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15110197
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: 15110197 22701 STEVENS CREEK BLVD CUPERTINO CA 95014 (342 12 025) Mr & Mrs SUNIL K AND VENKATARAMAN RAMY WALIA 220701 STEVENS CREEK BLVD CUPERTINO, CA 95014-5628 OWNER'S NAME: Mr & Mrs SUNIL K AND VENKATARAMAN RAMP WALLA DATE ISSUED: 03/30/2016 OWNER'S PHONE: 408-887-7771 PHONE NO: (408) 887-7771 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lie. # Contractor Mr & Mrs SUNIL KAND VENKATARAMAN RAMY WALIA Date — BLDG _ELECT _PLUMB MEC$ COMMERCIAL I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing _ —RESIDENTIAL_ with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: ENCLOSE (E) REAR PATIO WITH (I) 1/2 BATH ( 91 SQ FT). I hereby affirm under penalty of perjury one of the following two declarations: 1. I have and will maintain a certificate of consent to self-insure for Worker's REVISION #3: PROVIDE ADDITIONAL STRUC URAL DETAILS Compensation, as provided for by Section 3700 of the Labor Code, for the FOR INSPECTION; UPDATE ELECTRICAL PLA1,1; ADD ADDITIONAL performance of the work for which this permit is issued. DOOR TO ENCLOSED PATIO. - ISSUED 6/22/201 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 REV #2 - REVISE HALF BATH TO FULL BATH. ..SSUED 6/14/16 permit is issued. CERTIFICATION REV #1 - CHANGE FLOORING FROM PAVERSI 0 STEM WALL - APPLICANT 1 certify that I have read this application and state that the above ISSUED 5/13/2016 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 Sq. Ft Floor Area: Valuation: $62500.00 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. APN Number: Occupancy Type: 342 12 025 Signature Date/§ 22/2016 PERMIT EXPIRES IF WORK IS OT STARTED OWNER-13ULDERDECLARATION WITHIN 180 DAYS OF PERMIT I SSUANCE OR I hereby affirm that I am exempt from the Contractor's License Law for one of the 180 DAYS FROM LAST CALLED INSPECTION. following two reasons: 1. 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 Issued by ABBY AYENDE sale (Sec.7044, Business & Professions Code) : as owner of the property am exclusively contracting with licensed Date: 03/30/2016 /— to construct the project (Sec.7044, Business & Professions Code). contractors RE-ROOFS: I hereby affirm under penalty of perjury one of the following three declarations: All roofs shall be inspected prior to any roofing material installed first obtaining an inspection, I agree to r 3eing installed. If a roof is move all new materials for 1. I have and will maintain a Certificate of Consent to self-insure for Worker's without inspection. 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 Signature of Applicant: Section 3700 of the Labor Code, for the performance of the work for which this Date: 6/22/201 permit is issued. ri I certify that in the performance of the work for which this permit is issued, I ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE exemption, I become subject to the Worker's Compensation provisions of the I have read the hazardous materials requirements under Chapter 6.95 of the Labor Code, I must forthwith comply with such provisions or this permit shall California Health & Safety Code, Sections 25505, 2 533, and 25534. I will be deemed revoked.. maintain compliance with the Cupertino Municipal C de, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is material, Additionally, should I use equipment or de as defined by the Bay Area Air Qua ces which emit hazardous ty Management District I correct. I agree to comply with all city and county ordinances and state laws air contaminants will maintain compliance with the Cupertino Municip 1 Code, Chapter 9.12 and relating to building construction, and hereby authorize representatives of this city the above mentioned property for inspection purposes. (We) agree the Health & SafetyCo , Sections 25505, 2 533, and 25534. to enter upon to save indemnify and keep harmless the City of Cupertino against liabilities, City in 9-0- judgments, costs, and expenses which may accrue against said - Owner or authorized agent: consequence of the granting of this permit. Additionally, the applicant understandsJDnte:2612 /2016 and will comply with all non-point source regulations per the Cupertino Municipal Code, Section 9.1 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 Date 6/22/2016 Lender's Address I understand my plans shall be used as public records.. Licensed 1 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228 • FAX (408) 777-3333 bui1dingQcup9 n2:9M NEW CONSTRUCTION ❑ ADDITION � ALTERATION / TI ' REVISION / DEFERRED ORIGINAL PERMIT ## 110 19 PROJECT ADDRESSAPN # 2 OWNER AME PHONE 71 E-MAIL �v�t CITY, S ATE, ZIP FAX STREET ADDRESS �- 9SIO i 1 22"7o I S' r v rv� qac _V vp G'v kir"Vo CONTACT NAME PHONE E-MAIL A t7 p 7 @ TA STREET ADDRESS CITY, STATE, ZIP FAX X I OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT 0 ARCHITECT 11ENGINEER El DEVELOP ❑ TENANT d CONTRACTORNAME LICENSE NUMBER LICENSE TYPE BUS. LIC COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHO LICENSE NUMBER BUS. LIC # ARCHITECT/ENGINEER NAME COMPANYNAME E-MAIL FAX CITY, STATE, ZIP i PHONE STREET ADDRESS ��II DESCRIPTION OF WORK - doop, 4001-,10,-1 .�- 1VT,4LL 61 9001' fit` f}GH�k`>✓7 , t c.I�IGf11 3i ------rte_" EXISTING USE - PROPOSED USE CONSTR. TYPE 1 #STORIES USE TYPE I OCC. I SQ.FT. ! �ALUATION ( ) EXISTG NEW FLOOR. DEMO TOTAL AREA . AREA AREA. NET ARF•A BATHROOM - KITCHEN _- OTHER _ REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: n ATTACH P�ICN UNITS: ISA SECOND UNIT ❑ YES SECOND STORY U Y EJ BEING ADDED? []NO ADDITION? ❑NO _ YES RE FVED B Y TOTAL VA UATION: ATION ❑ Y$S - YES, PROVIDE COPY OE - IS THE BLDG AN ❑ DPL# ❑NO PLANNING APPROVAL LETTEREICHLER HOME? ❑NOnature below, I certify to each of the following: I am the property owner or authorized agent t act on Property owner s behalf. I have ad this and the information I have provided is correct. I have read the Description o� Work and verify it is accurate. I agree to comply with all ap hcubpe local s and state laws relating to buil ons ction I authorize representatives of Cupertino to enter the above- nti end property for inspecti npurposes. Date:of. Applicant/Agent: CITY OF CUPERTINO BUILDING PERMIT ING ADDRESS: CONTRACTOR: PERMIT NO: 15110197 TEVENS CREEK BLVD CUPERTINO CA 95014 (342 12 025) f22701 Mr & Mrs SUNIL K AND VENKATARAMAN RAMP WALIA 220701 STEVENS CREEK BLVD CUPERTINO, CA 95014-5628 OWNER'S NAME: Mr & Mrs SUNIL KAND VENKATARAMAN RAMP WALIA DATE ISSUED: 03/30/2016 OWNER'S PHONE: 408-887-7771 PHONE NO: (408) 887-7771 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic. # Mr SUNIL K AND VENKATARAMAN RAMY WALIA Date —BLDG _ELECT — PLUMB Contractor & Mrs MECH_ RESIDENTIAL _ COMMERCIAL 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 JOB DESCRIPTION: license is in full force and effect. ENCLOSE (E) REAR PATIO WITH (N) 1!2 BATH (59 SQ FT). I hereby affirm under penalty of perjury one of the following two declarations: t. 1 have and will maintain a certificate of consent to self -insure for Worker's REV #2 -REVISE HALF BATH TO FULL BATH. IS UED 6114/16 Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. REV #1 - CHANGE FLOORING FROM PAVERS TO 3TEM WALL- 2. I have and will maintain Worker's Compensation Insurance, as provided for by ISSUED 5/13/2016 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above is I agree to comply with all city and county ordinances Sq, Ft Floor Area: Valuation: $62500.00 information correct. and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for APN Number: Occupancy Type: inspection purposes. (We) agree to save indemnify and keep harmless the 34212 025 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. PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR Signature Date 6/14/16 180 DAYS FROM LAST CALLED EiSPECTION. rn=NFR BUILDER DELI AR TION Issued by: SEAN HATCH I hereby affirm that I am exempt from the Contractor's License Law for one of the Date: 03/30/2016 O following two reasons: i. I, as owner of the property, or my employees with wages as their sole RF ROOFS: compensation, will do the work, and the structure is not intended or offered for All roofs shall be inspected prior to any roofing material be` ig installed. If a roof is sale (Sec.7044, Business & Professions Code) installed without first obtaining an inspection, I agree to remove all new materials for 2. 1, as owner of the property, am exclusively contracting with licensed inspection. contractors to construct the project (Sce.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: J� Signature of Applicant' / 1 t. I have and will maintain a Certificate of Consent to self -insure for Worker's Date: 6/14/16 Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 HAZARDOUS MATERIALS DI L URE permit is issued. I certify that in the performance of the work for which this permit is issued, I I have read the hazardous materials requirements under California Health & Safety Code, Sections 25505, 2553, Chapter 6.95 of the and 25534. I will shall not employ any person in any manner so as to become subject to the maintain compliance with the Cupertino Municipal Cod , Chapter 9.12 and the hazardous Worker's Compensation laws of California. If, after making this certificate of Health & Safety Code, Section 25532(a) should I store or handle exemption, I become subject to the Worker's Compensation provisions of the material. Additionally, should I use equipment or devices defined by the Bay Area Air Quality which emit hazardous Management District I Labor Code, I must forthwith comply with such provisions or this permit shall air contaminants as will maintain compliance with the Cupertino Municipal ode, Chapter 9.12 and be deemed revoked. the Health & Safety Code, Sections 25505, 25533, and 25534. APPLICANT CERTIFICATION certify that 1 have read this application and state that the above information is /� Owner or authorized agent / correct. I agree to comply with all city and county ordinances and state laws and hereby authorize representatives of this city Date: _ /14/1 relating to building construction, CONSTRUCTION. LZNDRnAGE1qCy to enter upon the above mentioned property for inspection purposes. (We) agree I hereby affirm that there is a construction lending agency for the performance to save indemnify and keep harmless the City of Cupertino against liabilities, of work's for which this permit is issued (Sec. 3097, Cilf C.) judgments, costs, and expenses which may accrue against said City in understands Lender's Name consequence of the granting of this permit. Additionally, the applicant the Cupertino Municipal and will comp y with all non -point source regulations per Lender's Address ,% f !'IV CONSTRUCTION PERMIT APPLIGAI [UN COMMUNITY DEVELOPMENT DEPARTMENT •BUILDINGOI ONF 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255- (408) 777-3228 • FAX (408) 777-3333 • bullding(a cu pertino. org GUPERTEHO ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI REVISION / DEFERRED OR..1rNAL PERMIT' . 5 I I G} ©o I `7 ADDRESS APN n — 2 r– 0-fZ5 PROJECT . 2-701 f, U-Vr,11s CAFFA_ gLvd CUP5AT,N0 O\d'NERNANEPHONE E-NAIL �L)/,jl L l4 I STREETADDRESS CITY, STATE, ZIP I FAX .2-2--7.1 �' 7 `t%rN� Cr2 �k LYp I G�J,o �iN� CSI al's° Ll CONTACT NAME PHO? E I E-1,2AIL STREET ADDRESS CITY, STATE, ZIP FAX L OA ER ❑ OA?'ER-BUILDER ❑ OWNER AGENT ❑ CON R4CTOR ❑ CO TR4CTORAGENT ❑ ARCHITECT- E GLnEER ❑ DEvELOPzF, ❑ TENANT CONTRACTOR NAME I LICENSE NUMBER I LICENSE TYPE BUS. LIC CObOAN1 NA.7,E I E-MAIL FAX STREET ADDRESS I CITY, STATE, ZIP I PHONE ARCHITECT ENGLNEERNAI,4E I LICENSE NUMBER BUS. LIC r' C01, PAN'Y NAME E41fL4IL FAX STREET ADDRESS I CITY, STATE, ZIP PHONE DESCRIPTION OF \ `ORi: _F 3 ( �4?gt,� Q�lK %o FU" 1- E I Tt f E?;ISTIIdGL'SE PROPOSED USE CONSTR.TYPE -STORIES USE I. Ti PE I OCC. I SQ.FT. I V?TUATION(S) EXISTG NEW FLOOR DEMO AREA TOTAL NFT:4RE.4 I I AREA .I. AREA BATHROOM REAiODEL.AREA KITCHEN REMODEL AREA OTHER REMODELAREA PORCH AREA DECK ARE TOTPT DECI-POP.CH 6.REA I GARS GE AREA: DETACH ❑ ATTACH 15�LLTNG UNTTS: IS A SECOND NIT ❑ YES SECOND STORY F71 YES EELNG ADDED? El NO ADDITION? ❑NQ PRE-APPLICATION [[YES IF YS. PROVIDE COPY OF IS.Tkit BLDG.4X❑IES LETTER EICHLERHOME? ❑NO REOEIlED�$1 :_ TOT° VALLATION: PLANN-IN❑NO PLNNNINGAPPROVAL "... 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 By my signature information I have provided is correct, I have read the Description of Work- and verify it is accurate. I agree to comply with all applicable local application and the ordinances and state laws relating to building cction. I authorize representatives of Cupertino to enter the above- id rued property for in pection purposes.. Signature of Applicant/Agent: Date 6/ OUTI\G SLIP SUPPLEMENTAL iNFORvIATION REQliIRED r IlTet6' SFD Or Multifamily d�,�ellirgs: Apply rot demolition pernllt for` OZ ERxTIrE COUZTER'-I � BUILD IN PL.4\ RE\ I£`tiTw " _ building(s). Demolition petTnit is required prior to issuance of buildin k ' z existing � E�xEss�\L pen-nit for new building, G COmnlercialBldas: Provide a completed Hazardous Materials Disclosure d ST4\D4RD x PLELIC �ORI�� _ form if any Hazardous 1\/_aterials are bei,,Ig used as Dart off 1us project. L > 4RCE, Ili z DE r Copy of Planning Approval Letter or N eeting with Planning prior to � �L�ioR x O s4\iT 1 SES3 ER DISTRICT submittal of Building Peinait application. 3 { fl. E.\� IRO 11E �TAL HE3_LTH. Bldg4pp_2011.doc revised 06121/11 CITY OF CUPERTINO BUILDINGPERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: 15110197 22701 STEVENS CREEK BLVD CUPERTINO CA 95014 (342 12 025) Mr & Mrs SUNIL K AND VENKATARAMAN RAMY WALIA 220701 STEVENS CREEK BLVD CUPERTINO, CA 95014-5628 OWNER'S NAME: Mr & Mrs SUNIL KAND VENKATARAMAN RAMP WALIA DATE ISSUED: 03/30/2016 OWNER'S PHONE: 408-887-7771 PHONE NO:; (408) 887-7771 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lie. # Contractor Mr & Mrs SUNIL K AND VENKATARAMAN RAMY WALIA Date _ BLDG _ELECT _PLUMB MECH _ RESIDENTIAL _ COMMERCIAL 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. JOB DESCRIPTION: ENCLOSE (E) REAR PATIO WITH (N) 1/2 BATH (591 S Q FT). , I hereby affirm under penalty of perjury one of the following two declarations: 1. 1 have and will maintain a certificate of consent to self-insure for Worker's REV #1 - CHANGE FLOORING FROM PAVERS TO, STEM WALL - Compensation, as provided for by Section 3700 of the Labor Code, for the ISSUED5/13/2016 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 Sq. Ft Floor Area: Valuation: $62500,00 permit is issued. APPLICANT CERTIFICATION APN Number: Occupancy Type: 1 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 342 12 025 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 PERMIT EXPIRES IF WORK IS NO 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/15 3/16 Issued by: SEAN HATCH Date: 03/30/2016 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is following two reasons: installed without first obtaining an inspection, I agree to removeall new materials for 1. 1, as owner of the property, or my employees with wages as their sole inspection. compensation, will do the work, and the structure is not intended or offered for ; j sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed Signature of Applicant ` J A , s' " U contractors to construct the project (Sec.7044, Business &Professions Code). Date: 5/13/16. (-- I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER r. 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 HAZARDOUS MATERIALS DISCLOSURE performance of the work for which this permit is issued. have Worker's Compensation Insurance, as provided for by encs un I have read the hazardous requirements under hapter 34. of the 2. I and will maintain y Cmatode, California Health &Safety Code, Sections 25505, 25533, and 25534. I will Section 3700 of the Labor Code, for the performance of the work for which this maintain compliance with the Cupertino Municipal Code, hapter 9.12 and the permit is issued. Health & Safety Code, Section 25532(a) should I store or handle hazardous 1' 3. ) I certify that in the performance of the work for which this permit is issued, I material. Additionally, should I use equipment or devices hich emit hazardous shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality M magement District I Worker's Compensation laws of California. If, after making this certificate of will maintain compliance with the Cupertino Municipal Co le, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety Code, Sections 25505, 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent: APPLICANT CERTIFICATION Date:/5 13116 CONSTRUCTION LENDING A 1 certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agenc for the performance correct. I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued (Sec. 3097, Civ .) relating to building construction, and hereby authorize representatives of this city Lender's Name to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands ARCHITECT'S DECLARATION and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records. CONSTRUCTION PERMIT APPLICATION 4 - BUILDING DIVISIONCOMMUNI Y DEVELOPMENT T 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255' (408) 777-3228 • FAX (408) 777-3333 • building(o)cuaartino.org CCIPERT[N0 IGL PDRNITT ORL� A ;: /- B /,07 ❑ ',�EYd CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI LJ REVISION/ DEFERRED I APIA' :3-h 2 —, 2 — 2 PROJECTADDRESS / 0\I vERNA]JEPHONr E-A/4IL gvrV?z_ W� Lir'+ $9.7 -7 17 I i�.1r7L1.10p7 /L core STREET.4DDRESS CITY, STATE, ZIP I FAX CONTACT NAh4E I PHOIB E-1vL&IL STREETPDDRESS p CITY, STATE, ZIP I FA -X 10/1 OV rtER ❑ 0�3TER-3liILDER ❑ O'WNERAGENT ❑ CONT?SCT0R CON-TRACTORAGEI T ElARCHITECT 13E G SEER 1:1D ViLOP R ❑ TENANT LICENSE NUn4BER I LICE? SE TIDE BUS. LIC f CONTRACTOR NAME I COA�ANY NAAE E -IJ? IL FAX + STREET ADDRESS I CITY, STATE, ZIP I PY.O\IE ARCHITECT cldGLti�ER NA 1+iE LICENSE \7UI,BER I BUS. LIC . E-MIAIL I FAX COI\,L ANY N'A?: E I _ _ CITY, STATE, ZIP TP-HOwE STREETADDRESS I DESCRIPTION OF WOP.IY, EXISTPvGLSE PROPOSED USE ( C0NSTR. Thi"PE I -STORIES — USE. I TYPE I OCC. I SQ.FT. I \ :4._L.UATIOA' (S) EX- STGNEW FLOOR DEMO AREA NET .4P E.4 I TOTAL I I AREA I AREA KIHEN I REMTCODEL AREA I 0?I-:ER I I I REIAODE AREA. BATHROOM i , R-M.O DE- AREA PORCH : AREA DECK A3.EA I I TOTAL DECK-?ORCH A- E4 - ❑ATTACH I Gra +G- A3EA. DETACH I I DWELLING UNITS: - IS A SECC\D UNIT Li TE -S --f SECOND STORY ❑YES ❑3�0 I- BELNGADDED^ ❑NO ADDITION ar . _qP PLiCAT10\ ❑ 1'ES IF 1=S, PROVIDE COPY OF IS THE BLDG A\ ❑ : tS - tcE �.E� r5I -. - "� ` TOT AO'+4E' ' $x. °-L :? Lt AiiC?�: ❑N0 PLANI�iI�G APPROVAL LETTER I EICHLER ❑'\O ;. 00 PLA?gNINGAPPL' By my c_Enature below, I certify to each of the ollovvino. I am ue property ON\, er or authorized agent <o cr on tht property owner's behalf. Iamee to comply wit have rend t his a all applicable local the inform\�ation I have provided is correct. I have read the DP c iption of Wo:k and verify ,t is ac.:«e. application and property for inspection :o building o stivctlon. I zw.horize rep.esentatives of Clap --Ino to enter the z�� de ponoses. ��ed ordinances and state lPv'+'s relating nt/Agent D to Signature of Applicant/Agent OUTI\G SLIP _ J SLrPLE.\�ENTAL iNFOR,1ATION REQUIRED La1-,-'CHFCI. A -P 1 G PLA\ RE\ IEIi N-ce\' SFD I\ nitii'a. iily dvellirgs Apply or delrlo1 ,tio n _ r e mit for © Oti FR TSE COLTER ❑ rLILDI or existing building(s). Demolitio_i Permit is required prior to issuanC:. e: bu11_dii;g F s rf x �lPRESS pr\\ building. iG Pr AIS RE\ IF\ ii permit of ne,v , PUELI Co- „ rc al Bidas Provide a CoIT_pi� d F1c�u1CI0LS Mattr'_als D_SC1OSllI"� STy\D RD «ORI a _ fOP_i1 '} l azFrdous li!2 erials are be:..ig'ISed as pain Of this project. J TIRED II CODy of Planning Appro\`al Letter or ?\reetirg \i till P1arinina priOr t0 � , L4JOR ` ��$ � { "s. ❑ 54_\IT 1 SEii ER DT�TRICT _ I _ subrliiml of Build ng Pern?it application. n s . \1fE TAI EEALTH.. L E\� IR Bldg pp_2011.doc revised 05./21/11 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: 15110197 22701 STEVENS CREEK BLVD CUPERTINO CA 95014 (342 12 025) Mr & Mrs SUNIL K AND VENKATARAMAN RAMY WALIA 220701 STEVENS CREEK BLVD CUPERTINO, CA 95014-5628 OWNER'S NAME: Mr & Mrs SUNIL KAND VENKATARAMAN RAMY WALIA DATE ISSUED: 03/30/2016 OWNER'S PHONE: 408-887-7771 PHONE NO: (408) 887-7771 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic. # Contractor Mr& Mrs SUNIL K AND VENKATARAMAN RAMY WALIA Date —BLDG _ELECT _PLUMB RESIDENTIAL COMMERCIAL MECH 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. JOB DESCRIPTION: ENCLOSE (E) REAR PATIO WITH (I) 1/2 BATH (591 SQ FT). I hereby affirm under penalty of perjury one of the following two declarations: 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 Sq. Ft Floor Area: Valuation: $62500.00 permit is issued. APPLICANT CERTIFICATION certify that I have read this application and state that the above Number: Occupancy Type: information is correct. I agree to comply with all city and county ordinances 42 3 12 025 342 R3 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 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 3-30-16 Issued by: Sean Hhatc /-y Date: 3-30-16 OWNER -BUILDER DECLARATION? I hereby affirm that I am exempt from the Contractor's License Law for one of the RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for 1. I, as owner of the property or my employees with wages as their sole i nspection. 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 Signature of Applicant: contractors to construct the project (See.7044, Business & Professions Code). Date: 3-30-16 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. 2. I have and will maintain Worker's Compensation Insurance, as provided for by HAZARDOUS MATERIALS DISCLOSURE 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. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the permit is issued. Health & Safety Code, Section 25532(a) should I store or handle hazardous 3. I certify that in the performance of the work for which this permit is issued, I material. Additionally, should I use equipment or devices which emit hazardous V shall not employ any person in any manner so as to become subject to the 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 ofthe the Health & Safety Code, Sections 25505, 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. - `Owner or authorized agent, x APPLICANT CERTIFICATION bate: 3-30-16 rnNSTRUCTION LENDINGAGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance correct. I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued (Sec. 3097, Civ C.) relating to building construction, and hereby authorize representatives of this city Lender's Name to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands ARCHITECT'S DECLARATIO will co ply with all non -point source regulations per the Cupertino Municipal andN I understand my plans shall be used as public records. R _ i CUPERTIf40 I M NVW rONqTRT TVTTnlj CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (40j8)777-3223 - FAX (408) 777-3333 building0wpertino.gra 1H I 111T1111 M A r -- . —, a — M — — — — ____ BldgApp.2011.doc revised 06121111 0 U1, I "cFZMMMJ UKIIJIINAL rhKMI I j* PROJECT ADDRESS = —20 e�*eelt,' - r APN # e2s OWNER NAME PHONEE-MAIL STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME PHON�� ZZ, -��v STREETADIDRESS le? 7 CITY, STATE, 71P FAX LI OWNER 0 OVRTER-BTJILDER DWNERAGENT CONTRACTOR U CONTRACTOR AGENT 13 ARCHITECT ENGINEER El DEVELOPER 11 TENANT CONTRACTOR NAME LIC# 01 COMPANY NAME 2 E-MAIL P.,7 FA _X - gn7 ,f"4 STREET ADDRESS A0,77z CITY, STATE, 2JP 244e�&11114 PHONE ARCHITECT/ENGfNEER NAME LICENSE NUMBER - 4_ I BUS. LTC 4 7 f COMPANY NAME ff�� EMAIL FAX_ STREET ADDRESS CI PHONE DESCRIPTION OF WORK 17 "x L EXISTING USE fl. "I 1 PROPOSED USE 121-1-1 CONSTR. TYPE 1 4 STO S 7 USE TYPE OCC. SQFT. VALUATION - 11 EXISTG AREA O. -�? NEW FLOOR AREA _51q, DEMO AREA TOTAL NET AREA BATHRMOO------- 1 OTHER REMODEL AREA - REMODEL AREA REMODEL AREA - PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ATTACH I #DWELLINGUNITS: IS A SECOND UNITES HFTNG ADDED? jq0 SECOND STORY OYES ADDITION? 'P* PRE -APPLICATION F]YES IF YES, PROVIDE COPY OF PLANNING APPL 4 [j NO PLANNING APPROVAL LETTER IS THE BLDG A EICItLER TOTAL VALUATION;„ By my signature below, I certify to each of the following: I wn the property owner or authorized agent to �Iher on the ty owner's behalf. I have read this application and the information I have C�bn veprovided iseorrect I have read the Description of Work and verify' ti Uurate. I agree to comply with all applicable local �Z curate. I ordinances and state laws relating to buil truction. I authgfize representatives pfcuperfino to enter the above -id tifte property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INMRMAf [ON REQUIRED 1ROVTITUG 'SLUP' `ExOQNTAR New SFD or Multifamily dwellings: APP"J"for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. 0'" P[ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure PUBLIC For—rn if any Hazardous Materials are being used as part of this project WRE Owl Copy of Planning Approval Letter or Meeting with Planning prior to NM. StW9141JISTRICTITAP submittal of Building Permit application. MONMENTALjH EALTH BldgApp.2011.doc revised 06121111 CITY OF CUPERTINO FF.F ESTIMATOR — BUILDING DIVISION ADDRESS: 22701 STEVENS CREEK BLVD Ila i;ecd . TDATE: 11/30/2015 REVIEWED BY: MELISSA APN: 342 12 025 BP#: *VALUATION: 1$62,500 "'PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: $0.00 PENTAMATION 1 R3SFDADD PERMIT TYPE: woRK ENCLOSE E REAR PATIO & ADD N 1/2 BATH SCOPE $0.00 1'1In € heck I'hanb. 1'l a€z ('hee4'. ]Tle,. Pfa,a (1iec 03yher £ z'w'n(n"he J}€ i'ld 1 €€'1<S i}F 7:' i2E . d7:,x7, 17F 1 t'c: ek'Iz c.;,. e e:' jlha ^'b' Lisp, l : c : E' e c insp, Fee: NnTF._ 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 preliminary information available and are only an estimate. Contact the Dept -for addn'l info. FEE ITEMS (Fee Resolution 11-053 E . 7111131 FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 [5R1A s.f. Patio Cover / Sun Room $1,575.00 1PATIOENCM Metal, Enclosed Suppl. PC Fee: Reg. C) OT FO.OThrs $0.00 PME.Plan Check:: $0.00 Permit Fee: ' $0.00 Suppl. Insp. Feer Reg. 0 OT F0.0 hrs $0.00 PME Unit Fee: $0.00 P1V Permit Fee. ':. a ', $0.00 tzo UC 11 i`€inti c1F Work Without Permit? 0 Yes (E) No $0.00 Advanced,Plann a Fee:, $0.00 Select a Non -Residential Building or Structure Strong Motion Fee: IBSEISMICR $8.13 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $3.00 STBTOTAI�' $11.13 $1, 575.00 TL 'EE $1, 586.13 .. . Revised: 10/01/2015 CUPERTINO SMOKE / CARBON MONOXIDE ALARMS OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(d.cupertino.org Permit No. ( '511 C 119'-+ Address 4-40 1 S-Tit-V[-NSCC E t k IU, 2 Cult No Cly # of Alarms Smoke: Carbon Monoxide: 1 gS01 PERMIT CANNOT BE FINALED AND OMPLETED UNTIL THIS CERTIFICATE HAS BEEN SjGNE12 AND RETURNED TO THE BUILDING DIVISION PURPOSE This affidavit is a self -certification for the installation 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 INFORMATION Existing single-family and multi -family dwellings shall be provided with Smoke Alarms and Carbon Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds $1000.00, CRC Section 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 Outside of each separate sleeping area in the immediate vicinity of the bedroom(s) X X On every level of a dwelling unit including basements X X Within each sleeping room X Carbon Monoxide alarms are not required in dwellings which do not contain fuel -burning appliances and that do not have an attached garage. Carbon 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. 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 crawl space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for alarms which must be connected to the building wiring. As owner of the above -referenced property, I hereby certify that the alarm(s) referenced above has/have been installed in accordance with the manufacturer's instructions and in compliance with the California Building and California Residential Codes. The alarms have been tested and are operational, as of the date signed below. have read and agree to Comply with the terms and conditions of this statement Owner (or Owner Agent's) Name: "SO N I L iJ AV it Si nature...... � ............................................................................ Date: IF . ...... l.. Contractor Name: Signature..... ..................................................Lio.# .... W..1 1.3b Date: 4D.1-& Smoke and CO form.doc remised 03118114 CUPERTINO WATER -CONSERVING PLUMBING FIXTURES OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 - buildinQCa)cuaertino.or4 Owner Name .=i a>`) i L WALL fir Permit No. Address �22a01 STEVENS cRC€K 9L -VP e u f & P71 t -J 0 C A-- 9 5 014E 1. Is your real property a registered historical site? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. H�_No Go to Question 2. 2. Does your real property have a licensed plumber certifying that, due to the age or configuration of the property or its plumbing, installation of water -conserving plumbing fixtures is not technically feasible? ❑ 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. Lr No Go to Question 3. 3. Is water service permanently 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. L9,No Go to Question 4. 4. Is your real property built and available for use or occupancy on or before January 1, 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 form and sign bottom of form. IS/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 sign bottom of form.. Please check ONE of the following: L" My property is a single-family residential 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 plumbing 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). ❑ My property is a multifamily residential real property. See Civil Code Section 1101.5. On and after January 1, 2014, specified building alterations or improvements shall require non- compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures. On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water - conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). ❑ My property is a commercial real property. See Civil Code Section 1101.5. On and after January 1, 2014, specified building alterations or improvements shall require non- compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures. On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). 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 plumbing fixtures in accordance with Civil Code Sections 1101.1 through 1101.8, the current California Plumbing Code and California Green Building Standards Code, and manufacturer's installation requirements, and that the waf-conserving plumbing fixtures comply with the requirements as indicated in the table on the followine Daee. IL Owner or Owner Agent's Signature: l 6= Date: U4105/201 Upon completing and signing this Certificate, pleasV return it to the Building Division in order to final your building permit. SB407 2015.doc revised 08/26/15 CUPERTIt'10 OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 • buildinw cuoertino.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 A DRESS X2 0 IIAPN... BPS f:! �VIEN.f .GQr K Gi_4v. ........ :. :. OWNSP AME _ _.. OWNER ADD.RE S � DESCRIPTION OF WORK! B$q -rN 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. 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. t 2. 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. „V_3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. X 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. X5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. IL-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 understand my failure to abide by these laws may subject me to serious financial risk. 17. 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. Z8. 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. 0WnerBui1derF6rm 2010,doc revised 0114/10 I 9 9. 1 understand I may obtain more information regarding my obligations as an 'employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or wvnv.cslb.ca.gov for more information about licensed contractors. ,Z_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. /all11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by applicable laws and requirements that govern Owner -Builders as well as employers. 9 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 maybe in civil court. Itis 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 maybe 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 note 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 verify the property owner's si natur Property Owner's Signature: Date: 1 b ------------------------------ -- ------------------------------------------------------------------------------------------------------------- (NOTE: The follov✓ing Authorization Form is required to be completed by the property 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 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 owners signature. Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revisedO4114110