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13050062CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19133 MURIEL LN CONTRACTOR: DAVID MIGUEL PERMIT NO: 13050062 OWNER'S NAME: DAVID MIGUEL 19133 MURIEL LN DATE ISSUED: 05/07/2013 OWNER'S PHONE: 4087813283 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIALE] DEMO ACCESSORY STRUCTURE, AS PER BUILDING & License Class Lic. # PLANNING REQUIREMENTS (APPROX 872 SQ FT) 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: $2000 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 37508008.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAY 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 D S 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 r Is Da— te: 1 �7 granting of this permit. Additionally, the applicant understands and will comply y: with all non -point source regulations per the Cupertino Municipal Code, Section RE- ROOFS: 9.18. 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. 931- OWNER - BUILDER DECLARATION Signature of Applicant: Date: I 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 I, 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) I, 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 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(x) 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 Section 3700 of the Labor'Code, for the performance of the work for which this the Health & Safety Code, Sections 2550 25533, and 25534. Owner or authorized agen : Dater 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 snaking 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. z Date l Signatur CUPERTINO DEMOLITION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • buildings cupertino.ora �o PROJECT ADDRESS / ' APN # 15 OF r 0019 Tc3 OWNER NAME A00 +&Y/V-44 ' ` uiF� . /V1 (� PH ) 781-32C E -MAIL �V�� • /' /�itiF(i�i s� G7GQW�c STREET ADDRESS 9 (-3-!5 � t• -(zdGx- � • CITY, STATE, ZIP CC( �iinl0, 6;A 9571IV FAX 37o — Z92 CONTACT NAME &Ut.D X4 ' to " G7L PHON a) 7e l_3 Z r 2 / E -MAIL „� STREET ADDRESS % A15 /4j" J& An � CITY, STATE, ZIP FAX Fr'0WNER ❑ OWNER - BUILDER ❑ OwNERAGENT ❑ 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 DESCRIPTION OF WORK; Ent o L s f-f 6 Z) E��� /W"P" . 8 2 RESIDENTIAL # DWELLING OFFICE USE ONLY - USE OC . TYPE SO. Fr. VALUATION - FLOOR AREA UNITS COMMERCIAL FLOOR AREA TYPE OF CONSTRUCTION # STORIES AQMD JOB NUMBER r I RE D BY: UATION: J #: N 4 A By my signature below, I certify to eaA of the following: I am the property er or auth ' ed a to act on 4ZSpVe5rty owner's behalf. I have read this application and the information I have provided is correct. I have read the Descriptio and verify it is rate. I agree to comply with all applicable local —Work ordinances and state laws relating to building construction. I authorize representatives of upertino to enter the above - identified property for inspection purposes. Signature of Applicant/Agent: Date: 7 SUPPLEMENTAL INFORMAT N REQUIRED PRIOR TO ISSUANCE OF DEMOLITION PERMIT OFFICE USE ONLY PLAN CHECK TYPE Provide Job Number from Bay Area Air Quality Management District www.baagmd.org @ 415- 749 -4762. EXPRESS Provide three copies (Residential) or six copies (Commerical) of a site plan showing protection for any trees 10" in diameter or more at 3' above grade. STANDARD _Provide letter from PG &E (408- 725 -3325) stating all gas and electric has been disconnected. ❑ LARGE MAJOR 'rile Provide a letter of inspection, tests, and abatement of any Hazardous Materials. Letter to be initiated by person(s) certified in asbestos, mercury and/or hazardous material examination. Planning Dept building is _ clearance to verify not considered an historical landmark. Allow 10 business days. Provide letter of clearance of all vermin from a licensed pest control contractor. J _ Applicant shall call the Public Works Department at 408 - 777 -3104 and schedule a "habitable dwelling" inspection. Provide signed Debris Bin and Recyclable Materials form. DemoApp_2013.doc revised 02113113 vt—:F T CITY OF CUPERTINO 1VF1W 1P.QT111%4ATnR — RITILDING DIVISION IC FEE ED FLR AREA (s.f.) 1DEMORES 872 R A -h. Man Check Plumb. Plan ('heck Elec. Plan (7heck ,lec I I I I I I F-1-7,A Permit Fee: FF lumb. Permit Fee: Elec. Permit Fee: Other Xlech. Insp. Other Plumb Insp. Other Elec. lny. Allech. Insp. Fcv: Plumb. Insp, Fee., Elc,(. . Insp. Fee: NOTE: This estimate does not include fees due to other Departments (Le. manning, ruotic ryorKs, rtre, Sunitury 5ewerut3timi, "�fffvug •L... - -I ------ rnntart the Dent for addn7 info. FEE ITEMS (&e Resolution 11-053 Eff. 711112) ADDRESS: 19133 MURIEL LN DATE: 05/07/2013 REVIEWED BY: MELISSA Plan Check Fee: APN: 375 08 008, 1 BP#: *VALUATION: 1$2,000 *PERMIT TYPE: Demolition Permit PLAN CHECK TYPE: PRIMARY SFD or Duplex I PENTAMATION 1SFDWL-DEM I PERMIT TYPE: USE: Permit Fee: 'A WORK DEMO ACCESSORY STRUCTURE, AS PER BUILDING & PLANNING REQUIREMENTS (APPROX SCOPE 1872 SQ FT) FEE ED FLR AREA (s.f.) 1DEMORES 872 R A -h. Man Check Plumb. Plan ('heck Elec. Plan (7heck ,lec I I I I I I F-1-7,A Permit Fee: FF lumb. Permit Fee: Elec. Permit Fee: Other Xlech. Insp. Other Plumb Insp. Other Elec. lny. Allech. Insp. Fcv: Plumb. Insp, Fee., Elc,(. . Insp. Fee: NOTE: This estimate does not include fees due to other Departments (Le. manning, ruotic ryorKs, rtre, Sunitury 5ewerut3timi, "�fffvug •L... - -I ------ rnntart the Dent for addn7 info. FEE ITEMS (&e Resolution 11-053 Eff. 711112) FEE QTY/FEE L MISC ITEMS Plan Check Fee: A Suppl..K., Fee Permit Fee: $534.00 Suppl. Insp. Fee.(E) Reg. 0 OT 0,0 hrs $0.00 Plwnb.111e(.42-11sIec Plumb.111ech./1Iee Permit Fee: (','onsiruction Tax: F-1 Administrative Fee: J,Vork Without Permit? ,I dvanced Planning Fees: Trai>el Documentation Fees: Strong Motion Fee: 1BSEISAffCR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00, $535.501 01TAA $0. 00 -W Revised: 04/29/2013 P-60 L) I R-6meq 75 40 N ;Z. --S 2`r ( z vv, Ro ge b-amof,fs k ap 'Dra WAY '21-7 it RTY L I HE* A-If-frl �T s W NEVJ ?�Vf-:67b \0 (,0h(,j%TE PAD WiZ - MAIM rA#11L\/ UMIT m JEW q-g, 0,UPERbN0 1P Uepartment - MAY 0 7 2013 MAY 7 2013 REVIEWED FOR CODE COMPLIANCE Reviewed f3y. +Cy&ct)A a q 1133 .,_m U p- I fit._ 08 --l—A go I Li) I rOCIPLAN /V I II16 C0'1\4m,!-!r,jlTy E!'7 D'71DART1,1- Al �E zNF I iNo 7-5 tO T job ,t�H-e, dur;ng at the the-re-ft,orn, Without, app, or -�c jal fr.3,-,j The c*= !-:7ping of thl,,� p -d IC SP ")T 0! Gft'/ Or B TC- PERMIT NO. 13 - MAIM rA#11L\/ UMIT m JEW q-g, 0,UPERbN0 1P Uepartment - MAY 0 7 2013 MAY 7 2013 REVIEWED FOR CODE COMPLIANCE Reviewed f3y. +Cy&ct)A a q 1133 .,_m U p- I fit._ 08 --l—A go I Li) I rOCIPLAN /V I II16 CUPERTINO OWNER- BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 - buildincia-cupertino.org 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, .q EG�� 1 APN3 O 8 60� BP# O O V /'2_ OWNER NAME �-vt G nrDA ttm6, OWNER ADDRESS IA(' &tJ0a77^fv lad Q�Di�F DESCRIPTION OF.WORK:. R&KWO, 0/t- 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. (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information) . I understand afrequent 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. 1, 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. �. I 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. '^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. CtL- 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. . 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" understate and federal law. I understand If I am considered an "employer" understate 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. . I 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. I 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. OwnerBuilderForm 2010.doc revised 04114110 i &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 -CSL13 (2752) or www.cslb.ca.gov for more information about licensed contractors. 402-110. 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. 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. 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 pubiic. 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.) 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 owners driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to veri fy the property owner's si nature Property Owner's Signature: Date: 7 - - -- ----------------------------------------------------------------------------------------------------- -- -- - - -- - -- - -- ----- - - - - -- - (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)16 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 drivers 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 owners signature. Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revised 04114110 JOB ADDRESS: IT, 3 PERMIT # : '0V�¢O Z- OWNER'S NAME: 4 -(/6,h i�LC� Gf�(i PHONE # GENERAL CONTRACTOR: BUSINESS LICENSE #` ADDRESS: CITY /ZIPCODE: *Our municipal code requires all businesses working in the.city to have. a City of'Cupertino business license. , NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL; BE .;SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE'OBTATNED A :CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: r f Signature Date Please check applicable subcontractors and complete the following information SUBCONTRACTOR = BUSINESS NAME ; BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing IX 14 Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock - Tile Owner / Contractor Signature Date CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 19133 MURIEL LN CONTRACTOR: DAVID MIGUEL PERMIT NO: 13050062 OWNER'S NAME: DAVID MIGUEL 19133 MURIEL LN DATE ISSUED: 05/07/2013 OWNER'S PHONE: 4087813283 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIALS License Class Lic. # CONVERT DETACHED LIVING UNIT BACK TO PERMITTED USE Contractor Date AS U OCCUPANCY GARAGE, DEMOLISH ADDED I hereby affirm that I am licensed under the provisions of Chapter 9 STORAGE (commencing with Section 7000) of Division 3 of the Business & Professions STRUCTURE 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. 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 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 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: I, 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) I, 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 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 Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. 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 Sq. Ft Floor Area: I Valuation: $2000 APN Number: 37508008.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Date: 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 compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: 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 Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19133 MURIEL IN I CONTRACTOR: DAVID MIGUEL PERMIT NO: 13050062 OI WNEWS NAME: DAVID MIGUEL 1645 PEACHWOOD DR DATE ISSUED: 05/07/2013 I OWNER'S PHONE: 4087813283 1 SAN JOSE, CA 95132 1 PHONE NO: ❑ 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. 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 tjyg�® permit is issued. • pe 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 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: I, 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) I, 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 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 Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. 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. ;�_ P /) - JOB DESCRIPTION: RESIDENTIAL SEE REVISION - BELOW. CONVERT DETACHED LIVING UNIT BACK TO PERMITTED USE AS U OCCUPANCY GARAGE, DEMOLISH ADDED STORAGE STRUCTURE REVISION #I- REVISE PLANS - REMOVE NON PERMITTED DETACHED LIVING UNIT- ISSD OTC 8/22/2013 ISq. Ft Flo Area: f I Valuation: $2000 I . ` 37508008.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 00 DAYS OF PERMIT ISSUANCE OR 180 DAY F M LAST CALLED INSPECTION. Issued by: DaJl,vW /3 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 compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 255 , 533, and 25534. Owner or authorized agent: Date: ZZ 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 I PR,.Pe RTY L t KW' O� , Td ge Ci) toy a 3 PgFENT DEPA 1 M! NT BUILDING DlVj SION - CUPER T I , 0 p��4F yF,j�'yp.cx �q ¢R° f f U A @ R K1` This set of plans and specifications MUS be k,--D',- at the iob i 5= rii 1 tr` 4i'-l�jn. it �i jl�t�li t'_ J Y�r �.li cf j \� changes or ;era'gicns on same, or vi :e J �1 therefrom, witho t approval trcrn the d .' Re�` The stamping of t s I n �4' "�Iflcatio' �,i-?A .1 N - r be he f Fmi L' . any -10. City Ordinance , DAT 8 2.3 --�� PERMIT NO. t'0 - -- - s, s 3 t ' - -vr i f uiiding kJ _a i REVIEw MAY i 21 Review dCR CppE ©MPLiANCE '; � ey. � ��liM p A GLfriK S 0 ¢'Y Sj)2U C,-r J 1Z� R" U 1 R.fd A >N3