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11080096-F OI'L'Y OF CU P]Ell8TINO BUILDING PERMIT IT BUILDING ADDRESS: 20624 CLEO AVE CONTRACTOR:HABITAT FOR IZAERITNQ 080096 HUMANITY SILICON VLLY OWNER'S NAME: HABITAT FOR HUMANITY SILICON VLLY 513 VALLEY WAY DAT UED:01/27/2012 0 OWNER'S PHONE: 4089426444 MILPITAS,CA 95035 IqY(�1 E NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDGV ELECT PLUMB License Class Lic.4 r— r F MECH RESIDENTIAL COMMERCIAL Contractor Date 1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: NEW TWO-STORY SFDWL-LOT 2(959 SQFT)&PORCH(42 (commencing with Section 7000)of Division 3 of the Business&Professions SQFT)TOTAL I,OOI SQFT NO-GARAGE Code and that my license is in full force and effect. 7/12/12 DEFERRED SUBMITTAL-TRUSSES-ISSD 7/19/12 1 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:$170000 I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this APN Number:36231004.20624 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES]IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180���� ®��� � �������� ®� to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 1 180)(DAYS FROM(LAST CALLED lINS PIECTIION. 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 Issued by: Date: 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. OWNER-BUILDER DECLARATION Signature of Applicant: Date: hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGSTO 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) I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: health&Safety Code,Section 25532(a)should I store or handle hazardous 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 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: — 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 Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,1 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION 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. 1 Signature Date I CITY OF CUPEIEgT][NO BUILDING PERMIT BUILDING ADDRESS: 20624 CLEO AVE CONTRACTOR:14ABITAT FOR HUMANITY PERMIT NO: 11080096 SILICON VLLY OWNER'S NANIE: HABITAT FOR HUMANITY SILICON VLLY 513 VALLEY WAY DATE ISSUED:01/27/2012 OWNER'S PHONE: 4089426444 MILPITAS,CA 95035 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING I'ERItiI1T INFO: I$I.>mC J_ ELECT PI.IJI6IH License Class Lia# IbIECH J_ RESIDENTIAL COId MERCLAL - Contractor Date I hereby affirm that I am licensed tinder the provisions of Chapter 9 JOB DESCRIIPTION:NEW TWO-STORY SFDWL-LOT 2(959 SQFT)&PORCH(42 (commencing with Section 7000)of Division 3 of the Business&Professions SQFT)TOTAL 1,001 SQFT NO-GARAGE Code and that my license is in full force and effect. 1 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. 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:$170000 permit is issued. APPLICANT CERTIFICATION APN Number:36231004.20624 Occupancy Type: I certify that l have read this application and state that the above information is correct.l 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 PERMIT EXPIRES RIF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this pemrit. Additionally,the apptica t understands and will comply 180 DAYSFROMLAST CALLED INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. � Issued by: IDat,/' Z Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: 1 hereby affirm that 1 am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,l agree to remove all new materials for 1,as owner of the property,or,my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(See.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation,a:provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the perfonnance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will mainanin I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or-handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance,with the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any nnanner so as to become subject to the Worker's Health&S ty Code,Sections 25505,25533,and 25534. Compensation laws of California. If,after making this certificate of exemption,l become subject to the Worker's Compensation provisions of the Labor Code,l must Owl r z i ���� forthwith comply with such provisions or this permit shall be deemed revoked. Date: —1/07/a CERTIFICATION CONSTRUCTION LENDING AGENCY 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 of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,grid hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnity and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all not-point ince regulations per the Cupertino Municipal Code,Section 9.13. / 1 understand my plans shall be used as public records. Signature �� Date A/ , Licensed Professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION 10300 TORRE AVENUE^ CUPERTINO, CA 95014-3255 (408)777-3228^ FAX.(408)777-333:3 - building Qcupertino.org CUPERTIINO NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADD SS APN 0 ER NAME56) E-MAII.r Piz ITY S uevn� q4a- 4 u CWeAkr4r& d lns�t� STREI M'ffls� VA "TYvu�ATE� IIP S � ISOs F �1 ''��II YC I. � 1�� -&,f+(— CONTACT NAME a+ el '1 1 P NIE E-Mgg. STREITT ADDRESS �� o,l CffY (L 1 ZI 7no f\�'ra`a ❑ CA qO-3s OWNER OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER (©❑ TENANT CONTRACTOR NAME LICENSE NUMBERqq LICENSE TYPE BUS.LIC# CO AME lz Q CbrG V E-MAIL C.W eAv r STREET ADD SS CITYAXAflO ARCHrrECTIENGBVEg N VIE LICENSE NUMBER �� P Ai S BUS.LIC f� COM &�Po�1 f�� . E�L4II sG�e n STREET Aleg c� D Sr. �D OTY,STA ZIPaA DESCRIPTION OF & (iY/YV &Q®bU SI M 6LE EXISTING USE PROPOSED USE CONSTIL TYPE k STORIES 5► V IL (, 2 USEf1 TYPE�9 OCC. SQ.FT. VALUATION(S) TG FLOOR DEMO TOTAL AREAAREAAREA NET AREA tie /�✓� y �_1 \ ZR J!�®� �� BATHROOM KITCHEN OTHER REMODELAREA REMODEL AREA REMODEL AREA PORCH 1°AREA ^,�'.. DECK AREA TOTAL DECKIPORRCHAREA GARAGERA�REA. DETACH 160 Tlr q _ SY �olra ATTACH #DWELLING UNITS: LSASECONDUNIT OYES SECONDSTORY ❑YES I BEING ADDED? �ZNO ADDITION? 5�I0 PRE-APPLICATIONS IF YES,PROVIDE COPY OF IS THE BLDG AN [ CEIV YES REED BY.. TOT ALUATION: PLANNING APPL 9 NO PLANNING APPROVAL LETTER EICHLER HOME? 3NO y I`- (/ � Co By my signature below,I certify to each of the following: I am the property owner or authorized agent to acUn the property owner's behalf. I haVi read this application and the information I have provided i orrect. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buil ' g o truction. I authonze representatives of Cupertino to enter the above.-identific4prtipeV for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER BUB.DING PLAN REvrEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ WRESS PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD [ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE I=Dom, Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVUZONMENTALHEALTH BldgApp_ OILdocrevised06121/11 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTI NO (408)777-3228-FAX(408)777-3333•building(alcugertino.org Y �y ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATIION/n REVISION/DEFERRED/ ORIGR AL PERMFr# PROIECT ADDRESS �+ V4Ire !/ APN OWNERNAME'/ Sf�iAll�al` HONE EMAIL �Q .b+ �✓- STREEI ADDRESS S f r 1l + _`� CITY.STATE ZIP 1 I I I I�S C4 f..]��� FAX��® d�� CONTACT NAA,[E � PHONE E�1S�b�g�,., 1 " STEADDRE55 CITY,STATE. FAX -3t-3Va ( \JG C ❑OWNER OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHrrELT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# �w.� cts qb®v 01 COMPANY NAME E-MAIL- FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCH17ECTIENCINEER NAME LICENSE NUMBER BUS.LIC# CCMPANYNA?VM A/""--h1 S C'ke'tia J —5*-..{ef-,r IE-MAILg��1 ( FAX S s/ �c'L 1 P►�P1c �C3Q`6'V\ D�s-r�" r.Cp f �)��0�`8��© STREET ADDRESSCJ�1' CITY,STATE,ZIP P ®� PHONFr�t� 6 9 ° DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR TYPE #STORIES USE TYPE OCC. SQ-Fr. VALUATION(5) EXiSTG NEW FLOOR DEMO TOTAL AREA AREA AREA NErAREA d BATHROOM KITCHEN OTS REMODEL AREA RFMODELAREA REMODEL AREA PORCH AREA DECKAREA TOTAL DECKIORCHARFA GARAGEAREA DETACH ATTACH #OW RI ING UNITS: LS A SECOND IINTP YES SECOND STORY 0-'I ES BEING ADDED? []NO ADDITION? .. [JNO ''............ PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: TOTAL VALUATION: PLANNING ADPL it ❑NO PLANNING APPROVAL LETTER EICBLER HOME? []NO . By my signature below,I certify to each of the following. I am the property owner or authorized agent to act cn the property owner's behalf. I have read this application and the 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 ordinances and state laws relating to buildingau ze rep es fives of Cupertino to enter the above-identifie d property for inspection purposes. Signature of Applicant/Agent: Date: ?( � SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-Tri-COUNTER ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANMNG PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Matelials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ ivL�roR ❑ SANITARY SEWER DLSTRrCT submittal of Building Permit application. ❑ ENVERONMENTAL HEALTH BldgApp_2011.doc revised 06121/11 CITY OF CUPERTINO 2 4 610 FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 20624 cleo ave. lot I DA'Z'E: 07/1212012 REVIEWED BY: bobs. APN: �' ,�� P#: *VAILUATION: $0 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair PRIMARY SFD or Duplex PENTAMATION 1GENRES USE: PERMIT TYPE: WORK deferred truss. SCOPE the/r. flan Check Plwnh, Ilan Clieck Llecl%P!an Check bfecli. Pernril Fee: plumb. Permit Fee: Eley.Prrmit Fer Other,Uerh.Insp. Lj Ocher Plurnh Insp. Otho r l;'le(.Insp. C Ilech.hz,p.Fee: Plumb. Insp,Fee: E4or. rsp. 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 ees are based on the prelimina information available and are onl an estimate. Contact the De t or addn'l info. FEE ITEMS(Fee Resolution 11-053 E,�f.' 711111) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? E)Yes Q No $0.00 � hours Plan Check,Hourly Suppl. PC Fee: O Reg. ® OT 0.0 hrs $0.00 $532.00 1STPLNCK PME Plan Check: $0.00 Permit Fee: Hourly Only? ()Yes Q No $0.00 Suppl. Insp. Fee:Q Reg. Q OT FO-0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 C0120r11(1i0n Tas: Administratiw Fee: Work Without Permit? C) Yes O No $0.00 Advanced Planning Fee: $0.00 ® hours Inspections Travei DocurnEntwion Fees: $532.00 1STINSP Inspection,Hourly 0 Strong Motion Fee: $0.00 Select an Administrative Item BldgStds Commission Fee: $0.00 SUBTOTALS: $0.00 $1,064.00 TOTAL FEE: $1,064.00 Revised: 07/01/2012 CITY OF CUPERTINO FEE ESTIMATOR—BUILDING DIVISION Is ADDRESS: lot a , REVIEWED BY: bobs DE APN: 1BP#: W ' *VALUATION: 1$170,000 "PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY SFD or Duplex 2nd Unit? Yes No PIENTAMATIION 1 R3SFDW USE: PERMIT TYPE: „ wORK construct new 2 story sfd SCOPE OCCUPANCY TYPE: TYPE OF 1F1LR AREA PC FEES PC FEE➢.IID 13P FEES BP FEE ID CONSTR. s.t R-3(Custom) II-B,III-B,IV,V-B 1,008 $2,438.81 1R3PLNCK $1,586.38 IR3INSP TOTALS: 1,008 $2,438.81 $1,586.38 rr;, i .r4`?. `eruiC l' c•" 1'!�;i ..l';r;`sut I;:c: ;i f'<' r.?.'her;rr ,...,p. Ell Oflwu 1.. wv). LEI I NOTE. These ees are based on the prelimingg information available and are on! an estimate. Contact the IDe t or addn'l in o. FEE ITEMS (Fee Resolution.11-053 Eff'.'i li"I 1) FEE QTY/FEE M ISC IT1EIJtiIS Plan Check Fee: $2,438.81 Select a Misc Bldg/Structure Suppl.PC Fee: G Reg. 0 OT 0.0 hrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: $1,586.38 Suppl.Insp.FeelO Reg. OOT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Constr.Tax: IBCONSTAXR ET1 units#new $579.61 Acoustical Fee: 0 Yes (D No $0.00 Q Work Without Permit? 0 Yes E) No $0.00 E) Planning PLLONGRNGR $131.04 Select a Non-Residential G Building or Structure d Strong Motion Fee: 1BSEISMICR $17.00 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $7.00 SUBTOTALS: $4,759.84 $0.00 TOTAL FEE: 1 $4,759.84 Revised: 07/04/2011 %15- , `�yr?-/- Bu illding 1(Deparrtment City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 Telephone:408-777-3228 C M P E RT 0 N O Fax: 408-777-3333 CONTRACTOR SUBCONTRACTOR UST JOB ADDRESS: 206'.1d{ Ckk o Avp. PERMIT# QO OWNER'S NAME: 1,ter pew- f3c S is r-a dam► PHONE# GENERAL CONTRACTOR:�{q�,;}mss cr 5Rsv BUSINESS LICENSE# ADDRESS: ��,/ roael,�� CITY/ZIPCODE: q&&!r *Our municipal code requires all 661nesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITE' OF CUP ERTINO BUSINESS LICENSE. I am not easing any subcontractors: ; Signature Date Please check applicable subcontractors and complete the following aanfformnflon. V S>I BCONTIBAC70R BUSINESS ESS RAMIE BUR NESS ILX ENSIE# Cabinets &Millwork Cement Finishing Ala -,IN o,,c -v-4 •.1,} ^�"10 _ ' :, ,�; Electrical Excavation �1 Fencing Flooring/Carpeting Linoleum/Wood Glass/Glazing f Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving D��E . C'n�^-C+CwH'— Plastering Plumbing IJ Roofing ��ar���i �@o�-per Septic Tank f Sheet Metal __j; Iacc,"- M� ,� P> ��`� - Sheet Rock Tile Date w seer/Contractor Signature / ) OWNER-BUILDER DiSCLOSURE FORM, COMMUNITY DEVELOPMENT DEPARTMENT^BUILDING DIVISION 103DO TORRE AVENUE ^CUPERTINO,CA 95014-3255 O U P E RTE M® (4D8)777-3228 ^FAQ (408)77 7-3333= buiidinQ C1JDertino.orQ Dear Properly 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 �si /���A �e 6 , �iPfJ _ g,r� BP# o o R NAM " _qd q�) lli4L1� O VV( D VEL l.Ui4`t� M(LSC S OA l` 35 DESCRIPTION OF WORK: 60/9772&6f!O,J DC 91A.12-;,46 L 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'acid ress-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 (DIR,E,.CITIONS:Please read and initial each statement below to signify you understand or verify this information.) 61. 1 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. -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. &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. 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. 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the otal 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. 1-4' 6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and federal government,withhold payroll taxes, provide workers'compensation disability insurance,and contribute to unemployment compensation for each"employee." I also understand my failure to abide by these laws may subject me to serious financial risk. 7. 1 understand under California Contractors'State License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. W-8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. DirnerBuildPrForn: 2010.doc revised 09/19/10 L e T� 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 Califomia 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 v,�wvr.cslb.ca.gov for more iniormation about licensed contractors. m—d10. I 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. NAL11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. *-12. 1 agree to notify the issuer of this form immediately of any additions, deletions; or changes to any of the iniormation I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license,the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property,you may be held liable for damages, If you obtain a permit as Owner-Builder and wish to hire Contractors,you will be responsible for veru ing whether or not those Contractors are properly licensed and the status of their workers'compensation insurance coverage. CONSTRUCTION LENDING AGENCY _(DIRECT_(_ONS:-0ease_complete_the-follo.wing_cons truction-len ding.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: /v� LZIV / -- 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' suing the permit. Note:A copy of the property owners driver's license, form notarization, or other verificatio c ptable to the city may be required to be presented when the permit is issued to veru the ro ertowner's si n cure I Property Owner's Signature: Date: - - ------------------------------------------------------------------------------------------------------------------------------------------- (NOTE: The follov✓ing Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner-Builder). AUTHORIZATION OF AGENT TO ACT Oil 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: Tel No 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. Property Owner's Signature: Date: Oi4,y7e'Buildel-FOJ-n72010.doc reilLc-J 04114/10