B-2016-1558 CITY OF CUPERTINO BUILDING PERMIT
BUIL,DINGADDRESS: CONTRACTOR: PERMIT NO:B-2016-1558
20840 CHERRYLAND DR CUPERTINO,CA 95014-2958(3.59 20 042) CHERRYLAND LLC
20846 DUNBAR DR
CUPERTINO,CA
95014-1802
OWNER'S NAME: CHERRYLAND LLC DATE ISSUED:03/17/2016
OWNER'S PHONE:408-568-0616 PHONE NO-
LICENSED
O-
I I FN FD CONTRACTORIDYXLARATION BUILDING PERMIT INFO:
License Class Lie.#
Contractor CHERRYLAND LLC Date X BLDG X ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing _MECH X RESIDENTIAL—
COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
I hereby affirm under penalty of perjury one of the following two declarations: Installation of temporary power pole(200 amp).
1. I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
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. Sq.Ft Floor Area: Valuation:$1000.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 359 20 042
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 PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 3/17/16 Issued by:Sean Hatch
Date:3/17/16
O R-B ILDFR DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(See.7044,Business&Professions Code). Date:3/17/16
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. I have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
permit is issued, maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
shall not employ any person in any manner so as to'become subject to the material. Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,2 533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATIM (®ate: /3 17/16
1 certify that I have read this application and state that the above information is CONSTRUCTION L INGAGENCY
correct.I agree to comply with all city and county ordinances and state Jaws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. �J 1 understand my plans shall be used as public records.
Licensed
Signature ; (,` Date 3117/16 p ofess onal
u
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 -
(408)777-3228•FAX(408)777-3333•buildina(a�_cupertino.orCUPERTINO: a
M I S C
PLUMBING ❑MECHANICAL ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS Z0440
API L
OwNERNAMF - y p PHONE k E-MAIL -
d �6j
STREET ADDRESS CITY,STATE,ZIP FAX
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
I I
OWNER ❑ ONVNEER-BUILDER ❑ OR`NERAGENTP ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGIN-EER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME @�` ,L- LICENSE NUMBER LICENSE TYPE BUS.LIC
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHiTECT/ENGIN'EER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF KS;;.,DUPLEX ❑ MULTI-FAMILY PROJECT IN wILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES
BUILDING: COMMERCL&L URBAN INTERFACE AREA NO FLOOD ZONE NO EICHLERHOME? aNO
e
DESCRIPTION OF WORK
62
7<
TOTAL VALUATION: — RECEIVEDJ3Y
By my signature below,I certify 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 provided is correct. I have read the Description of NVork and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building co struction. I autho`i representatives ofC�Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: /C Date:
SUPPLEMENTAL IYFORMATION REQUIRED oFTcIJsE6iv �s .
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hlfEPtllliscApp_2011.doc revised 06/21/11
OWNER-BUILDER DISCLOSURE FORI`rlI
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
EUPERT[hi0 (408)777-3228 • FAX(408)777-3333•build!no( 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 _ ..- ..AP i3P
OWNE NAME �. OWNER ADDRESS,, f
DESCRIPTION OF WORK:
-
17 6/
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.)
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.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. Iam willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
Cg'
l 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.
7 e1I understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may
po
- ect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
LZA. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
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
considered an "employer"under state and federal law.
. I understand if I am considered an"employer"under state and federal law, I must register with the state and
f doral 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.
7 ,. 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.
O»merBuilderForm 2010.doc revised 04/14/10
`7111 . 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.csib.ca.gov for more information about licensed
contractors.
M1410. 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.
1. 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.
41' 2. 1 agree to notify the issuer of this'form 'immediately of any additions, deletions, or changes to any of the
information-I-have-provided on this form. Licensed contractors are regulated by_Iaws 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 maybe in civil court. If 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 perormance 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 verify the propeffy owner's signature_
Property Owner's Signature: z,'".-7 Date:
V
(NOTE: The follotjving Authorization Form is required to be completed by the properly ov✓ner 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 necessaryto obtain an
Owner-Builder Permit for my project. I
Scope of Construction Project(or Description of Work): Tee r) Imo'
Project Location or Address: 2d2jGt y
Name of Authorized Agent: faa _ l Tel No •--c->6> r
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.
Properly Owner's Signature: � A Q Date:
OwnerBuilderForm 2010.doc revised 04./19/10