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13080217 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10290 FARALLONE DR CONTRACTOR:PELLE HEATING&AC PERMIT NO: 13080217 INC OWNER'S NAME: LEE DOUGLAS C AND NOONAN KELLE 3751 D CHARTER PARK DR DATE ISSUED:08/28/2013 OWNER'S PHONE: 4085373221 SAN JOSE,CA 95136 PHONE NO:(408)978-7060 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL0 COMMERCIAL 13 License Class 4C—Z U Lic.# ���'�� REPLACE FURNACE, 10 SUPPLY ADD A/C TO NORTH � / SIDE ContractorCl � � 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 'Pfrformance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$9390 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:36930014.00 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 relating 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 D:7M LAST CALLED IN CTI N. indemnify and keep harmless the City of Cupertino against liabilities,judgments, r7 costs,and expenses which may accrue against said City in consequence of the Issued b Date: granting of this permit. Additionally,the applicant understands and will comply Y' 2�/7 with all no -point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date2� Ali 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. ❑ 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(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 this14 6 permit is issued. Owner or authorized agen Date 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 CONSTRUCTION LENDING AGENCY 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. Signature Date GENERAL PERMIT APPLICATION MEP G .>' COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION •10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 - (408)777-3228•FAX(408)777-3333•building&-cupertino.orq CMISC UPERT] ;0 ❑PLUMBING. MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECr ADDRESSJrA0APN# /„ D/ q 30 OWNER NAMELk A. PHONE O%'J c Quuob ([/ STREET ADDRESS 1TY STA ENIP FAX IT DAD Rmllne, MM CONTACT NAME PHOS O(DMAII a� 'TV D STREET ADDRESS STA O ZIP S FAX a ' ORB 7fJJO ❑ OWNER OWNER-BUILDER '❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑'TENANT . CONTRACTORNAME LICENSE NUMBERLICINSE TYPE/� /►� BUS.LIC# V. COMPANY NAME j(�q I gC)M14 AIL E-MAIL FAX-gob n STREET ADDRES$; CITY,STATE,ZIP T p, PHON `I O • Uu� ARCHITECT/EIJGINBERLAAME LICENSE NUMBER BUS.LIC# i COMPA'NYNAMLI E-MAIL FAX STREET ADDRESS j j CITY,STATE,ZIP PHONE USE OF SFljgc DUPLEX © MULT[•FAMILY PROJECT IN WILDLAND ❑ YES PROTECT IN ❑YES IS THE BLDG AN ❑YES BUILDING:,:, [3 COMMERCIAL URBAN INTERFACE AREA X NO FFLOOD ZONE NO EICHLER HOME? ❑NO DE$CR1PT8144V 61kigoo A{ yy Q i4`�+.. I . ''' d TOTALYAT�UgTION �' By iiry srgnatwo below,I.certify to each of the following: I am the property owner or authorized agent to act oA the p rty owner's behalf. I have read this apphcatlo»and, Ie tn#ormat�on.I have rovided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local: ordinances and'stafe Taws r to uI g construction. I authorize representatives of Cupertino to enter the abov4-identified property for inspection purposes. S Igltature of Apel►'ant/Agent Date: 2� SUPPbEMENTAL INFORMATION REQUIRED j 0,..:i� i MEPMiscApp_201 Ldoc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION ADDRESS: 10290 farallone dr DATE: 08/28/2013 REVIEWED BY: mendez APN: BP#: *VALUATION: 1$9,390 —� %PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY SFD or Duplex PENTAMATION FURN/AC USE: PERMIT TYPE: WORK [[e lace furnace 10 supply add a/c to north side of sfdwl SCOPE y Mech.Plan Check "00 $0.00 Plumb.Plan Check Elec.Plan Check Meeh.Permit Fee: IMPERMIT Plumb.Permit Fee: t,\lec.. Permit Fee., Other Mech.Insp. 0.0 hrs $47.00 Other Plumb Insp. Other Elec.Insp. Dlech. Insp.Fee: Plumb. Insp,Fee: Insp.Fee: NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). Thesefees are based on therelimfna information available and are only an estimate. Contact the De t or addn'1 in o. FEE ITEMS (Fee Resolution 11-053 Ef.' 711112) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 1 # Mechanical Suppl.PC Fee: (D Reg. ® OT 0.0 hrs $0.00 $139.00 iwR=<I00 Furnace,Forced-Air PME Plan Check: $0.00 1 # Mechanical Permit Fee: $0.00 $70.00 IBREMAIR A/C Units(<=10K cfm) Suppl. Insp.Fee:Q Reg. ® OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $47.00 C;onstrzu:tion .Tax: Administrative Fee: IADMIN $44.00 Work Without Permit? ®.Yes (j) No $0.00 E) Advanced Planning Fee: $0.00 Select a Non-Residential E) Travel Documentation Fee: 1TRAVDOC $47.00 Building or Structure i Strong Motion Fee: IBSEISMICR $0.94 Select an Administrative Item Bldg Stds Commission Fee: . IBCBSC $1.00 $139.941 $209.0051, Q`, E $348.94 u Revised: 07/01/2013 HVAC ALTERATIONS ENERGY COMPLIANCE FORM L COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION ALBERT SALVADOR, P.E.,C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 GUPERTthtQ (408)777-3228•FAX(408)777-3333•buildinal-cupertino.ora WHEN IS A PERMIT REQUIRED A construction permit shall be obtained from the enforcement agency prior to the erection, construction, reconstruction, installation, relocation, or alteration of any mechanical system, except as permitted in Chapter 1,.Section 112.2 of the 2010 California Mechanical Code. Projects requiring permits include, but are not limited to: • New HVAC installation • HVAC Changeout • Replacement of furnace, coil;FAU or condenser • Relocation of an existing HVAC unit • Adding or replacing more than 40ft ducting in unconditioned space BUSINESS AND PROFESSIONS CODE, SECTION 7110 Willful or deliberate disregard and violation of the building laws, including the California Building Code, and local permit requirements constitutes a cause for disciplinary action from the Contractors State License Board working in conjunction with the local building department. This action may consist of fines up to $5,000 per violation or suspension/revocation of a contractor's license. 2008 BUILDING ENERGY EFFICIENCY STANDARDS (Title 24,Part 6)REQUIREMENTS INCLUDE: 1. Heating equipment must have a minimum 78%AFUE(Exception: Wall & floor furnaces; room heaters). 2. Central air conditioners&heat pumps less than 65,000 Btu/hr must have a minimum 13 SEER. 3. Newly installed or replaced ducts must have a minimum insulation value of R-4.2. 4. A setback type thermostat(24 hr clock with four set points) is required for all alterations. 5. New or replacement ducts must meet the mandatory requirement of Section 150(m). • All joints and openings in the HVAC system must be sealed. • Only UL 181, UL 181A, or UL 181B approved tapes or mastic shall be used to seal duct openings. • Connections of metal ducts and the inner core of flex ducts shall.be mechanically fastened. Flex ducts must be connected using a metal sleeve/coupling. • Flex ducts that are suspended must be supported every 4 ft. max for horizontal runs with no more than 2"of sag between supports and 6 ft. max for vertical runs. 6. The CF-6R-MECH-04 must be completed and signed by the installing contractor. The Inspector will collect this form and verify that the model numbers are the same as the installed equipment. 2008 Residential Compliance Forms.doc revised 04/10/12 Simplified Prescriptive Certificate of Compliance:2008 Resirfenthdl WACAI erasions CF-IR-ALT-HVAC Climate Zones 1 and 3- MeAddnav EnforcmnemAgency: IJut :;< Permit#: U I Conditioned Duct insulation E4dvmentTVMI hist Minimum Effirien Floor Aiea" regaiiimeni Thermostat Packaged Unit Over 40 8 of ducts` Setback Furnace ® COP Saved by system ` added or replaced in Indoor Coil [3SEER� �HSPF oiolreadypresou,mustbe Condensing Unit ®EER E3 Resistance ` sf unconditioned space: . Other R 6 (CZ 1,3-5) 1.Equipment Type:Choose the equipment being installed;if more than one_system,use another CF-JR-ALT-HVAC for each system. 2.NCnimum Equipment Efficiencies 13 SEER,78%AFUE,7.7HSPF for typical residential systems. Contractor(Documentation Author's/Responsible Designer's Declaration Statement) I certify that this Certificate of Compliance documentation is accurate and complete. • I am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the design identified on oris Certificate of Compliance. • I certify that the energy features and performance specifications for the design identified on this Certificate of Compliance conform to the requirements of Title 24,Parts I and 6 of the California Code of Regulations. • The design features identified on this Certificate of Compliance areconsistent with the information documented on other applicable compliance forms,worksbeets,calculations,plans and specifications submitted to the enforcement agency for approval with the permit application. _ Name: rJ-�,e��' , s-� Signatins. Company:©-e-((e T - D .- 9 2 0 Aadr'ess: City/StwAcip: Pbime: 2008 Residential Compliance Forms.doc revised 04/10/12 CUPERTINO Building Department . AUG 2 g 2013 REVIE D FOR CODE COMPLIANCE Rei owed B 1 I I I !i vu rTYnFVFLOPMENTD4 EPARTMEN BUILDING DIVISION-CUPERTINO APPROIED 11s sst of plans and specifications MUST be k anges or alterations on same,or to deviate Building Official. mping of this plan and specifications SHALL NOT c e A a y provisions of any City Ordinance or Stats Law. PERMIT NO. PL41. P tAl �D G DEI'TV CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 902 BROOKGROVE LN CONTRACTOR:STRASILLA UDO J AND PERMIT NO: 13080214 ARLENEJ OWNER'S NAME: STRASILLA UDO J AND ARLENE J 902 BROOKGOVE LN DATE ISSUED:08/28/2013 OWNER'S PHONE: 4089243920 CUPERTINO,CA 950144668 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB'S License Class Lic.# r MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE(E)WATER HEATER&INSTALL A TANKLESS (commencing with Section 7000)of Division 3 of the Business&Professions WATER Code and that my license is in full force and effect. HEATER(RL94LS)AND RUN 3/4"GAS LINE FROM GAS METER 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. Sq.Ft Floor Area: Valuation:$2663 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:37539038.00 Occupancy Type: 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, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. Signature Date Issued by: t�s Date: OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection. Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. ;permit is issued. Additionally,should I use equipment or devices which emit hazardous air rtify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534. 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. O� *�u d age Date: APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of work's to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in of the Lender's Address granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. s` I understand my plans shall be used as public records. Signatdre Date Licensed Professional CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION ADDRESS: 902 Brookgrove Lane DATE: 08/28/2013 REVIEWED BY: Sean ,91APN: BP#: pj QoZ/ *VALUATION: 1$2,663 *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex PENTAMATION PRWHEATR USE: PERMIT TYPE: WORK Remove existing water heater and install a tankless water heater RL94LSi and run 3/4" gas line from SCOPE gas meter. APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Water Heater 1PRWHEATR 1 # $28 Piping, Gas <=4 Outlets 1PGASRES 1 # $70 TOTALS: $98.00 tllech. Plan Check Plumb.Plan Check 0.0 hrs $0.00 Elec.Plan(.hock L17Permit Fee: Plumb.Permit Fee: IPPERAfIT lace.. Permit Fee: Chher 11(xh.Insp. Other Plumb Insp. 0.0 hrs $47.00 Oilier Elec.Insp, Heck Ins17,I°'ere: Plurnb. hish.Fee: Elce.Insp. Fee: NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These-fiees are based on the relimina information available and are on an estimate. Contact the De t or addn'1 info, FEE ITEMS(Fee Resolution 11-053 E . 711112) FEE QTY/FEE MISC ITEMS Plan Check tee: .5uppl. PC I'ee PME Plan Check: $0.00 Permit Fee: Supp/, 117sp fee PME Unit Fee: $98.00 PME Permit Fee: $47.00 Consir action Tax: Administrative Fee: IADAHN $44.00 Work Without Permit? ® Yes (F) No $0.00 Advoneed Planning I4ees: Travel Documentation Fee: 1TRAVDOC $47.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 a m $237.50 $0.001 $237.50 Revised: 07/01/2013 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333•buildingCW-cupertino.org misc /LJ PLUMBING [—]MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS W2 ��O �®� APN# 7 5 r 3 a 3e OWNER NAME y(�' //j�/,n YCGG� t/ p`/ - PHONE_ Z�' LJn f E-MAIL ¢c`J (�+ _,i'"t25i'LZap3 c0dhoo.lsd0► STREET ADDRESS �8 CITY,STATE,ZjP FAX V Ctc��rfjr►o C4 a) CONTACT NAME PHONE E-MAIL yS'�T/REEET ADDRESS CITY,STATE,ZIP FAX (�OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME es LICENSE NUMBER P�/�l� f 33 LICENSE TYPE BUS.LIC# COMPANY NAME �(/ ��%,.M�`2 E-MAIL 7 6 [ G FAX STREET ADDRESS , CITY,STA� � ,4i?,A0t4t ZIP PHONE s,35- 333V ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD.r DUPLEX ❑ MULTIFAMILY YE PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN S BUILDING: E]COMMERCIAL URBAN INTERFACE AREA 49-NO FLOOD ZONE 43-50- EICHLER HOME? ❑NO DESCRIPTION OF WORK �n s ,L q�L 4� R/It•� r��Y t ew� Q m o✓e e-SllS/7rj 6O n waOr i.1 s-,x—e eG 6'on TOTAL VALUATION: �` a� RECEIVED BY: By my signature below,,,II certrtdf to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provide ct. I have Description ork and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to build' I a o 'e represe es Cupertino to enter the above--iidentified property for inspection purposes. Signature of Apphcant/Agent: Date: d 2 y �� SUPPLEMEN INFORMATION REQUIRED OFFICE USE ONLY W OVER-THE-COUNTER ❑ EXPRESS ❑ STANDARD U Z ❑ LARGE a ❑ MAJOR MEPMiscApp_2011.doc revised 06/21/11 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333-buildinp(abcupertino.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 ADDRESS470 2 eIV� ro!/fe "� APN BP# OWNER NAMEe l'y.O � �sf d� OWNFRd4�RESS DESCRIPTION OF WORK: >� � L �¢ ''Z_T IQcn1tai, /tel)!rt ee o« n GC kv*'fe•^ he.,q to. 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 to signify you understand or verify this information) Of,1. I 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 acting as an Owner-Builder and am aware of the limits of my. insurance coverage for injuries to workers on my property. _�2. 1 understand building permits are not required to be signed by property owners unless they are responsible for 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 ame instead of my own. 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license umbers on permits and contracts. 5. 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 onsidered 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 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' 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. 8. 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 04/14/10 s 9. I understand I may obtain more information regarding my obligations as an"employer"from the Internal evenue 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. 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that l am the party legally and financially responsible for proposed construction activity at the site address listed above. 11. 1 agree that,as the party legally and financially responsible for this proposed construction activity, I will abide y all applicable laws and requirements that govern Owner-Builders as well as employers. a,2. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the formation 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 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.) I 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 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 verifythe property owner's si,natur . Property Owner's Signature: Date: 9(12F /2o.1-3. - ------------------------------------------------------------------------------------- ------------------------------------------------------ (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)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 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: OwnerBuildeYForm 2010.doc revised 04/14/10 Building Department City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 C O P E RT I N O Telephone: 408-777-3228 Fax: 408-777-3333 CONTRACTOR/SUBCONTRACTOR LIST JOB ADDRESS: 2 & b evP? PERMIT# OWNER'S NAME: 64,4 CS-61 z'r zlw- PHONE## GENERAL CONTRACTOR: BUSINESS LICENSE-# ADDRESS: 9eZ rs�a�2y��Y L,=K 'C6r�u,/i�v 95 af5t— 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)-WILLMRi..,SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A-CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following inforriiation: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE# Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring/Carpeting Linoleum/Wood Glass/Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing X Roofing Septic Tank Sheet Metal Sheet Rock Tile O er/Contractor Signature Date