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13010165 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10751 SANTA LUCIA RD CONTRACTOR:SOLARCITY PERMIT NO: 13010165 OWNER'S NAME: MADAN;VIRANJrr S. 3055 CLEARVIEW WAY DATE ISSUED:01/31/2013 OWNER'S PHONE: 4088571841 SAN MATEO,CA 94402 PHONE NO:(650)638-1028 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL - COMMERCIAL❑ License Class C d Lic.# 4o/oz( INSTALLATION OF EVC STATION IN GARAGE Contractor SClof CI l1 y Date II I hereby affirm that I 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. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificateof 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. Sq.Ft Floor Area: Valuation:$1000 I have and will maintain Worker's Compensation Insurance,m provided for by Section 3700 of the Labor Code,for the performance of the work for which this APN Number:34217090.00 Occupancy APe•• permit is issued APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.d agree to comply.with all city and county ordinances and state laws relating WITHINA80 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property,forinspection purposes. (We)agree to save180 DAY FRO LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs;and expenses which may awme against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply 'Issued by: Dated 7 with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 4J RE-ROOFS: Signaturey '�`U Date I� All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. _ ❑ OWNER-BUILDER DEC Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Lew for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the property,or my employees with wages as their sole compensation, will do thework,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 HAZARDOUS MATERIALS DISCLOSURE construct the project(Scc.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations:. Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 2 505,25533,an 25534. Section 3700 of the Labor Code,for the performance of the work for which this /��,/�1 I/�1I1 permit is issued. - Owner or authorized agent: "!l( Date: I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any mannersoas to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions;or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 to building construction,and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenseswhichmay accrue,against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature - - Date ALTERNATIVE ENERGY PERMIT APPLICATION tQ�� COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION '\\17 AE ' 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 hh\V CUPERTINO (408)777-3228•FAX(408)777-3333•building cuoertino.oro 0V PROJECT ADDRESS to 751 � � CI J APNN --21 -7010 7010 OWNERNAME VV /j I VU[jay, PHONE 0 f7 liq E-MAIL STREETADDRESS /P75/ Soi 1 CITY, STATE,ZIP e( I D a FAX ,I n CONTACT NAME nII//✓�,,-JJ�, 6V�MI ^ 1/L,/N PHONE 10 ^'1 j E-MAIL ocaf ./1 CC I C`/ STREET ADDRESS L[hI S y`rJC(Jv CITY,STATE,ZIP nCK,I AV147IO FAX ❑OWNER ❑ OWNER-BUILDER ❑OWNERAGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONIRACTORNAME SolarCity LICENSE NUMBER 888104 LICENSE YPE( �! BUS.LIC# COMPANY NAME CO ( 1 l E-MAIL f -� 6 FAX 65G - 0 J / �C {� rJ)YI �l1'I �JCIQrLJ ,LC{ STREETADDRESS r-L C( CITY,STATE,ZIP CI� p^ /1 Q PHONE ARCHITECT/ENGINEER NAME CI Jj7L ) (V LICENSENUMBER J / BUS.LIC# rzk COMPANY NAME J J 1 E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF d�%SFD or Duplex ❑ Multi-Family PROJECT IN WILDLAND PROJECT IN STRUCTURE: ❑ Commercial I URBAN INTERFACE AREA ❑ Yes NO FLOOD ZONE ❑ Yes YNo El SOLAR PANELS %-ELECTRIC VEHICLE CHARGING STATION 1 ❑ SOLARWATERREATING ❑ OTHER: FON.SOJARPANEI.S: NUMBER OFPANELSNNITS: 0KILOWATTS: TOTAL VALUATION: 000 DESCRIPTION OF WORK E4stal(d t011d 1JfC R )CisI Ff. c A( �f' RECEIVED Y By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the pro rty wner's behalf. I have read this application and the information 1 have provided is correct. I have read the Description of Work and verify it is accurate. I alme to comply with all applicable local ordinances and state laws relating to building construction. I Guthu ro sentetives ofCupenino to enter the above J-identfifi dTrty for inspection purposes. Signature of Applicant/Agent: Date: / 11/ SUPPLEMENTAL INFORMATION REQUIRED oFFI Be ONLY ,� oveR-TxccouNreR ❑ EXPRESS ❑ STANDARD ❑ LARGE d ❑ MAJOR PVApp_2012.doc revised 06/20/12 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10751 SANTA LUCIA RD DATE: 01/31/2013 REVIEWED BY: MENDEZ APN: I BP#: 'VALUATION: $1,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY SFD or Duplex PENTAMATION SOLAR-RES USE: p PERMIT TYPE: WORK INSTALLATION OF EVC STATION IN GARAGE SCOPE i ami Mech. Plan Check Plumb.Plan Check Elec. Plan Check ibfech. Permit Fcs?• Plumb. Permit Fee: hlec.Permit Fee Other Alech. Insp. Other Plumb Insp. Ej Other F.lec,Insp. Hech. Insp. hee.. Plumb. htsp.Fee: Elec.Insp.Fee: NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School Dstrict etc). These.fees are based on the prelfinina in ormadon available and are only an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/121 FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 F-1-7 # Alternative Energy System Suppl. PC Fee: Q Reg. 0 OT rO.OThrs $0.00 $102.00 ICHRGSTA EV Charging Station PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp.Fee.e Reg. 0 OT 0,0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Consovelion Tax. Administrative Fee: O Work Without Permit? 0 Yes Q No $0.00 Advanced Planning Fee: $0.00 Select a Non-Residential Building or Structure 0Travel Documentation Fees: Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee; IBCBSC $1.00 k3hul;;t? t $1.50 $102.00 °"; fisT�o7ALFEE"'i $103.50 Revised: 10/01/2012 r� 4 (E) 200A Main Panel (N) Tesla HPWC s F OFFICE COPY, 0 z (1) #3 AWG THHN-2 C NITY ELOPMENTDEPA TMENT ( ) #8 AWG THHN-2 WING DIVISION-CUPERTI O 1" EMT-5' APPROVED J\ This set of plans nd specifications MUS1 be kept at the �54 job site during c nstruction. It is unIaWfL I to make any F ' changes or .Iterations on same, or t deviate therefrom, witho approval from the Bu(ding Official. #,.rl?1A '✓„ �r� � Q.'i� Tha stameing of this p n and specificatiojis SHALL NOT on approval ci thevioio.-Iion PLOT PLAJNS C. cIV provisions of any U Ordinance pr Staya Law. i GO CHECKED BY DATE _ PLANNTN DATE___. E➢i r;. CONnDENTm- THE INFMATION NEREIN JB-9501104 Cupertino "EI"`°"& .:"!• CONTAINED SNALL NOT BE USED FOR THE V i ra n ji t Madan -- �� NNERT OF ANYONE EXCEPT SOLARCITY INC., MAWV-. WAN PANEL SERVICE RATlG , ,SolarCity NOR SHALL IT BE DISCLOSED IN MHOLE OR IN EV Charger 200A 10751 Santa Lucia Road PART TO OTHERS OUTSIDE THE RECIPIENT'S PRO.ECT WWACFI! ORGANIZATION,EXCEPT IN CONNECTION WTH CNgllf WLTACE/NPkRACE: Cupertino, CA, 95014 THE SALE AND USE OF THE RESPECTIVE of in Flyon 240V/100A 3055 Clearview Way SOLAIiCnY EgNPNENT, 011110.1 71E San Mateo,CA,94402 P°"'L`�`NOFSOLARCITY INC. Zeke Carnes—Masor Tesla HPWC (408) 857-1841 (888)-BOL43iY(7652489) w»wsolanily.mm a SPECIFICATIONS • The maximum rating for the High Power Wall Connector is 20 kW or 80 amps at 240 volts.Your vehicle will charge from 200 to 240 volts. LU 120V ABOVE GROUND(common in North America) 230V ABOVE GROUND(common in Europe,Asia,and Australia) • ' 240V AC single-phase:L1,L2,and safety ground 230V AC single-phase:LINE,NEUTRAL,and EARTH. s - 2' 208V AC 3-phase,wye-connected:Any 2 phases,and safety ground. % -t 240V AC 3-phase,delta-connected:With center tap on one leg,use only the two phases on either side of the center tap.The two phases must both measure 120V AC to ground.Do not use the third leg(208V"stinger"). �J'Yr' 1 .(4• 4� it Maximum 100A Circuit Breaker. Maximum 100A Circuit Breaker. if 0 Pu The maximum current for charging the vehicle is 80A or 20 kW. The maximum current for charging the vehicle is 80A or 20 kW. At 240V,this will be 19 kW maximum. At 230V,this will be 18 kW maximum. Requenscy j - �' 60 Hz 50-60 Hz Cable Length Approximately 25'(Z6 m) Height:15"(382 mm) Brecket-0lmensions, Width:6.22"(158.2 mm) - Depth:3.7"(96 mm) Weight(Including bracket) 20 lbs(9 kg) Operating Temperature -22°F to 113°F -30°C to 45°C • Storage Temperature -58°F to 185"F < - -50°C to 85°C Enclosure Rating Type 3R IP 44 aLJ Agency Approvals UL,FCC Part 15 EN,IEC r. NEC 220.83 - Adding a Circuit to an Existing Dwelling Unit Square Feet: 1,250 Panel Breaker Rating: 200 A L1/L2: 240 Vac NEC 220.83(A)(1) "General lighting and general use receptacles ... @ 3 volt/amperes per square foot as determined by 220.12" 1,250 square feet x 3w/sq ft 3,750 VA NEC 220.83(A)(2) Small appliance and laundry branch circuits @1500VA per 20 amp circuit Number of circuits 4 x 1500= 6,000 VA NEC 220.83(A)(3)(b) "Household Range(s),wall-mounted oven(s), and counter-mounted cooking unit(s)" Ott 7,680 VA Microwave VA 7,680 total VA NEC 220.83(A)(3)(a) "All other appliances that are permanently connected, fastened in place, or connected to a dedicated circuit, at nameplate rating" Dishwasher/Disposal 3,840 VA Refrigerator 1,760 VA Range 7,680 VA Washer 1,760 VA ,Dryer 5,760 VA VA VA VA VA 0 VA VA Tesla HPWC 19,200 VA EVSE 1: 0 VA EVSE 2: 0 VA 40,000 total VA Total of non air-conditioning loads: 57,430 total VA First 8kVA of load at 100% 8,000 VA Remainder of load at 40% 19,772 VA Adjusted total of non air-conditioning load 27,772 VA NEC 220.83(B) "Where additional air-conditioning equipment or electric space-heating equipment is to be installed..." tlt.lttit#1 9,600 VA A/C Equipment Unit#3 0 VA Total of A/C Loads and All Other Loads: 37,372 total VA Total Proposed Calculated Load: 155.72 Amps JB - Madan " �SolarC�t ©copyright SolarCity 2008 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21598 ROSARIO AVE CONTRACTOR:CONNELLY THOMAS J PERMIT NO:13010161 AND DOROTHY OWNER'S NAME: CONNELLY THOMAS J AND DOROTHY 21598 ROSARIO AVE DATE ISSUED:01/31/2013 OWNER'S PHONE: 4089961374 CUPERTINO,CA 95014-4757 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL❑ COMMERCIALS License Class Lic.# REPLACE(E)WATER HEATER,SAME LOCATION Contractor Date I hereby affirm that I 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. I 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. Sq.Ft Floor Area: Valuation:$2021 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 APN Number:35619017.00 Occupancy TN pe: permit is issued. APPLICANT CERTIFICATION I certifythat I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED PP correct.I agree to comply with all city and county ordinances and state laws relating WITfIIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYSX4Z9M LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the IssuDate• < < 3 granting of this permit. Additionally,the applicant understands and will comply y: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is i installed without first obtaining an inspection,I agree to remove all new materials for inspection. OWNER-BUILDER DECLARATION Signature of Applicant: Date: 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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) 1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will 1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous 1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Q��7� / / Owner or authorized agent: • �i,"*h.�d-(- � ate: - 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If,after making this certificate of exemption,I become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address — 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 to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature��r}liL ��`� Date v�\ GENERAL PERMIT APPLICATION O\ COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION MEP 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 MO CUPERTFNO (408)777-3228• FAX(408)777-3333• building(a--)Cuoertino.orq MISC PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS � . ^ PROJECT ADDRESS .APN OWNER ' PHONE E-NAIL CJ be STREET ADDRESS I STATE,ZIP FAX ll✓IJ.Q. 9R- U/ COTTA T NAME PHONE 17 STREET ADDRESS CITY,STATE, ZIP )SpOH'NER ❑ OWNER-131ID..DER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL 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.,DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ 7-Fs BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK /\�i l�e-� /= /A/�� //� �• �+G�U: TOTAL VALUATION: 2 I Q Z RECEIVE By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the properTy owner' beh ave read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above-identified propeffy for inspection purposes. Signature of Applicant/Agent: Date: / ' I-- C3 SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY OVER-THE-COUNTER I" ❑ EXPRESS U ❑ STANDARD U ❑ LARGE c ❑ MAJOR 1fEPMiscApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 21598 ROSARIO AVE DATE: 01/31/2013 REVIEWED BY: MELISSA APN: 356 19 017 BP#: 'VALUATION: $2,021 FPERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/Repair PRIMARY SFD or Duplex PENTAMATION PRWHEATR USE: p PERMIT TYPE: WORK REPLACE E WATER HEATER SAME LOCATION SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Water Heater 1PRWHEATR 1 # $27 TOTALS: $27.00 A-tech. Plan Check Plumb.Plan Check0.0 hrs $0.00 lJec.Plan Check Alfech. Perrnir F>, Plumb.Permit Fee: IPPERMIT Elec. Permil Fee: Other•:Wech.Insp. Other Plumb Insp. 0.0 hrs 1 $45.00 Other Elec.Ins,, 1�ech.Insp.Fee: hrrub. hrslr.Fee: Iles(nsP.Pce' NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These ees are based on the prelimina information available and are only an estimate. Contact the Det or addn'l info. FEE ITEMS (Fee Resolution 11-053 Eff 7%1;12) FEE QTY/FEE MISC ITEMS Plan Check Fee: Suppl. PC Fee PME Plan Check: $0.00 Permit Fee: .Supp1. Insp Fee PME Unit Fee: $27.00 PME Permit Fee: $45.00 Construction Tax.- Administrative ax:Administrative Fee: IADMIN $42.00 Work Without Permit? ® Yes (D No $0.00 Advanced Planning F1'�s Travel Documentation Fee: ITRAVDOC $45.00 'A Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $160.501 $0.00 TOTAL FEE: $160.50 Revised: 10/01/2012 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 GUPERTINO (408)777-3228- FAX (408)777-3333 - buildinc cui)ertino.ora 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_ _ APN BP# NER NAME � OWNER ADDRESS DESCRIPTION OF WORK: 7 C1Lx.0 �4 -ct.[l.'t o�(iJa 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.) �A'L� 1. 1 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 the construction and are not hiring a licensed Contractor to assume this responsibility. x� 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. `,sem 4. I understand Contractors are 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 considered an "employer" under state and federal law. ,A�K C 6. 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 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 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. 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. 0i571e/'Buildel'Fa"nt_2010.doc revised 04/14/10 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 1-800-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed contractors. 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the parry 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. O(L_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 signature. Property Owner's Signature: ?i , Date: 1 -------------------------------------------------------------------------------------- - - - (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 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: O4rv-Builde7-Form 2010.doc revised 04/14/10