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15090052CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10305 VIRGINIA SWAN PL CONTRACTOR: GILLETTE LYNN H AND PERMIT NO: 15090052 JOLENE G T OWNER'S NAME: GILLETTE LYNN H AND JOLENE G T 10305 VIRGINIA SWAN PL DATE ISSUED: 09/09/2015 OWNER'S PHONE: CUPERTINO, CA 95014-2024 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ REMODEL (E) 230 S.F. KITCHEN (NO STRUCTURAL License Class Lic. # CHANGES) 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: t. 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. 2. 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 sa indemnify and keep harmless the City of Cupertino against liabilities, jud 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. Date 0 OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. 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) 2 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: t. 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. 2. 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 'J a �/y' 2 Date - ! a20I-C Sq. Ft Floor Area: I Valuation: $29000 APN Number: 31646013.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAY FR„ ONLLAST CA1L NSPE TI N. RE -ROOFS: All roofs shall be in 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. 1 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 uthorized t: Date: `,:;P,- 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 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(a-cupertino.org l 5v 900_5_Z_ F NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT 4 PROJECfADDRESS {(/ �/�� APN# OWNER NAME PHONE/ )� `2 COH(Cli7� C - D ` /(J STREET ADDRESS A� STATE ZIP- f 5O FAX n E-MAIL CONTACT NAME PHONm� STREET ADDRESS 5/ CITY, STATE, ZIP FAX El OWNER ❑. OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT El ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHON]E�,, j DESCRIPTION OF WORK ,� ✓K- L- dF l �.� r 1 �� 7 - 7 J D .S%j �`-1 c'r/tC�Bk l ` ( �2 O �/ `� K� E)GSTING USE PROPOSED USE CONSTR TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA.). -rat I f REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ATTACH # DIATLUNG UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑YES BEING ADDED? []NO ADDITION? []NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES: TOTAL VALUATION: PLANNING APPL N ❑ NO PLATTING APPROVAL LETTER EICHLER HOME? NO By my signature below, I certify to each of the following: I am the property owner or authorized agent to act property owner's behalf. I have read this application and the information I have provided is correct. I h ve read the Descri ti9p of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buildi construct' I uthor' repr of Cupertino to enter the above -identified property for i/nspection purposes. Signature of Applicant/Agent: Date: — C C SUPPLEMENTAL IntORMATION REQUIRED Q `'� ,PLAN,CHECKTIPE w,a w.ROtifLSG SLIP o«x TSlicoul.TEx O sr II,I)i\c PL-- I r New SFD or Multifamily dwellings: Apply for demolition permit for❑ existing building(s). Demolition permit is required prior to issuance of building }rr permit for new building. p g p� s , EXPRESS � ❑ PLAySLSG YL4'S REVIEW i5 ? _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STANDARD D PVBLiewoRxs form if any Hazardous Materials are being used as part of this project. € ® LAL_GE `� ., .;, ❑ FIRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to _ C1 ❑ submittal of Building Permit application. nI AroR V- _ sA\rrAR1 SI NN rR DIS ?Kier - ❑ E-NVI KO\SILNTAL HEALTH - BldgApp_2011.doc revised 06/21111 Me't CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ILEADDRESS: 10305 VIRGINIA SWAN PL DATE: 09/09/2015 REVIEWED BY: MELISSA Mech. Permit hee: APN: 316 46 013 BP#: *VALUATION: 1$29,000 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex :'lumb. Inv) Fee: PENTAMATION 1 R3SFDREM USE: PME Plan Check: PERMIT TYPE. WORK REMODEL E 230 S.F. KITCHEN NO STRUCTURAL CHANGES SCOPE Permit 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 fees are based on the nreliminary information available and are onlv an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11-053 Ef: 71 /1/13) Mech. Plat Check Plumb. Plan Cheep Llec. Plat Check Mech. Permit hee: Plumb. Permit Fee: F/ -,,,c-. Permit Fee: )ilter laech. Insp. � )iherPlumb Insp.Ll LLI Other Elee. histo ilech. Insp. Fee: :'lumb. Inv) Fee: klec. 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 fees are based on the nreliminary information available and are onlv an estimate. Contact the Dept for addn'l info. FEE ITEMS (Fee Resolution 11-053 Ef: 71 /1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 =s.f $645.00 Remodel, Kitchen (<=300 sf) IREMRESKIT Suppl. PC Fee: 0 Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee. -(j) Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: .141ministralive Fee: 0 E) Work Without Permit? C) Yes O No $0.00 Advanced Planning Fee. $0.00 Select a Non -Residential Building or Structure E) 0 i Travel Documentation Fees: Strong Motion Fee: IBSEISMICR $3.77 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $2.00 SUBTOTALS: $5.77 $645.00 TOTAL FEE: $650.77 Revised: 07/02/2015 Building Department `��,�� 1 City Of Cupertino �; � �`�� `� 10300 Torre Avenue ' Cupertino, CA 95014-3255 C U P E RT I IV O � � Z,� �� Telephone: 408-777-3228 Fax: 408-777-3333 CONTRA�TOR/SUBCONTRACTOi� I,IST JOB ADDRESS: :�' � v // i��-- �''�" PERMIT# �I� Q�Z OWNER'S NAME: PHONE# GENERAL CONTRACTOR: '�/',�.v,�;` �,��, �5 .� BUSINESS LICENSE# 5 3 7z�'-�' aDD�ss: ��r�� 5�� „�� ;z, Sz -�� clTYizlPcoDE: �� *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCC'UPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS �IAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. �y�� -; .� � .f �:��: � I am not using any subcontractors: � `� �� " ' -� . ��' � �—�l� Signature Date Please check applicable subcontractors and complete the following information: , � ✓ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # I Cabinets & Millwork � Cement Finishi ng Electrical Excavation ; Fencing ' Flooring/Carpeting � Linoleum/Wood Glass/Glazing i Heating i Insulation ' Landscaping Lathing ' Maso '� �'Y Painting/Wallpaper �I Paving , Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile �''(��L�� f f-��-�.� Owner/Contractor Signat�nre Date Sl1liOKE / CAI�BO�1 NiONO)C�DE ALARlV�S ..�-, :�, . ;� �OVVNER CEt�.TI�ICAT� �OF COl�IIPLIAiVCE �'.}Y � ; COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION ��,��.�� 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 � `� �-� r�1 � (408)777-3228• FAX(408) 777-3333< buildinq(a�cupertino orq " Permit No. �-s��d dSZ Address �Q��?�" LJr rn� S�✓c�,-� ��; > �'�'� #of Alarms Smoke: Carbon Monoxide: PEI2IV�I'I'CANNOT�E F][loiA�,ED AND COIIVIPLE�'�D LTN'I"�,'�'�rgI[S �'��I�IcCr�� 3[A��IE7E1�1�� 1�IE��I��1��'�Z�TL� '�� 7C�g�1��T�I[,}�][l��]I��g�I�T _. .. PURPOSE This affidavit is a self-certification for the ulstallation of all required Smoke and Carbon Monoxide Alarms for compliance with 2013 CRC Section R314, 2013 CBC Sections 420.6 and 907.2.11,2 where no interior access for inspections are required. GENERAL IlVFORMATION Existing suzgle-family and multi-family dwellings shall be provided with Sinoke Alarins and Carbon Monoxide alarms. When t11e valuation of additions, altera�ions, or repairs fo existulg dwelling units exceeds $1000.00, CRC Secfion R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon Monoxide Alarms be installed in the following locations: --- ; AREA SMOKE ALARM CO ALARM � I Uutside of each separate sleeping area in the immediate vicinity of the X X '' bedroom(s) � On ever level of a dwellin unit i.ncludin basements X X Within each sleeping room X ' �arbon Monoxide alarms are not required in dwellings which do not contain fuel-burning appliances and that � do not have an attached garage. Carboiz monoxide alarms combined with smoke alarms shall comply with � CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal. Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated. I In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do not result in the removal of wall and ceiling finishes or there is no access by means of attic,basement or cra�Tl space. Refer to CRC Section R314 and CBC Secfions 907.2.11.4 and 420.6.2. An electrical permit is required for ; alarms which must be connected to the buildulg wirulg. , As owner of the above-referenced property, I hereby certify that the alarm(s) referenced above has/have been installed in ac�ordance with the manufacturer's instructions and in compliance with the California Buildin g and California Residen ' t�al Codes. The alarins have been tested and are operational, as of the date signed below. /have read and a ree to com l with the terms and conditions of this statement Owner(or Owner AgenYs)Name: Sinature..................................................................................................................Date: ........... Contractor Name: •.•..... t V'l�I� � � - � � � �CL��.�a.! 1' r / �j��-,,✓Ni Si nature.... ............:.........................:.f..`�...................Lic.# ..��..��..��..�.............Date:(��3 I Smoke and COfo�m.cloc revised 03/18/14 ��q i� tNATER-CONSE�if(NG PLI�l41�B(NG FlXTURES 4Wf�ER CERTIFtCATE OF C�I�IPLlANCE �.. � � / COMMUNfTY DEVELOPMENT DEPARTMENT• BUILDING DIVISION . l`�� CUPERTINO Ta300 TORRE AVENUE• CUPERTINO, CA 95014-3255 ' (408)777-3228•FAX(408)777-3333• buildinp a(�.cupertino orq c Owner Name vr��,,,,�e%r,/,ptit� �i7-J�� Yermit No. �Sd 7 O.U�Z Address �� Q .S— Vjl,^c��dv' � S r.�v�^�i-, �'�f �-�c � C � t�r��1 h c' Cal�- l f� � � 1. Is your real property a registered historical site? ❑ Yes Civil Code Sections 1101.1 t1u•ough 1101.8 do not apply. Skip the rest of the form and sign bottom of form. C] No Go to Question 2. 2. Does your real property have a licensed pluinber certifying that,due to the age or configuration of the property or its pliunbing,installation of water-conserving pluznbing fixtures is not technically feasible? I� Yes Civil Code Sections 1101.1 through 1101.8 do not apply. ❑ The licensed plumber's certification has been provided to the Building Division. Skip the rest of the form and sign bottom of form. � No Go to Question 3. � 3. Is water service peimanently disconnected for your building? ; ❑ Yes , Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. ' C�7 No Go to Question 4. ' �-. Is your real property built and available for use or occupancy on or before January l, 1994? ; ❑ No My real property is built and available for use or occupancy after January 1, 1994. Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the fonn and sign bottom of form. � I7J Yes My real property is built and available for use or occupancy on or before January 1, 1994. Civil Code Sections 1101.1 through 1101.8 apply. Check one of the three following statements and si�n i bottom of form.. , � i 5. Please check ONE of the follo�,ving: ; �� Myproperty is a single family�-esidential real property. See Civil Code Section 1101.4. ! On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing fixtures to be replaced with water-conserving pluznbing fixtures throughout the building. On or before January 1, 2017, all non- compliant plumbing fixtures shall be replaced with water-conserving plumbing fixtures (regardless of whether property undergoes alterations or improvements). ' ❑ Myproperty is a nazclt�cznzily��esidential real property. See Civil Code Section 1101.5. On and after January 1, 2014, specified building alterations or improveinents shall require non-com liant plumbing fixtures to be replaced with water-conserving plumbing fixiures. � On or before January],2019, all non-compliant pluznbing fixiures shall be replaced with water- conserving pluinbing fixfures throughout the building(regardless of whether property undergoes alterations or unprovements). ❑ Myproperty is a commercial real property. See Civil Code Section 1101.5. On and after January l, 2014, specified building alterations or unproveinents shall require non-coinpliant plumbing fixtures to be replaced with water-conserving pluinbing fixtures. On or before January 1, 2019, all non-coinpliant plumbing fi�tures shall be replaced with water- conseiving plumbing fixtures fhroughout the building(regardless of whether property undergoes alterations or unproveinents). I,as the owner or owner's agent of this property, certify under penalty of perjury that non-compliant plumbing fixtures will be replaced prior to date specified above with water-conserving pluinbing fixtures in accordance with Civil Code Sections 1101.1 through 1101.8,the current Califomia Plumbing Code and California Green Building Standards Code, and manufacturer's installation requirements, and that the water-conserving plumbing fixtures coznply with the requireinents as indicated in the table on the following page. � Owner or Owner Agent's Signature: �� Y Date: ,��Z L/� Upon completing and signing tlus Certificate,please return it to the Building Division in order to final your building permit. SB407 201 S.doc revised 08/26/I S � OWNER-BUILDER D(SCLOSURE FORM C CO�MUNITY DEVELOPNiENT DEPARTMENT• BUILDING DIVISION � 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)7i7-3333 • buildinanacuoertino.ora — CUPERTfNO Dear Pr�perty 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: SITEADDRESS IL',3CS 6�'�, i��;�, _S.� ;c�� _.. . . APN � � � � �� I � BP#� � OS !i OWNGR NANE OWNER ADDR SS- �^�►�<<<'�a S�-c. -- "t �(��c' _ ��- �, � � �-,.`I��. _ _ _ + : . _�, � ��-, - �� z� DESCRIPTIONOFWORKt � ��tic S• �•�rl / �c. i�c .ir� �.3C� S � ,� ti.��]�� /. p_. ._ / . . . . �.. . . . . r �C �! C CC � � `(�� t We are providing you with 2n Owne�-Builder Acknowledgment and Information Veri ication 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, �he property owner, obtain the prior approval of the permitting authority. OWNER'S A�KNOWLEDGMENT AND VERIFICATION OF INFORMATION (DlREC7(ONS:P(ease read and initial each stafement below to signify you undersfand or verify fhis iniorriafion.) :/'�1`i11. I understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner- Builde�' 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 i�juries. I am willfully acting as an Owner-Build2r and am aware of the limits of my insuranca coverage for inj�ries to workers on my property. �/`��2. I undersfand building permits are not required to be signed by property owners unless they are responsib/e for the construction and are not hiring a licensed Contractor to assume this responsibility. ��i'3. 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. ' -:��. I understand Contractors are required by law to be licensed and bonded in California and to list their license � numbers on permits and contracts. ��5. I understand if I employ or otherwise engag2 any persons, other than Califomia 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. I 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 und2rstand my failure to abide by these la�vs may subject me to serious financial risk. �%-�7. 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 oner them for sale, unl2ss a/l 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 per`ormed under contract vrith a licensed general building Contractor. ��8. i understand as an O�vner-Builder if I sell the property for�vhich this permit is issued, I may be held liable`or any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. O�vnerBuilderrorm 2010.doc revised 04/19/10 r . � �/�/� 9. I undersfand I ma obtain more inrormation re ardin m oblia�tions as an "em lo er" from the Internal Y 9 9 Y P Y Revenue Service, the United States Smail 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 vrw�v.csib.ca.gov for more information about licensed contractors. ��'� 10. I am aw�re of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the party legally and financialiy responsible for proposed consfruction activity at the site address listed above, �/`�1. I agree that, as the party legally and financially responsible for this proposed construction activity, I will ak��d2 by all applicable laws and requirements that govem Owner-Builders as vdell as employers. ��y-12. I agr2e to noti`y the issuer of this form immediately of any additions, deletions, or changes to any of the - information I have provided on this form. Licens�d 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 v✓ith any inancial loss you may sustain as a result of a complaint.Your oniy remedy againsf unlicensed Contractors m�y be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or irm is injured while working on your proper�y, you may be held liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractors, you vrill be responsible for verifying whether or not those Contractors are properly lic2nsed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDWG AGENCY (DIRECTIONS:Please complete the following consfruction lending agency information.) I hereby aifirm that there is a construction lending agency for the perormance of the v✓ork for�vhich 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. Nofe:A copy of the property owne�s drive�s license, form notarization, or other verification accepfab/e to the city may be required to be presented v✓hen the permit is issued to verif the ro ert o�vne�s si nature. > Property O�vner's Signature: `—'%'� �' � � � Date: �- �- 2C /� --------------------------------------------------------------------------------------------------------------------------------------------- (NOTE: The follo�a�ing Authorization Form is required to be completed by the property owner only v✓hen designafing an agenf of the property owner fo apply for a consfrucfion 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 undersiGnd is my personal responsibility, I hereby authorize the follo�ving 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 orAddress: Name of Authorized Agent: Tel No Address of Authorized Agent: I declare under penaliy of perjury that I am the property owner for the address listed above and I personally filled out the above information and certi`y its accuracy. Note:A copy of the property ov✓ner's dnver's license, form notarizafion, or other verification accepfab/e to the cify may be required fo be presented v✓hen the permit is issued to verify the proper�y ov✓ners signature. Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revised 04/14/10 r:.� y- v � - � O � � � � ��K��- ��. . � - - - � - - ;'�` �; . i _.___ _ r. !. �jC 6 � ll ► �1, � ��i �C `1 C:' {'1 \``� o �!'=� � v.'c' �� ` _� �,' ��-- � �r>=�' ,-_ � - , �� ,'� � �� % _ i;�- V � � �. `vlf r� � i G/. , \ �_ -I r�� i .� _ �� i - -� ; 'i � , ; C ,�, ! 4 � � �� YV�, � -.j� � � ( i � � � , � �, � , c� _ `-�:�, _ _ `� � DUcv-I-�Pa� �0. 1 I � . �, �.�1 ��,) . �� ,r;;. , __ -__--- - , <<<, , � /� � C If ��'` i�� -1 �l�'✓�J�e�� UPE��(�' ;�6 ;^� T�.�� ., y ��urfding pe � � � � ; ; (�..� f' 'Q� � .._:� SEP �1� Z015 ; �� ,�.ti ' �EviE�vEu Fo� caoE ' �� viewed C��'�IANCE � .. � � � By � � _- � � � � - Vent&cabinets — , I � °�.° `�' Gl ' � , ,�-` A y. �=;,(�t� � L.t, --. 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