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10090164 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 874 BRENT DR CONTRACTOR:PATEL SUMITRA PERMIT NO: 10090164 OWNER'S NAME: PATEL SUMITRA 874 BRENT DR DATE ISSUED:09/17/2010 WNER'S PHONE: 4084184706 CUPERERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL C1 COMMERCIAL License Class Lic.# REMOVAL OF EXISTING 300 SQ FT ILLEGAL STRUCTURE IN Contractor Date THE REAR OF SFDWL 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:$100 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 APN Number:36924031.00 Occupancy Type: 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.I agree to comply with all city and county ordinances and state laws relatin; WITHIN 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 DAYS FROM 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 Issued Date: granting of this permit. Additionally,the applicant understands and will comply b 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 _ installed without first obtaining an inspection,I agree to remove all new materials for inspection. Qf • OWNER-BUILDER DECLARATION Date: Signature of Applicant: I hereby affirm that I am exempt from the Contractor's License Law for one )f 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 compensatic n, will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) HAZARDOUS MATERIALS DISCLOSURE I,as owner of the property,am exclusively contracting with licensed contractors to 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 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 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: permit is issued. I certify that in the performance of the work for which this permit is issued,I shal 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 Co� work's for which this permit is issued(Sec.3097,Civ C.),I m ist 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 tc�yd d. 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 anon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION nnify and keep harmless the City of Cupertino against liabilities,judgments. a,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 �� � Date ' CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk : Lot: APN . . . . . . . . : 36524031. 00 DATE ISSUED. . . . . . . : 09/17/2010 RECEIPT #. . . . . . . . . BSC00011490 REFERENCE ID # 10090164 SITE ADDRESS . . . . . : 87L: BRENT DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER PATEL SUMITRA ADDRESS . 874 BRENT DR CITY/STATE/ZIP CU?ERERTINO, CA 95014 RECEIVED FROM SUAITRABEN PATEL CONTRACTOR LIC # *OWNER* COMPANY PArEL SUMITRA ADDRESS . 874 BRENT DR CITY/STATE/ZIP CUPERERTINO, CA 95014 TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- --- 00 1BCBSC VALUATION 100 .00 1. 00 0 .00 1 . 00 0 • 1BSEISMICR VALUATION 100 .00 0 .50 0 .00 0 . 50 0 . 00 1SUPINSFEE HOURS 2 .00 252 . 00 0 .00 252 . 00 ----- 0 . 00 - --------- ---------- ---------- TOTAL PERMIT 253 .50 0 .00 253 . 50 0 . 00 METHOD OF PAYMENT AMOUNT -- - REFERENCENUMBER-- --------------- ----------------- CHECK 253 .50 1140 --------------- TOTAL RECEIPT 253 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- --------------------------- -------- -------------------------- 704 DEMO OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, C4 95014-3255 (408)777-3228•FAX(408)777-3333-bui din(a�cuoertino.or9 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 -4 Lr ' �&RESS R 2 ZI o31 BP# OWNER NAME Com )sz t-l' a (04wtOWNER C ��� e� IDESCRIPTION OF WORK: rification rm to make you aware We are providing you with an Owner-Builder y incur by hav,nt and this permit issued on in your amoe as the Owner-Builder. We your responsibilities and possible risk you may enc y 9 will not issue a building permit until you have read, ate�iinitia! An agent oathe ownergannot execute th noticesned your unerstaninof each provisio , signan sd returned this form to us at our official address of the a�mitting authority. you,the property owner, obtain the prior approval P OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) 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 actinc, as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my propi)rty. 2. 1 understand building permits are not required :o be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contrac.or to assume this responsibility. that I 3. I understand as an"Owner-Builder" I hminhea licensed Contractorrecord having the permit filed in sdor her may protect myself from potential financial risk by 9 name instead of my own. w i o be licensed and bonded in California and to list their license 4. I understand Contractors are required by la numbers on permits and contracts. ge any persons,other than California licensed Contractors, and the 5. I understand if I employ or otherwise enga 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 lave. under state and federal lawI must ister with the state 6. 1 understand if I am considered an"employee empl de viorkers'ompensat on disability insurance,and contribute and o federal government,withhold payroll taxes, prove unemployment compensation for each"employee." I also understand my failure to abide by these laws may subject me to serious financial risk. er uilds 7. 1 understand under California Contractoweintent tLicense o offerLaw,themOan for sae, udnlesshalbwork ssingle-family performed by residential structures cannot legally build them with Ihe 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 ouilding Contractor. 8. I understand as an Owner-Builder if I sell thE:property for subsequent owneir(s)thach this t any latent s issued, I maybonstrudctionle for any financial or personal injuries sustained by any defects in the workmanship or materials. OwnerBuilderForm_2010.doc revised 04/14/10 5:,p9. 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 al,--,o understand I may contact the California Contractors' State License Board (CSLB)at 1-800-321-CSLB (2752)or%Nm.cslb.ca.gov for mere information about licensed contractors. S-P 10. 1 am aware of and consent to an Owner-Builcler building permit applied for in my name, and understand that I am the party legally and financially responsible for prc posed construction activity at the site address listed above. S-IP 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 Cwner-Builders as well as employers. GX' 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as 3 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 a responsible for verifying whether or not those Contractors are properly licensed and the statu 3 of their workers'compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS:Please complete the following constructicn lending agency information.) 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: !EF�i Lencler Address: Before a building permit can be issued,this form must be completed and.igned 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 c'ty may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: S,N,r„4 ag, Date: -1 1 I--1- a -- -- - - ------------------- - ---------------------------------------------------------------------- (NOTE: The-following--Authorization- - --Form is required to 1)e 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 c wner for the address listed above and I personally filled out the above information and certify its accuracy. Note:A copy :)f 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: Gate: OwnerBuilderFonn 2010.doc revised 04/14/10 CITY OF CUPERTINO DIKMO COPE CITY OF PERMIT APPLICATION FORM kTINO AP:N# - Date: to Address: `� Building A Mailing Address (if different from building addr-Iss): Owner's Name: Phone: 61 a J-4 AA A Phone contractor'. Fax: Contractor License if Cui)ertino Business License #: Phone: Contact: Fax: =Fax: (40D) 7 Residential JZ Sq Footage Commercial E] Sq Footage Job Description: Valuation: /06 Project=Siize: Express [�J-�StandardF* LargeF-1 Major ❑ Express -en Building Checklist & attach it to the application "m Pte rel Please complete relevant portions of the Gr( or if applicable, include on the plan set & the sheet index. Type e 1DEMORES Quantity Fee ID Fee I)escription Fee Group. Permit Tit yp Demo--lesidential B 1SFDWL-DEM 1DEMOPRES -iiolD1-mo Residential B 1SFP00L-DEM- 1BCBSC Cal Bldg Standards B ALL PERMIT Commission Fee TYPES IBSEISMICRE Seismiz: Residential B Revised 01/07/09