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10090205CITY OF CUPERTI140 BUILDING PERMIT I BUILDING ADDRESS: 10218 PASADENA AVE OWNER'S NAME: D & B LEGACY LLC CONTRACTOR: D & B LEGACY LLC 10164 CARMEN AVE gER'S PHONE: 4082344835 CUPERTINO, CA 95014 LICENSED CONTRACTOR'S DECLARATION Icense Class Lic. # .ontractor Date hereby affirm that I am licensed under the provisions of Chapter 9 commencing with Section 7000) of Division 3 of the Business & Professions .ode and that my license is in full force and effect. hereby affirm under penalty of perjury one of the following two declarations: have and will maintain a certificate of consent to self-i9sure for Worker's compensation, as provided for by Section 3700 of the Labor Code, for the >erformance of the work for which this permit is issued. 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 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. Signature Date OWNER -BUILDER DECLARATION PERMIT NO: 10090205 DATE ISSUED: 09/21/2010 PHONE NO: BUILDING PERMIT INFO: BLDG F ELECT r— PLUMB I— MECH r— RESIDENTIAL r COMMERCIAL I hereby affirm that I am exempt from the Contractor's License Law for one c f the following two reasons: I, as owner of the property, or my employees with wages as their sole compensatim 1, 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 withb en'sed/ ors to construct the project (Sec.7044, Business & Professions Cod- I 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, 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 Co u st forthwith comply with such provisions or this permit shall be deemed re APPLICANT CERTIFICATION JOB DESCRIPTION: TEMP POWER POLE 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 relati ug to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save unify and keep harmless the City of Cupertino against liabilities, judgments, , and expens w ich may accrue against said City in consequence of the granting of this a Addition ly, the applicant understands and will comply with all non -point s e regulati s per the Cupertino Municip Code Section 9.18. _ _ Signature Date 2 Sq. Ft Floor Area: I Valuation: $1000 APN Number: 35718021.10218 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. G1 Issued by" Date: L 11_ . _= 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 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 co liance with the Cupertino Municipal Code, hapter 9.12 and the Health & f Code,kSections 25505, 25533, and 2 534. i Owner Or iz t: Z 1 ( a Date 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 5 ITEMS OF 5 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 35718021.10218 DATE ISSUED.......: 09/21/2010 RECEIPT #......•••: BE000011526 REFERENCE ID # ...: 1C090205 SITE ADDRESS 1C218 PASADENA AVE SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OWNER D & B LEGACY LLC ADDRESS . 10164 CARMEN AVE CITY/STATE/ZIP CUPERTINO, CA 95014 RECEIVED FROM D & B LEGACY,LLC CONTRACTOR .......: LIC # *OWNER* COMPANY D & B LEGACY LLC ADDRESS . 1)164 CARMEN AVE CITY/STATE/ZIP CUPERTINO, CA 95014 TELEPHONE ......... OPERATOR: patg COPY # : 1 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT ---------- THIS REC ---- NEW BAL ---------- 1BCBSC ------------- VALUATION ---------- 1,000.00 ---------- 1.00 0.00 1.00 0.50 0.00 0.00 1BSEISMICR VALUATION 1,000.00 0.50 0.00 0.00 42.00 0.00 IEPERMITFE FLAT RATE 1.00 42.00 42.00 0.00 42.00 0.00 1ERT<200 UNITS 1.00 1.00 42.00 0.00 42.00 1TRAVDOC FLAT RATE ---------- ---------- ------0_00 ---------- 127.50 0.00 127.50 0.00 TOTAL PERMIT METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT : AMOUNT --------------- 127.5C --------------- 127.5( VOICE ID DESCRIPTION -------- ---------------------------- 402 TEMPORARY POWER REFERENCE NUMBER -------------------- #1083 VOICE ID DESCRIPTION -------- ---------------------------- CITY a -F CUPERTINO No FEE ESTIMATOR - BUILDING DIVISION APPLIANCE / EQUIP TYPE FEE ID DATE: REVIEWED BY: 11alADDRESS: APN: BP#: *VALUATION: j$1,000 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY USE: SFD or Duplex 707AL FOO 41%/1"ll: PENTAMATION 1REAP14 PERMIT TYPE: WORK Pct-rnit f`e>e� SCOPE Suppl. Irisp 1"Ce APPLIANCE / EQUIP TYPE FEE ID ,x;,F d,, 1'hm C:1 , .. QTY UNITS BP FEES Elec. Permit Fee: IEPERMIT Temporary Power 1 ERT<200 Other Elec. Insp. 0.0 hrs $42.00 100 Amps $42 Pct-rnit f`e>e� Suppl. Irisp 1"Ce PME Unit Fee: :;42.00 PME Permit Fee: :42.00 ('oilso-11clion IOx .1couslical 1&,viciv Fec': Work Without Permit? 0 Yes 0 No $0.00 TOTALS: Travel Documentation Fee: ITRA VDOC Travel $42.00 Strong Motion Fee: NOTE. These fees are bated on the nreliminary informatu in available and are only an estimate. Contact the Dent for addn V info. FEE ITEMS (&e Resolutiorn 09-05I Ef'. '.%'l.%IOZ t,"c( /v / ',m ,x;,F d,, 1'hm C:1 , .. Elec. Plan Check 0.0 hrs $0.00 it ._�,. Aru%r VI-", � rrn�f�, t' ern f I�ae. Elec. Permit Fee: IEPERMIT (?rhe r ;it th. r`n";, �)rr���� T'1�r,n1, Irt >> Other Elec. Insp. 0.0 hrs $42.00 PME Plan Check: $0.00 NOTE. These fees are bated on the nreliminary informatu in available and are only an estimate. Contact the Dent for addn V info. FEE ITEMS (&e Resolutiorn 09-05I Ef'. '.%'l.%IOZ FEE QTY/FEE MISC ITEMS Muir Check SlIppl. PC ,-CV PME Plan Check: $0.00 Pct-rnit f`e>e� Suppl. Irisp 1"Ce PME Unit Fee: :;42.00 PME Permit Fee: :42.00 ('oilso-11clion IOx .1couslical 1&,viciv Fec': Work Without Permit? 0 Yes 0 No $0.00 Mannino FCC . - Travel Documentation Fee: ITRA VDOC Travel :142.00 Strong Motion Fee: $0.50 Select an Administrative Item Bldp- Stds Commission Fee: IBCBSC $1.00 SUBTOTALS:' $127.50 $0.00 TOTAL FEE: $127.50 Revised: 9/14/2010 OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 - b,ildin_q@_c_uRertino.org CUPERTINO Dear Property Owner(s): ourself as the builder of the property An application for a building permit has been submitted in your name listing y improvements specified at: 'ITAPN I BP# SITE ADDRESS /02-/S- OWNER 0Z/G OWNER NAM OF OWNER ADDRESS / r ! D TV -1 n Form to make you aware We are providing you with an Owner -Builder Acknowledgment t th s pend rmit issued on in youroname as the Owner -Builder. We your responsibilities and possible risk you may encu y 9an will not issue a building permit until you have read, An agent oathe ownergannot execute th noticesnudn�les s returned this form to us at our official address inda you, the property owner, obtain the prior approval of the pi:rmitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIT IONS: Please read and initial each statement be'ow to signify you understand or verify this information.) 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an °Ownerer" 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 IiablE and subject to serious fin M cihomeowneral risk ffor an insurance sustained may nby an unlicensed person and his or her employees while working on my property. Y provide coverage for those injuries. I am willfully actir g as an Owner -Builder and am aware of the limits of my i urance coverage for injuries to workers on my property. 2. 1 understand building permits are not requirec, to be signed by property owners unless they are responsible for construction and are not hiring a licensed Contra ;tor to assumeresponsibility 3. I understand as an "Owner -Builder" I am the -esponsible party of record on the permit. I understand that I may rotect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her Te instead of my own. 4. 1 understand Contractors are required by lav, to be licensed and bonded in California and to list their license rrtbers on permits and contracts. 5. 1 understand if I employ or otherwise engagE any persons, other than California licensed Contractors, and the tai value of my construction is at least five hundred dollars ($500), including labor and materials, I may be onsidered an "employer' under state and federal law. the state I must 6. I understand if I am considered an "employer�ounder s' compensfederal ation on disability insurance, contribute to d r with ederal government, withhold payroll taxes, provide unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject to serious financial risk. s single-family L&/ 7. 1 understand under California Contractors' ;eLicensintent to offer�theman Ofor sale uiudnlesser halbwodrk is performed by residential structures cannot legally build them N 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. liab 8. I understand as an Owner -Builder if I sell tf'e property for subsequent owneich this r(s) thapresuiltifrom any latent s issued, I maybonstructonle for y financial or personal injuries sustained by any q defects in the workmanship or materials. avnerBui/derForm_2010.doc revised 04/14/10 my ons as an "employer" from the Internal L9. I understand I may obtain more information regaidnist ationbl he'Califb mia Department of Benefit Payments, Revenue Service, the United States Small Business Adr rnia Contractors State and the California Division of 321CSLB (2752) orrlso wHw.cdslb cangovnfor mare infoay conct rmation oln about licensed License Board (CSLB) at 1 -800 -321 -Cal 8000-- ntractors. 10. 1 am aware of and consent to an Owner-Builde - building permit applied for in my name, and understand that I the party legally and financially responsible for proposed construction activity at the site address listed above. 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide all applicable laws and requirements that govern Oti ner-Builders as well as employers. f any additions, ldeletions, or changes to any of the 12. 1 agree to notify the issuer of this form immediately ontraco�s a e regulated by laws designed o protect the public. If formation I have provided on this form. License be unable to against unlicensed you contract with someone who does not have a asna license, of a complaint. Yourte only remedy 9 y assist you with any financial loss you may Contractors may be in civil court. It is also important fo you to understand thaou may be held liable for damages. If employee of that individual or firm is injured while worts ing on your property, i be responsible for verifying whether or not you obtain a permit as Owner -Builder and wish to hire Contractors, y P those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following constructio�i lending agency information.) hereby affirm that there is a construction lending age for the performance of the work for which this permit is issued I Y (Sec 3097 Civ.) Lenc er Address: Lender Name: nd signed by the property owner and Before a building permit can be issued, this form m er be completed y oft a property owner's driver's license, returned to the agency responsible for issuing the permit. Nbeerquiirred to be presented when the permit is issued form notarization, or other verification acceptable to the cif may to verify the property owner's signature. Date: Property Owner's Signature: owner onl when designating an - --------------------------------------------------------------------------------------------- ----------------------- to e comp ed by the (NOTE: The following Authorization for a construction pbrmit for thte Owner-Builder).Y y agent of the property owner to apply AUT HORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF apply for, sign, and file the documents necessary to obtain an Excluding the Notice to Property Owner, the execution to I understand is my personal responsibility, I hereby authorize the following person(s) to act as my agent(s) PP Y 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: personallyfilled out the I declare under penalty of perjury that I am the properfi� of the ner f� o ert the downer's drdress ivers er's license,above and ) om notarization, or other above information and certify its accuracy. N e: A copy P p Y owner's verification acceptable to the ci be req iced to b : presented when the permit is issued t ver' the property signature. __ - Z Date: Property Owner's Signature: OwnerBuilderForm_2010.doe revised 04/14/10 CITY OF CUPEi�TINO APN # Building Address: Owner's Name: Contractor: CITY OF CUPERTINO TEMP ]POWER PERMIT APPLICATION FORM L Lc - Contractor License #: C'unertino Business License #: Job Description:, Ncqor"C- Residential � it CI �� �? 2 t Group Permit Type E 1REAP14 E E E E B B B ALL PERMIT TYPES Revised 01 /07/09 Valuation (cost ofproject): Quantity Fee ID Fee Descripti F�n IERT>1K Res. Temp Power >1K Am s IERT<200 Res. Temp. Pcwer <200 Am s 1 ERT2001 K Res. Temp Power 200-1 K Amps lEPERMITFE Electric Permit Issuance IELCPLNCK Electric Plan Check 1BCBSC Cal Bldg Standards Commission Fee 1BSEISMICR Seismic Residential 1TRAVD0C Travel & Documentation Fee it CI �� �? 2 t Group Permit Type E 1REAP14 E E E E B B B ALL PERMIT TYPES Revised 01 /07/09