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15120110SIU CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21152 MCCLELLAN RD CONTRACTOR: SOSO THOMAS N AND PERMIT NO: 15120110 DOLORES C TRUSTEE OWNER'S NAME: SOSO THOMAS N AND DOLORES C TRUSTEE 5630 PYRACANTHA DR DATE ISSUED: 12/14/2015 OWNER'S PHONE: 831-419594 CUPERTINO, CA 95014-4265 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL CONSTRUCT (N) 144 SF UTILITY SHED AT REAR. License Class Lic.# 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: 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: $2500 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 35903052.00 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 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS FROM LAST CALLED 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 Issued by: Date: L 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. DECLARATION OWNER -BUILDER Signature of Applicant: Date: 1 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) 1, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will 1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District 1 performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505, 255 5534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agen Date: 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 C RUCTION 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 regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Iq y orf Signature Date /G1az5— CONSTRUCTION PERMIT APPLICATION 1 CON410UNITY DEVELOPIdiEN T DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 85014-3255 CUPERT[NO (408) 777-3228 - FAX (408) 777-3333 • buildinola cuoerino.ora / f ® NEW CONSTRUCTION ❑ ADDITION 1 U 1 (c I.- ❑ REVISION/DEFEND ORIGIKA PROTF,CI fDDP.ESS I .L pERMIT T A -PN' R O'V1WZR NAf.�' _ PHONB sTP;rADDRESs I" vdo5oltt� /nr�;/. �u1� /tint: -S C A crry, A D,1, , sT r ZI? f1 �ac�ir FAx all � s U I PHONE S-1 =--I ADDRESS Do,, crtY' aria,—, 'Fli ,„��( Iit -I&jI( 7j �AX Otl�eit I oWnv-R.ntTIID ❑ogn�AG_,-r ❑co"-,RACTOP ❑col-1?.acToaAG-,7 ❑ ARCTzTCT ❑ CONftiA"CrORNAV_ GN =-- ❑ A`1- LOPS ❑ — u�Ns IvLII✓,3r^R ,_NAhT 601.4PANY NA>,�'__ YP LICENSE TE I BUS. LIC # E -N 4II, STREET' ADDRESS FAX I CITY, STATE, c, ZI? PHOh� ARC UEC1ENG-IN_E_RNEug _ I LIC�SE f\^SABER BUS. LIC COMPANY NAb r FAX STFIFT ADDRESS CITY, STA—,r, ZIP P ti01•;E DESC?,21I0N OF t;+OP.K �AG I I,'EW FLOOR DEMO TOTAL USE I TYPE � OCC. � SQxT. I VALUATION (S) BA EMOOV iC.--�T OrrrJ2 iLVODEI �SLa R_A40DELAREA I p�,40D=LA'�A ATTACi 4 DW -9 -LING Ui,7rS: I 1S A SECOND UNIT e ❑YPS SECOND „TORY I]1iS BEING ADDED? []NO ADDITION? ❑Np I PR_ , PLICATION ❑ NO 12- � S, ?RO\ �= COPY Or I IS TIRE BLDG AN ❑ 1 cS PLtRSnG?3PL: []NO ?Lf?7,�GE�.= owj-L=TT=R EICHLERHO1.SE? p 1C 7OT.ALVr'.L.UA'1ION:''� By my r'ga_:ere below, I ce; ify to Baca of the felloz,,inz I an"'het property o;;lller or authorized agent to act on the property ow Ier's behalf. I have read his 2pp!icatien and the information I have provided is correct. I have read the Description of Work and verily it is actuate. I a� ee to comply with all applicable local ordinances and state laws relating to building const action. I autttoriu representatives lues of Cupertino to enter the above-identised prope„y for inspection purposes. Si atuseofAoplicant/Agen` %rt-%�/” Of$— • ' ��-----._] - Date• SUPPLED NTS AL LNFORI`ATIO{� D-�� OTT ?;ew StD OI l lllltifily Li;;reliLngs: Apply .`oI demolition 1 A� lit foI- �'�y eaiSting bL 1IG Q(S). Demolition permit is required prior t0 :SSL=ice or builoLna F L�T�Z�GBLAT, RE��-�5 penmit for new buildine. � I Y - d �""��...t - - Co.:,,nerciaiBldgs: Provide a wmpleted Hazardous 1laterials Disclps'" =L,c�.�� :o-1 i f�1y Hazardous Materials are being used as part Ot lois project. � . ��_*�- �� ��' c rlwl0 er EDEP� _Copy of P12tu1ing Approval Letter, or Neetirg with Planning prier to W0s txs' av u� ?"any: submittal of Building Pe -,lit application. Bldgl�p_�011.doc revised 06/21/11 ww CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION W ADDRESS: 21152 McClellan Rd DATE: 1 211 4/201 5 REVIEWED BY: Phuong APN: 359-03-052 131'4: *VALUATION: 1$2,500 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Duplex USE: 0.0 PENTAMATION 1 GENRE PERMIT TYPE: i WORK Construct N 144 SF Utility shed. SCOPE NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, tire, Sanitary Sewer District, School rl'* tf s atn 1 Tho faac oro ha d nn tha nraliminary infnrmatinn availahlo and aro anly an estimate. Contact the Dent for addn'l into. FEE ITEMS (Fee Resolution II -053 Eft. ? 1,-73) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 =# $430.00 Shed ISHED Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 Penn it Fee: $0.00 Supp1. Insp. Feer Reg. () OT Q,Q hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 '_'flilslrllction Tax: 1(liJtl7it:1'{f"LFICi: Fec O Work Without Permit? 0 Yes 0 No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg; Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $1.50 $430.00 TOTAL FEE: $431.50 Revised: 10/01/2015 A Microso TI -e Hot Rod Service Co. 19169837037 p.1 1-408-375-3590 p.1 OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT- BUILMNG DIVISION 10300 TORRE AVENUE • CUPERTINO. CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 - buildinciO)cupertino-ora 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 ADDRESSt3� !(l S� cG � �l� APN OWNER NAMEO ANDRE i�orst N &Sc) �jc �IrtC�r►Ltl�q ;tit. SN�vt�r S.7af -vc s DESCRIPTION OF WORK; Are are providing you with an Owner -Builder Acknowledgment and Informatior 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 urless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERJFICATJON OF INFORMATION (D!RECTiCNS_ Please read and initial each statement below to signify you understand or verify this raformation.) �1- I understand a frequent practice of unlicensed persons is to Pave 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-Buiider, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees white working on my property. Uy homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Bui(der and am aware of the limits of my insurance coverage for Injuries to workers on my property. okk-12. 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_ 4!U3. t understand as an "Owner -Builder' I am the responsible party of record on the permit. 1 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. JV4. t understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contrails. ". i understaird if I employ or otherwise engage any persons, other than California licensed Contractorsth , and e total value of my construction is at least five hundred dollars ($540), including labor and materials, I may be considered ar "employer' under state and federal law. � 6. I understand if t am considered an "empioyeu" 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 taws may subject me to serious Fnanciaal risk. = dential 1 understand underCalifomia Contractors' State License Law, an Owner -Builder who builds single-famJy istructures cannot legally build them with the intent to offer thern for sale, unless alf work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, of all of the work is performed under contract with a licensed general buik*V Contractor. A/,,//Z_ 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 Qyfrvg5) mat rmuit from any latent castwoon defects in the workmanship or materials- OrmcrBtutdtrFcrm_7010.doc revised 01,1'14/10 M icroso The Hot Rod Service Co. 't 19169837037 p.2 1-408-376-3590 a 2 ,e9. 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 CalifomEa Division of Industrial Accidents. I also understand I may contael the California Contractors' State License Board (CSLB) at 1-8C0-321-CSLB (2752) or www.r-sth.ca.gov for more information about licensed contractors. ,Ad4o. I am aware of and consent to an Owner -Builder binding permit applied for in my name, and understand that I am the party legally and fmancialy responsible for proposed construction activity at the site address listed above. 1404- 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-8uilders as well as employers. ,92- I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information 1 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 indMdual or firm is injured while working on year property, you may be held liable for damages. rf you obtain a oermit as Owner -Binder and wish to hire Contractors, you will be responsible for verifying whether er not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DlRFCTIONS. Please compiete the foilowing 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 diiver's ffcense, 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 sfcnature. Property Owner's Signature: Cate - ----- - - - - ------------ ---------------------------------------------- (NOTE. The following Auttronzation Form is required to be completed by rhe property owner only when designaVng 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 1 understand is my personal responsibility, I hereby authorize the following persons) to act as my agent(s) to apply for, sign, and fire the documents necessary to obtain an Owner -Builder Permit for my project. Sine of Construction Project (or Description of Work): Project Location or Address: _ f t s�. M o ' �C. rl ;Z tJ Name of Authorized Agent: /Tel No t%cte'� - ` c, Address of Authorized Agent l `�U I Jedare under penalty of perjury that t am the property owner for the address listed above and I personalty filled out the a xwe information and certify its accuracy. Note: A copy of tine 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. 7"operty Owner's signature: r? Date: DFG iolt-6 1k)/S— Owne!BwrderForm 7070 doe revised 04/14/1.