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10060031 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDTitESS: 20902 FARGO DR f209UPO2 ONT ItACTOR:ROSE KERDI PERMIT NO: 10060031 OWNER'S NAME: ROSE KERDI FARGO DR DATE ISSUED:06/07/2010 4ER'S PHONE: 4087681291 EI:TINO,CA 95014 PHONE NO: JOB U ESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ ❑ LICENSED CONTRACTOR'S DECLARATION REMO VE INTERIOR WALL AND LIGHTS IN THE GARAGE. RESTORE THE GARAGE BACK TO ORIGINAL CONDITION. 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. Sq.FI Floor Area: Valuation:$600 I hereby affirm under penalty of perjury one of the following two declarations: 1. I have and will maintain a certificate of consent to self-insure for Worker's anc Occu T e Compensation,as provided for by Section 3700 of the Labor Code,for the APN Slumber:32630115.00 occupancy Yp performance of the work for which this permit is issued. 2. 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 FERMIT EXPIRES IF WORK IS NOT STARTED permit is issued. WITHIN 180 DAYS OF PERMIT ISSUANCE OR APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is 180 DAYS FROM LAST CALLED INSPECTION. 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 Issu:d b Date: (� upon the above mentioned property for inspection purposes. (We)agree to save Y� 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 RE-ROOFS all non-point source regulations per the Cupertino Municipal Code,Section 9.18. All r)ofs 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 Signature Date inspi:ction. Signature of Applicant: Date: OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER the following two reasons: t. 1,as owner of the property,or my employees with wages as their sole HAZARDOUS MATERIALS DISCLOSURE compensation,will do the work,and the structure is not intended or offered for 1 ha ve read the hazardous materials requirements under Chapter 6.95 of the sale(Sec.7044,Business&Professions Code) am exclusively contracting with licensed contractors to California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain 2. I,as owner of the property, Y compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& construct the project(Sec.7044,Business&Professions Code). p yo Saf:ty Code,Section 25532(a)should I store or handle hazardous material. L�•� Additionally,should I use equipment or devices which emit hazardous air I hereby affirm under penalty of perjury one of the following three declarations: contaminants as defined by the Bay Area Air Quality Management District I will 1. 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 ma ntain compliance with the Cupertino Municipal Code,Chapter 9.12 and the He dth&Safety Code,Sections 25505,25533,and 25534. performance of the work for which this permit is issued. 2. 1 have and will maintain Worker's Compensation Insurance,as provided for by Ov ner 9 authorized agent: Section 3700 of the Labor Code,for the performance of the work for which this _T n p �� Date: permit is issued. 9 3. 1 certify that in the performance of the work for which this permit is issued,I shall CONSTRUCTION LENDING AGENCY not employ any person in any manner so as to become subject to the Worker's I h:reby affirm that there is a construction lending agency for the performance of work's Compensation laws of California. If,after making this certificate of exemption,I fo►which this permit is issued(Sec.3097,Civ C.) become subject to the Worker's Compensation provisions of the Labor Code,I Le nder's Name must forthwith comply with such provisions or this permit shall be deemed Lf nder's Addres revoked. P_ s APPLICANT CERTIFICATION ARCHITECT'S DECLARATION I certify that I have read this application and state that the above information is I t nderstand my plans shall be used as public records. 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 L censed Professional upon the above mentioned property for inspection purposes.(We)agree to save i •ify and keep harmless the City of Cupertino against liabilities,judgments, c nd 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. Date Signature J CITY OF CUPE:2TINO 3 ITEMS OF 3 PERMIT REC:3IPT OPERATOR: suew COPY # 1 Sec: Twp: Rng: Sub: Blk: Lo=. APN . . . . . . . . : 32630115. 00 DATE ISSUED. . . . . . . : 06/07/2)10 RECEIPT #. . . . . . • • • : BS00001)578 REFERENCE ID # . . . : 10060031 SITE ADDRESS . . . . . : 20902 FARGO DR SUBDIVISION . . . . . . . CITY CUPERTIVO IMPACT AREA . . . . . . . OWNER ROSE KERDI ADDRESS . . . . . . . . . . : 20902 FARGO DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : ROSE MA CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY ROSE KERDI ADDRESS 20902 FARGO DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 600 . 00 1. 00 0 .00 1 . 00 0 . 00 1BSEISMICR VALUATION 600 .00 0.50 0 . 00 0 .50 0. 00 1DEMORES SQ FEET 0 . 00 5C7 .00 0 . 00 507 .00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 5C8.50 0 . 00 508 .50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- --- ----------------- CREDIT CARD 508. 50 VITA --------------- TOTAL RECEIPT 508 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 704 DEMO OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTIN0 (408) 777-3228- FAX (408)777-3333 �u �rin�.crc 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 1 APN y> 7,0 OWNER NAMEOWNER DDRE!;S �T YI.O G j—p S�a"I iv1 oy � v�� � DESCRIPTION OF WORK: vk o V 9_1e. �A aY(L a 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 t:)signify you understand or verify this information.) 1. I understand a frequent practice of unlicensed per:ons is to have the property owner obtain an "Owner - uilder" building permit that erroneously implies that the pi operty 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 F-w% 2. 1 understand building permits are not required to b 3 signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor t assume this responsibility. ,P—YA 3. 1 understand as an "Owner-Builder" I am the respc nsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licer sed Contractor and having the permit filed in his or her name instead of my own. L4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. f�5. I understand if I employ or otherwise engage any cersons, 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. 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 worki;rs' compensation disability insurance, and contribute to unemployment compensation for each "employee." I alsc understand my failure to abide by these laws may subject me to serious financial risk. 4y'^ 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 dons not exceed four within any calendar year, or all of the work is performed under contract with a licensed general builcing Contractor. f'r 8. 1 understand as an Owner-Builder if I sell the pro)erty for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsE quent owner(s)that result from any latent construction defects in the workmanship or materials. O�n7erBuilderForm_2010.doc revised 04/12/10 �O 9. 1 understand I may obtain more information regarding my obligations as an "employer"from the Internal Revenue Service,the United States Small Business Admini:;tration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also unc erstand 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. �10. I am aware of and consent to an Owner-Builder bu Iding permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the following address: X11. I agree that, as the party legally and financially res)onsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. 2. 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 a resL,lt of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for yon 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 .) 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: Af A 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 agenc.1 is required to be presented when the permit is issued to verify the property owner's signature. Signature of property owner: Date: AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF N (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 `or the Owner-Builder). 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 owne-for the address listed above and I personally filled out the above information and certify its accuracy. Note:A copy of tho owner's driver's license, form notarization, or other verification acceptable to the agency is required to be presen ed when the permit is issued to verify the property owner's signature. Property Owner's Signature: l�h l'> / .�_ Date: Ox7nerBuilderFoi-m_2010.doc revised 04/12/10 CITY OF CUPERTINO DEMO CITY OF CUPEkTINO PERMIT APPLICATION FORM 10�(e6rj ' APN# Date: 617110 Building Address: 0�0 WO Mailing Address (if different from building address): Owner's Name: Phone: Contractor: 0WNER1 3 u1 LDS )Q Phone : Fax: Contractor License #: Cupertino Business License #: Contact: Phone: �o F— 7�,f/�-y / SE NIA Fax: Residential Sq Footage 1�l o Commercial ❑ Sq Footage Job Description: mU��e ;n eyi0 Y GJ.�// n„ ;��' S ;7n 1��t-� �f et y'`���. Resin Valuation: foo. Project Size: ess Standard ❑ Large [] Major ❑ Please complete relevant portions of the Green Building Checklist & attach it to the application or if applicable, include on the plan set & the sheet index. Quantity Fee ID Fee Description _Fee Group Permit Type 1DEMORES Demo-Residf;ntial B 1SFDWL-DEM 1DEMOPRES Pool Demo Residential B 1SFP00L-DEM7 1BCBSC Cal Bldg Standards B ALL PERMIT Commission Fee TYPES 1BSEISMICRE Seismic Residential B Revised 01/07/09