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14070118CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20665 ACADIA CT CONTRACTOR: MSG FAMILY LP PERMIT NO: 14070118 OWNER'S NAME: MSG FAMILY LP 20665 ACADIA CT DATE ISSUED: 07/28/2014 OWNER'S PHONE: 4082572092 CUPERTINO, CA 95014 PHONE NO: JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL E] ❑ LICENSED CONTRACTOR'S DECLARATION REPLACE WOOD SIDING WITH (N) HARDIE BOARD License Class Lic. # SIDING (1600 S.F.). RELOCATE DOOR IN BEDROOM 4 FROM ENTRY Contractor Date TO HALLWAY (WINDOW TO MEET EGRESS) I hereby affirm that I am licensed under the provisions of Chapter 9 REV # 1- REPLACE 4 (E) SLIDING GLASS DOORS, LIKE FOR LIKE - (commencing with Section 7000) of Division 3 of the Business & Professions ISSUED 8/1/2014 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: $9000 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 32656020 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 D NIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter 180 RO ALLED INSPECTION. 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 Iss / granting of this permit. Additionally, the applicant understands and will ply with all non -point source regulations per the Cupertino Municipal Code, Sect 9 18. RE- ROOFS: 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. L11/ 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 1, 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) owner of the roe y g p p rty, am exclusivel contractin with licensed contractors to Fas HAZARDOUS MATERIALS DISCLOSURE nstruct 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 Are Air Quality Management District I Cuper ' icipal Code, Chapter 9.12 and performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by for this will maintain compliance with t o the Health & Safety Code, Sec ns 255 255 nd 25534. Section 3700 of the Labor Code, for the performance of the work which Owner or authorized agent: Dater ermit is issued. ertify 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 making 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 r gulations per the Cupertino Municipal Code, Section Licensed Professional 9 18. Signature f Date �'d CONSTRUCTION. PERMIT APPLICATION COMMUNITY DEVELOPMENT. DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • building eouoerting.org F��, m 4 11 . ,. r7 11 -r--'D A rrnrr i rT u> viC7nN / nFFFRRED ORIGINAL PERTH 4 I Lt U T c) I 19 U NFW UUN6 IlKU(.-11UIV I Pal%iJ1111J'N LJ - PROIECr.ADDRESS I c APN �.= t«a i 1�1P J F7 01ANERNP.h4E PHOh°E E-IJAII S C ,,., elfL'A'. s 4u ; S o` © � Ac �.d14•�. c I �� if FAX STREET ADDP.ESS Cri 1', STATE, ZIP ` I (,k CONTACT NA N.= PHONi E -MA.IL �A ' 0 4 STREET ADDRESS CITY, STATE, ZIP I FAX C 1. 4 q S—D l ❑ owNER ❑ owIm- BLiLDER ❑ OWN'ERAGENT ❑ CONT.; CTOR ❑ CONT'RACTORAGLTT ❑ P.RCICT ❑ EN 1� i ❑ D1rzI OP`- ❑ 'zI AST COA'TRACrORN ?h S C s( L n I LICENSEXTUh�ER I LICENSE TYPE I c r BUS.LIC� COMPANY NAME ( � � � } Q ESC � � � f't+� I FP X ' / / STREET ADDRESS t }+ q G` ✓` K I CITY, STATE ZI` I PI'61-1 ARCHF r-CTrr G1T'EFR NA -ME r I LICENSE NUMBER I BUS. LIC' N � 14, COMPANY NAME ( l�l E -MAIL �A- FAX STREET ADDRESS r !� / CITY, STATE, ZIP '4J PHONE DESCRIPTION OF WORK v < .-SL , ✓\�' EXISTING USE PROPOSED USE CONSTR TYPE R S ?OR ES USE TYPE OCC. I SQ.FT. I VALUATION (S) EXISTG NEW FLOOR DEh40 TOTAL AREA I NET AREA AREA I AREA BAT700M REMODEL AREA I KITCHEN OTHER REMODEL AREA REMODEL AREA PORCHAREA I DECK AREA TOTAL DECK/PORCH AR.EA GARAGE AREA: DETACH ❑ ATTACx f DIA LLING UNITS: IS A SECOND UNIT ❑ YES BEING ADDED? [3 \'O SECOND STORY ❑ YES ADDITION? ❑NO — PILF- A-Px�L- IG:4Ti0 \—[� l'-ES— Irk= 1,S,- PAOYmE1_0PY DI ,�S THE BLDG .4N tilt ECBi3iE >" l Im__ - - TOT.AL VALUATION: PLA.'�7NG APPL: ❑ NO PL.A�RSII�TG APPROVAL LETTER I EICHLER HOME? ❑ By my signature below, I certify to each of the fo110" �: I he property owner or authorized agent to act o erty owner's behalf. I have read this application and the information I have pr ed is c ect. I read the Description of Work and verify it i ecurate. I agree to com ly with all applicable local ordinances and state laws relating to b ng cons ction, t rize representatives of Cupertino' o enter the above- i ed prop° for inspection purposes. Signature of Applicant/A.gent: Date: ` SUPPLEh4ENTALBNTFOirN, ON L D y C C Ti {g a :x TiRG zPr _ New SFD or h4ultifamil d%vellings: A 1 for emolition ermit fore � ' ` �— Y PP Y P �❑ OVER cotmTER❑ BLTLbIZGPL�'�T EkIEEFT existing building(s). Demolition permit is required prior to issuance of building'_�� permit for nevd building. Disclosure _ Commercial Bldgs: Provide a completed Hazardous h4aterials being as of this form if any Hazardous h4aferiOs are used part project. Copy of Planning Approval Letter or Meeting ladth Planning prior to RV S cry_ fl _ Building Permit application. -�. submittal of s �`�E 73'S�IEiY?TH s� �3IRON1iE?�T Bldggpp_2011.doc revised 06/21/11 CITY OF CUPERTINO IwIlum TTT Inc7Tw -MAr A TlID 112TTTT "1r1VC_ "'FV1CT(1N 1` jJ LI 1'IV 1111�1 t v 20665 ACADIA CT — — — DATE: 08/01/2014 REVIEWED BY: MELISSA WtADDRESS: N: 32656020 BP #: 14070118 VALUATION: �0 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY USE: SFD or Duplex Window / Sliding Glass Door I WINPEP Replacement PENTAMATION 1GENRES PERMIT TYPE: i WORK REV # 1 - REPLACE 4 E SLIDING GLASS DOORS LIKE FOR LIKE - ISSUED 8/1/2014 SCOPE $0.00 NOTE: This estimate does not tnctuae fees aue to Diner /ie�lu.[iiae.a� ��•�• • ��•.•..,�6, - w - _ __ _, _ ______ District, etc.. These fees are basea on the preuminur FEE ITEMS (Fee Resolution 11 -053 E f 7f /1/13) to ur nuuv.t u�u.w.,« FEE t 7" S ' � �••- - __.._____ _ _ ___ MISC ITEMS Plan Check Fee: f $0.00 ® # $431.00 Window / Sliding Glass Door I WINPEP Replacement .a a 20" 0:0 hrs $0.00 PME Plan Check: F $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. 4 OT _ ACS Atfi ee• 1111,frab, Permit Fee, _T= / 3rr nr(er Atvrsr 07- Other � %. h sr >. i4c, It. tidIp� F t:: f1%7U'1b, hap. Fee: I-le". ht sp, ul.,,.I o Faro cn ;tnm Vowor t)i.ctrict. School NOTE: This estimate does not tnctuae fees aue to Diner /ie�lu.[iiae.a� ��•�• • ��•.•..,�6, - w - _ __ _, _ ______ District, etc.. These fees are basea on the preuminur FEE ITEMS (Fee Resolution 11 -053 E f 7f /1/13) to ur nuuv.t u�u.w.,« FEE w•w »• QTY /FEE �••- - __.._____ _ _ ___ MISC ITEMS Plan Check Fee: $0.00 ® # $431.00 Window / Sliding Glass Door I WINPEP Replacement Suppl. PC Fee: Q Reg. ®OT 0:0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. 4 OT 0,0 hrs $0.00 _T= PME Unit Fee: $0.00 Permit Fee: $0.00 //PMEtt j [1. {,id1'Z l III ?fj "r„7j ilr`e? "`(;fie ". 0 Work Without Permit? 0 Yes E) No $0.00 Advanced Planning Fee: $0.00 Select a Non - Residential Building or Structure G uti 'l t?t ttrrr<:atZtzrir rt Rees: Stroh Motion Fee: $0.00 Select an Administrative Item Bldg Stds Commission .Fee: $0.00 ,, _`S�w $0.00 $431.00 TOTALFEE: $431.00 FNUVIOcu. v i ivicv i� =F CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20665 ACADIA CT CONTRACTOR: MSG FAMILY LP PERMIT NO: 14070118 OWNER'S NAME: MSG FAMILY LP 20665 ACADIA CT DATE ISSUED: 07/28/2014 OWNER'S PHONE: 4082572092 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL REPLACE WOOD SIDING WITH (N) HARDIE BOARD License Class Lic. # SIDING (1600 S.F.). RELOCATE DOOR IN BEDROOM 4 FROM Contractor Date ENTRY I hereby affirm that I am licensed under the provisions of Chapter 9 TO HALLWAY (WINDOW TO MEET EGRESS) (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 Sq. Ft Floor Area: Valuation: $9000 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 APN Number: 32656020 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 WIYU4N 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 DAYS F 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 I., �L Date: / 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. RE- ROOFS: 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. L4� 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 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 W 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 Q ality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertin un' ipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sect' 25505 5533, d 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Date: 4L, - permit is issued. I certify that in the performance of the work for which this permit is issued, I shall 7 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 making 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, t applicant understands and will comply with all non -point so ce regul ns p the Cupertino Municipal Code, Section Licensed Professional 918. r Signature Date =F CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT. DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 850143255 �O (408) -177-3228 • FAX (408) 7777-3333 • buildiner5egoertino.ora \ CUPERT(Is10 ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALIr�"2t ATION/n Q R- -tviSION /DuE�R_D OFiGINALM -1,9'1 T Of"t -6 1J owr/ar;r1� � P'rioN 't -Is3II �O cc, tL • �d& ST22^"- a ADDS b �.v C� c t`� C {' . IT, I t.�` r t~E c� a C v� v a t �€ 6, 6 d C, cohTACrxt� ,V14 y� - f P:iO!v= 4- fltg°l33 �� L r_tYtin � ��PA/ S 1 :��r AD1iR s CT � ClrY( _A �( "�� �4 � C:) ! FAX � D OWh'ERAc_=,T D coh�ii (CaoiL DC*-iACrORAQ? D A L0=Z:Cr ❑ ��+ � D D1�o° -1t D CON-14B I.'e LIC SE I B[ S. iC ° COWA),YNAAJ _ /itS6T Fw't c v_M it'iS f Q G r LtA-K FAX �C/i' STREET ADDP._Ms I CITY. �i � PnOht S e - LAC1U-TZCr/?4GN=-- W-M-z IICrTSENLM3�i A f /t_ l ( BUS. 11Cf a- coMPAhY xaS � - frMAIL � { la- . I FAX �J / STREET ADDRESS CI-i Y. STATE. TIP ` 1 ! - I PF0 : /,J f I DESCRIPTION OF WORK p, VI(tiC.SZ -a: I'�L,4 pK(4`� j. ( ", Ha,,YC•�; A3PV� P v E �eK Ue✓� *.L�rat4.Cc f�t� i ) °���^ {yQ., � � �tQ 4-1 PROPOSED LISE ' CO!25IA t YPE I ��S US g I i Y?E I OCC I SQ FT. � YAI i ATION (S) r'YISTIG FLOOR ( DEMO A 20rAL YE I AR A E& NETI AREA BATHROOM wCrT�t OTHMt RM40DELAREA I R*- MODn'LARrA I A�2doDr� AREA BELRGADDED! [I- ADDIr10h D tTO* D� G tv r, ` ._ TOT.4! VALUATION: PLANN'-2G APPL 9 ❑ NO 14�3CZT`rG APtTi(oYAL I�'Trr� EICBL.ER AOSt£'. D IrO _ -��� • O U f By my sim -atvre below, I cer* to each of the folIONNI : the property ow or 2 =IEhorized z�� a property owner's .. read this application and the information I have prov Jmt I e read the Description of Work and v:; iry it is acute. I a_:es to comply with all applicable loczl ordinances and state laws relatingto bu g co representatives of Cupertino to enter the above -id^ rifled p operty for inspection pu-goscs. SiesamreofApplicant/A¢ent Date: Au �f l�rcL Hew SFD or - Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new buildinz Commercial BIdgs: Provide a completed Hazardous Materials Disclosure fo_ rm if any Hazardous Materials are being used as part ofthis project. —Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. B1dg11pp 2011.doc revised 06121111 FM_7 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 20665 ACADIA CT FEE DATE: 07/28 /2014 REVIEWED BY: MELISSA APN: 326 56 020 BP #: *VALUATION: 1$9,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY USE: SFD or Duplex Suppl. PC Fee: (E) Reg. 0 OT 0.0 PENTAMATION PERMIT TYPE: 1GENRE WORK REPLACE WOOD SIDING WITH N HARDIE BOARD SIDING 1600 S.F.. RELOCATE DOOR IN SCOPE BEDROOM 4 FROM ENTRY TO HALLWAY (WINDOW TO MEET EGRESS) NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.. These fees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l in o. FEE ITEMS (Fee Resolution 11 -053 Ef. 7111131 FEE QTY /FEE MISC ITEMS Plan Check Fee: $0.00 17600 s.f. $1,076.00 Siding ISIDEOTHER All Other Suppl. PC Fee: (E) Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 0 # $286.00 New Door Opening IDOORNONST Non - Structural Permit Fee: $0.00 Suppl. Insp. Fee-.(E) Reg. 0 OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 F-71 ldwifn,:Ivativ,, 0 E) Work Without Permit? ® Yes (j) No $0.00 Advanced P I 'lannin g a ee: $0.00 Select a Non - Residential Building or Structure E) 0 i rUl vl "'rum rte f�; �l <rrt /'e? >.s: Strom Motion Fee: IBSEISMICR $1.17 Select an Administrative Item Bldp, Stds Commission Fee: IBCBSC $1.00 L K v $2.171$1,362.001 f TOTAL FEE: $1, 364.17 Revised: 07/10/2014 CUPERTINO OWNER- BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • building(okupertino.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 ADD SS CT C u 7A11 l«a OWNER NAME S ask. OWNER ADDRESS 6 DESCRIPTION OF WORK: �-.� La CF - T2.., -rte, pct! We are providing you with an Owner - Builder Acknowledgment ar% 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.) 1�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. C4_02. 1 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. 61_E3. I 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. w—P. 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 undewstand if I employ or othenuica Pngan� any ern sons 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. k n 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. t 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. 1 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. OwnerBuildeYForm 2010. doe revised 04114110 �9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1- 800 -321 -CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. 10. 1 am aware of and consent to an Owner - Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. '11. 1 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. 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 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 cit may be required to be presented when the permit is issued to verify the p ro erty owner's signature. Property Owner's Signature: Date: ttom ZZ -------------------------------------------------------------------- ------------------------------------------------------------------------ (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: Address of Authorized Agent: Tel No I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderForm 2010. doe revised 04114110 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014 -3255 Telephone: 408 - 777 -3228 Fax: 408- 777 -3333 JOB ADDRESS: 6�d-�� CT Cc� i V �•� PERMIT # �D 7" O1 OWNER'S NAME: 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 INSPECTION(S) WILL, BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTOR E OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. 7 l' I am not using any subcontractors: ��&- 1 cr Signatur Date Please check applicable subcontractors and complete the following information: Owner / Contractor Signature Date 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 Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date Sc 1 (Gtr 70", 0 W -) ro 0 "- " - 6 , - D /; ISe 4r0 4n 3 S, PLOT PLANS p& P(AZ (e) CHECKED BY 4L r"IE LAt1iNING DEPT. DATE 20 -6 I � r %j LKI 6G. -DFPT. of, kz dwo This < jr;b,,, L-vi, f (�- SUILD" Of Plans and or Is on therefrom, without approval fi ThIlSt2r,'ping of this Plan and s be held to Permit or to b of any provQ��� c Z_ DATE 0- C Is -PERMIT C) 9: c M ;U 0 jz CD S MU (J PP 1(-Pt at the un!awful,�c r Iake any II S, or to dov,!�a-e the Building Official. ifications SHALL NOT ;oval of the V' ;oia- Llon dance or Staia Law. 0 0 01 Ro 0 CH >i zi M L-vi, f (�- SUILD" Of Plans and or Is on therefrom, without approval fi ThIlSt2r,'ping of this Plan and s be held to Permit or to b of any provQ��� c Z_ DATE 0- C Is -PERMIT C) 9: c M ;U 0 jz CD S MU (J PP 1(-Pt at the un!awful,�c r Iake any II S, or to dov,!�a-e the Building Official. ifications SHALL NOT ;oval of the V' ;oia- Llon dance or Staia Law. M/!o PNO - Adpi NCE ,. Y