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10090014CITY OF CUPERTI BUILDING ADDRESS: NW CORNER OF STEVENS CREEK BLVD @ FWCII OWNER'S NAME: 500 FORBES LLC 'WNER'S PHONE: 5039758733 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. # 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. NO BUILDING PERMIT 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. 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 laws relatin; 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. Signature. Date / OWNER- BUILDER DECLARATION v I hereby affirm that I am exempt from the Contractor's License Law for one iof the following two reasons: 1, as owner of the property, or my employees with wages as their sole compensatio i, 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 construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three f declarations: CJM 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, 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 Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoke L 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 laws relatij►g 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, nd expenses which may accrue against said City in consequence of the g. ..rg of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date C2" f CONTRACTOR D I PERMIT NO: 10090014 V C, � � 5 L& C.-- I DATE ISSUED: 09/02/2010 PHONE NO: BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r MECH r RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: PUMPKIN PATCH & CHRISTMAS TREE LOT - WHISPER SOFT GENERATOR FOR PUMPKIN PATCH & CHRISTMAS TREE FARM Sq. Ft Floor Area: Valuation: $100 APN Number: 31620085.ABC I Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued b� - Date: 5;�F'e, "­6 6 RE- ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I 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. Owner or authorizegen Date• °11 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 Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: B]k: Lot: APN ........: 31.620085.ABC DATE ISSUED.......: 0SI /02/2010 RECEIPT # ......... B= 000011368 REFERENCE ID # 10090014 SITE ADDRESS .....: N11 CORNER OF STEVENS CREEK BLV SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OWNER 5)0 FORBES LLC ADDRESS ..........: 2.164 EL CAMINO REAL CITY /STATE /ZIP SANTA CLARA, CA 95051 RECEIVED FROM A3C TREE FARMS, LLC CONTRACTOR .......: T3D - TO BE DETERMINED LIC # 00096 COMPANY T3D - TO BE DETERMINED ADDRESS .......... CITY /STATE /ZIP ...: TELEPHONE ........ FEE ID UNIT QUANTITY AMOUNT PD -TO -DT --- - - - - -- THIS REC NEW BAL ---------- 1BCBSC ------- - - - - VALUATION -- ---- - - - - -- 100.00 ---- - - - - -- 1.00 0.00 1.00 0.00 0.00 1EPERMITFE FLAT RATE 1.00 42.00 0.00 0.00 42.00 42.00 0.00 1ERT<200 UNITS 1.00 1.00 42.00 42.00 0.00 1TRAVDOC FLAT RATE -- ---- - - - - -- - - -- -42_00 - - - -- -0_00 TOTAL PERMIT ---- - - - - 127.00 0.00 127.00 0.00 METHOD OF PAYMENT --------------- -- CHECK TOTAL RECEIPT : AMOUNT 127.0( 127.00 VOICE ID DESCRIPTION -- - - - - -- ----------------------------- 304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL REFERENCE NUMBER --------------- - - - -- #26593 VOICE ID DESCRIPTION -- - - - - -- ---------------------- - - - - -- 402 TEMPORARY POWER CUPERTINO OWNER- BUILDER DIS,,LOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014 -3255 (408) 777 -3228 - FAX (408) 777 -333:- - building(alcuoertino.org Dear Property Owner(s): An application for a building permit has been submitted n your name listing yourself as the builder of the property improvements specified at: SITE ADD ESS Dt lC lug( h4c/ � APN �du 3S BP# e c 4� OWNER NAME OWNER ADDRESS Crjauijv M 9 DESCRIPTION OF WORK: ills Y Vr [ + 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 VERIFICATIO14 OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) 1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Builder" building permit that erroneously implies tha: the property owner is providing his or her own labor and, material personally. I, as an Owner - Builder, may be held liat le 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. ':ff 2. 1 understand building permits are not requirE�d to be signed by property owners unless they are responsible for the 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. %I� 4. 1 understand Contractors are required by la%v to be licensed and bonded in California and to list their license numbers on permits and contracts. A5. I 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 haw. L� 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' 1c;tate 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 genera building Contractor. �f 8. 1 understand as an Owner - Builder if I sell th a property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any : >ubsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerBuilderFonn 2010.doc revised 04114110 �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. 6110V0. 1 am aware of and consent to an Owner- Buildei 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. 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. L--d 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information 1 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 IicensE , 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 'ending agency information.) I hereby affirm that there is a construction lending agency -or 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 ac to le to the city may be required to be presented when the permit is issued to verifv the property owner's siqnatur . Property Owner's Signature: Date: - - - - - - - - - - - - - - - --------------------------- (NOTE: The ?-o- ollowing Authorizati Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction perriit 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: OwnerBuilderForm_2010.doc revised 04114110 Method of Operations Proposed Christmas Tree Sales ABC Tree Farms, LLC NW Corner of Stevens Creek Blvd. @ Finch Street Cupi -Irtino, CA 2010 Proposed Days are November 20`', 2010 through December 28th, 2010 for the Christmas tree sales, which will include s .-t up and tear down of the operation. Hours of operation will be Seven days a week, Sunday through Thursday we will open @ 9:30 AM and close @ 9:00 PM. Friday and Saturd,-.y we will open @ 9:00 AM and re until 9:30 PM. The area will be as diagrammed in the attached Potential Christmas T��ales _ Plot Plan. All necessary permits and approvals will be acquired from the City Cupertino. Garbage and chemical toilets, Vill be provided on the site. We will have no hazardous chemicals on our site. We are requesting the use of a 60' x 60' tent. This will be cleared through the City of Cupertino :Planning Departments. Power will be supplied through a "whisper soft" generator. Durir..g operation the generator will be grounded to a grounding road and will not be located w .thin 25 feet of tents or canopies. It will be properly diagrammed with "caution" pose ing and enclosed by a 4 foot tall fence that will completely surround the generator area and make it inaccessible to all customers, including children and animals. All lead:- into the generator will be enclosed in conduit. Traffic flows as diagrammed on the site Ilan. We are requesting that a trailer be allowed on site for use as a temporary office, storage for the manager. We will also make sure to have a section of the cashier booth to be ito higher than 34" and at least 36" wide to accommodate wheelchairs. A diagram is attached. Our application is identical to the operations we ran in the 2009 season. Items that will be sold will be Cliiistmas trees, wreaths and garlands. Anticipated attendance over the course of 30 days is E pproximately 1500 people. If you require further information please contact my project manager, Holly Prinz, @ 808 - 268 -3158 or via email @ abctreetarms!ctwahoo.com. Jerome R Klima JR Owner /Operator ABC Tree Farms, LLC Apl'Ho Vf () IN A(: ORf)ANi i .VI T H T HE CITY C4- CUPf 14 INCA //Ul1f � ANO ORDINANCES DOTE_ 71�VO SI 3NED This set of plans and spe(rficati MUsT be kef; t on the fob at all times and it is unlawful 1 o make any changes or alteration on same without written permission from the Build ng Department, City of Cupertino The stam ping of this plan and specifications SHALL 1 JOT be held to permit or to be an approva of the viol,itl,)n of any provisions of s1 City Ofdfn;]n( -e ur Mate I aw CITY OF CUPEkTINO CITY OF CUPERTINO TEMP POWER PERMIT APPLICATION FORM L� APN # i Building Address: Fee Description Owner's Name: r Phone #: �� 7 ? 6 C Jf 3 S .J Permit Type Contractor: , p l / �� 1 G� (11 Res. Temp Power >1K Amps Phone #: WY14 IREAP14 Fax #: Contact: l �� / %�� � E Phone #: Contractor License #: 1 ERT2001 K Cupertino Business License #: E Job Description:' Residential Commercial Valuation (cost of project): 6f -LO -0L / Type of Construction: � Quantity Fee ID Fee Description Fee Group Permit Type IERT >lK Res. Temp Power >1K Amps E IREAP14 IERT <200 Res. Temp Power <200 Amps E 1 ERT2001 K Res. Temp Pi wer 200-1K Amps E l EPERMITFE Electric Permit Issuance E IELCPLNCK Electric Plan Check E 1BCBSC Cal Bldg Sta:idards Commission Fee B ALL PERMIT _ TYPES 1BSEISMICR Seismic Residential B 1TRAVDOC Travel & Documentation Fee B Revised 01 /07/09