby affirm under penally of perjury one of the following three IIAZARDOUS hIATF,RIAI S DISCLOSURE
declarations: I have read lime hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Ileallh&Safety Code.Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code.Chapter 9.12 and the Ileallh&
performance of the work for which this permit is issued. Safety Code,Section 25.532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices ,inch emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this 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
permit is issued. Ileallh&Safely Code.Sections 25505,25533,and 25534.
1 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 Lite Worker's Owner�r xnthn ized i ent:
Compensation laws of California. If,after making this certificate ofesemplion,l Date:
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. CIlNS9RUCy'ION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of work's
APPLICA\I'CF,RTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application mid state that the above information is Lender's Name
correct.I agree to comply with all city and county ordinances and state Imus relating
to building construction,and hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, .\RCII I'1'ECI"S DECLARATION
granting
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I Understand my plans shall be used as public records.
with all non-point urce regu lions per the Cupertino Municipal Cade,Section
9.18. Licensed Professional
Signature DatejI z� v
12 11 bt s2--�
GENERAL PERMIT APPLICATION M E d
- .. COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION ,
10300 TORRE AVENUE• CUPERTINO, CA 950143255 A I .
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CUPERTINO (40 (D
8) 777.3228• FAX(408)777-3333 • buildinacuoerino.ora fe`aeI
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DESCRIPTION OF WORK nn
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TOTAI VALUATION: s P.ECEty°BY: .�
By my sipaTu-c below,I c--rd w each of the following: I an the property owner or zntbodzed agent to act on the property cwntr s behaif. I bavc read las
zpplicz-:on and Lhe info-ado- •'-pmvidcd is correct. I havc,-rad the Desripaon of Wo.-and ve..y it is zc=rate. I ag:ee a cempty wick all zpplicable Local
c,dinznccs and ssrelzws ating;o b ']ding con dtorze:epresectatiVes of CUDCMno to enter the above-i a5edp. Deny for inspection put?oscs.
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OWNER-BUILDER DISCLOSURE FORM
• COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408)777-3228 • FAX(408)777-3333 • buildina(e)cuoertino.ore
CUPERTINO
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 �-CT IA APN BP#
OWNER.NAME k17 / V OWNER ADDRESS
DESCRIPTION OF WORK: L—/ J
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.)
L" 1. I understand a frequent 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, 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.
2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
he 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
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.
11'�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.
V 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
otal 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.
6. 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.
7. 1 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
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
his 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
ny financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OmnerBuilderForrn ?010.doc revised 04/14/10
9. 1 understand I may obtain more information regarding my obligations as an "employer"from the Internal
evenue 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 www.csib.ca.gov for more information about licensed
contractors.
q�*110. 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.
L.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.
$A-192. 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 signature.
Property Owner's Signature: Date:
- --- Ei.. -- e— ---------- --------- -- ----------- ------------------ --- --------- -------e"d,y" w "r,, -- -''- ---- ------ - ...---
(NOTE: The followirig Authorization Form is required to be completed by the property owneonly 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. p / p - n
Scope of Construction Project(or Description of Work): /-Q/»p0QgtLJ / Qd�t T( r caX f�dvl/(vK_
Project Location or Address: /G���r� �_�] & C.Cm C►i �2_ d Q l�ucaNQ�Tn l��,SO
Name of Authorized Agent: 11w240('X 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 thgs' maybe required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
OwneYBuilderFornl 2010.doc revised 04114/10
HARMIN INVESTMENTS, LLC
1891 JUNESONG WAY,SAN JOSE,CA 95133
(408)807-3636 408-519-3739(FAX) (408)258-8870(FAX)
LETTER OF AUTHORIZATION
Re: 10573 Gascoigne Dr, Cupertino, CA 95014
Date: Nov 26, 2012
To Whom It May Concern:
BE IT KNOWN, that the undersigned Daniel Li, the General Partner of Harmin
Investments LP, hereby authorize Dennis Le to act as my behalf to apply for any
permits needed forthe construction of my new home.
Your cooperation is greatly appreciated, if there is any question, I can be reached
at 408-807-3636.
Daniel Li, ManadeL.9f Harmin Investments, LLC
and General Partner for Harmin Investment LP