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11080098-F CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20626 CLEO AVE CONTRACTOR:HABITAT FORRMI 1080098 HUMANITY SILICON VLLYa , 0 OWNER'S NAME: HABITAT FOR HUMANITY SILICON VLLY 513 VALLEY WAY E ISSUED:01/27/2012 OWNER'S PHONE: 4089426444 MILPITAS,CA 95035\" Z PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION o r r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lie.0 MECH RESIDENTIAL COMMERCIAL Contractor Date 1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: NEW"TWO-STORY SFDWL-LOT 4(1009SQFT)&PORCH (37SQFT). TOTAL 1,046 SQFT-NO GARAGE. (commencing with Section 7000)of Division 3 of the Business&Professions 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: 1 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:36231004.20626 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that 1 have read this application and state that the above information is ]PERMIT EXPIRES IF WORK IS NOT STARTED correct.1 agree to comply with all city and county ordinances and state laws relating WITHIN" ��®�� ®� PERMIT ISSUANCE®� 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. ION. 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 all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RF,-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: I hereby affirm that 1 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). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will 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 1 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,1 CONSTRUCTION LENDING AGENCY 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, w'ork'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. Signature Date �� CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20626 CLEO AVE CONTRACTOR:HABITAT FOR HUMANITY PERMIT NO: 11080098 SILICON VLLY OWNER'S NANIE: HABITAT FOR HUMANITY SILICON VLLY 513 VALLEY WAX DATE ISSUED:01/27/2012 OWNER'S PHONE: 4089426444 MILPITAS,CA 95035 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG f— ELECT r PLUMB r- License Class Lic.# NgECH RESIDIENTI41, COMMERCIAL, Contractor Date hereby affirm that I am licensed under the provisions of Chapter 9 .1013 DESCRIPTION:NEW TWO-STORY SFDWL-LOT 4(1009SQFT)&PORCH (commencing with Section 7000)of Division 3 of the Business&Professions (37SQFT). TOTAL 1,046 SQFT-NO GARAGE. 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. 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:36231004.20626 Occupancy Type: I certify that I have read this application and state that the above infomtation 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 PERMIT EXPIRES IF WORK IS NOT S7AR7 EID indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the WI'I'IIIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS IP'I8OM LAST CALLED INSP EC'I'I®N. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued b Date-""?—;7--!/ Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: �Ih,reby affirm that[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,t agree to remove all new materials for I,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(See.7044, Business&Professions Code) Signature of Applicant: Date: 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER [hereby affirm under penalty of perjury one of the following three declarations: 1IAZARDOUS MATERIALS DISCLOSURE I have and will maintain a Certificate of Consent to self-insure for Worker's Corn pensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain 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 ani 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,l shall maintain compI' ice with the Cupertino N4unicipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health&, afe Code,Sections 25505,25533,and 25534. Compensation laws of Cal iforn in. If,after making this certificate of exemption,l P become subject to the Worker's Compensation provisions of the Labor Code,l nmst Owner or• Date:Ila! I forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATIONCONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is l hereby affirm that there is a construction lending agency for the performance of work'scorrect.I agree to comply with ail city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and 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.Additional[y,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.13. ---�//'� / l understand my plans shall be used as public records. Signature Date / /T�//i/ver Licensed Professional I CONSTRUCTION PERMIT APPLICATION :B COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 950143255 (408)777-3228 • FAX(408)777-3333•building(cDcupertino.org CUPERTINO I ❑NEW CONSTRUCTION ❑ ADDMON ❑ ALTERATION/TI 9 REVISION/DEFERRED ORIGINAL PE U ffr 4 PROIECTADDRESS !1 A �� / @ � ^ VN# '� / L/ OWNER NAME t 7( b,,. 4r NHgwA �Qll PHONE(- STREET ADDRE�SS� CITY.STATF_ZIP r t; c` ^ C� / FAX l A�MX/l- 6 CONTACT NAME goo r\+a, STREET ADDRESS `�j CITY,STATE IIP ❑OWNER ROWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME. LICENSE NUMBER LICENSE TYPE BUS.LIC# �cpw.T q�e v P COMPANY NAME E-HAM FAX STREI•Z'ADDRESS CrTY,STATE,ZIP PHONE ARCHriECT/ENGINEER NAME _fcA-e r/ 11 SE NUMBER l\ S,6 BUS.LIC# COMPANY NAME '3_" "' SC%t-,f a r�^ I�f'e�� E-MAIL o K int°may- H OrM 01 Oi jrz� STREET ADDRESSCITY,STALE ZIP PHONE st,L Cl 2516-)gc�r6 X66 �s�s DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR TYPE #STORIES USE TYPE OCC SQ.FT. VALUATION(S) EGSTG NEW FLOOR DEMO #-f- AREA TOTAL AREA AREANET.4AE?.BATHROOM KITCHEN REMODEL AREA REMODELAREA EL AREA PORCH AREA DECK ARE°. TOTAL DECIC/PORGIGE AREA: DETACH ❑ATTACH #DWELLING UNITS: IS A SECOND UFTT' ❑YES SECOND STORY ❑YES BEING ADDED? ❑NO ADDITION? ' []NO PRE-APPLICATION 1]YES IFYES,PROVIDE COPY OF IS TIDE BLDG AN ❑YES RECEIVED BY: TOTAL VALUATION: PLANNING APPL# []NO . PLANNING APPROVAL LETTER EICHLER HOME? ❑NO By my signature below,I certify to each of the following I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct I have read the Description of Worst and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buil ' constru tion. I authorize sentatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant(Agent Date: SUPPLEMENTAL INFORMAnON REQUIRED PLAN CHECK TYPE qRO=G SLIP New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-TEM-cOUMR ❑ BUILDING PLAN REVM7V existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ DRESS ❑ PLANmcPLAN REVIEw Commercial BldgS: Provide a completed Hazardous Materials Disclosure ElSTANDARD El PUBLIC WORKS fo_rm if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ Faiz D» _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ NEAJOR ❑ sA=ARY SEWER DISTRICT submittal of Building Permit application. ❑ ENvIRoNMENT.AL BEALTH Bld r_Appj011.doc revised 06/21/11 I ( 0�- CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 - (408)777-3228- FAX(408)777-3333 - buildinQCcDcupertino.org CUPERTINO NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROTECT ADDRESS � 4- GSC '.4 APN o NAME mAo &,%) VAaf 6 44a Z,9414 1 3,08 E'TwekVcrr WkS V,Orr STREET ADDRESS, /q CITY, ST�ApTE.ZIP /�p FA--* y CONTACT N,-ME�i �r R�J W �i M1 PA 7p/� I19 I� °1 STREET ADDRE(S� O �� (L Ir `A ❑OWNER OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME .a� 1 LICENSE NUMBER O,o r_ LICENSE TYPE BUS.LIC p COMPANY NAMEgorW tlyrrswf5y &UP,II � EMAIL o eavere STREET ADDRESS 51� b A I L cITY S IT)LV�'i�MS � /fir 0 A Lta-OfO ARCHITECT/ENG F Nr MF�f 41 LICENSE NUMBER �/(/g n v' r� BUS.LIC# COMPANY NAME G �v� 111 C. E�w�.a..� C^.�d��Gc STREET ADDRESS�D _ir>9-1. -4 0700 CITY.�� 0, q .l g 51--a, � DESCRIPTION OF WORK �/ EXISTING USE PROPOSED USE - CONSTR.TYPE I STORIES SIQ(C�ti 9 USE TYPE pOCC. �SaQ.FT. VALUATION(S) AREAEXIST �FLOOR DAREA EMO. TNET AREA�OTAL �`�G IZL1 BATHROOM KITCHEN OTHER 1 REMODELAREA REMODEL.AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGEAREA: DETACH ATTACH q DWELLING(UNITS: 15 A SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? )R8 o ADDITION? _ �70 *PRE-APPLICATION YES IF YES,PROVIDE COPY OF IS THE BLDG AN )E33 YES RECEIVED BY:. TOTAL VALUATION- ;2 , PLANNING APPL NO PLANNIIVG APPROVAL LES�R EICHLER HOME? WO `) CSO lJt/ By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prrperty owner's behalf. 1 have read this application and the information I have provi6. 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 b ' nstructi I authorize representatives of Cupertino to enter the above-idendZ prr�op for inspection purposes. Signature of ApplicanUAgent: Date:_ e� � SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for ❑ ovER-TETE-coummR BUILDING PIAN RENUW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPREss 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 FIRE DEP, _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR g SANrIARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_?011.doc revised 06/31111 CITY 01F CUPERTINO FEE ESTIMATOR-BUR LIlDING Df VffSffON IF I ADDRESS: lot 4 DATE: 08/12/2011 REVIEWED BY: bobs APN: #: 'VALUATION: 1$170,000 'PERMI'H TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY SFD or Duplex 2nd Unit? lies No PENTAMATIION 1 R3SFDR USE: PERMIT TYPE: WORK construct new 2 story sfd SCOPE OCCUPANCY TYPE: TYPE OF IFILR AREA PC(FEES PC]FEE RHD BP]FEES BP PEE RHD CONSTR. s.f. R-3(Production Phase) II-B,III-B,IV,V-B 1,046 $1,257.93 1R3REPPLNc $1,586.38 1R3REPINSP TOTALS: 1,046 $1,257.93 $1,586.38 , y Fee- ,;a3Ci7. t''..<°�..F2:':;'f,: ,.%tifi%;. r<C7?i.,i'rE:f:k .,:3:', l+i{IR c:,,•..<.„ry .. • ��, ¢•J'£Y�•'i<`!< . (.lai7l<I .. ..,. 1;11,17. ...<... in,"o f`ee .�.. NOTE.These ees are based on the prelinfinaryin ormation available and are only an estimate. Contact the De t or addn'l info. ]FEE ITEMS (Fee Resolution 11-053 Eff.7;1-"111 FEE QTY/FEE Ia ESC R'1C]EMS Plan Check Fee: $1,257.93 Select a Mise Bldg/Structure Suppl.PC Fee: E) Reg. 0 OT 0.0 hrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: $1,586.3 Suppl. Insp.Feed Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Constr.Tax: 1BCON5TAxR 1 a new units $579.61 Acoustical Fee: 0 Yes (E) No $0.00 0 Work Without Permit? Q Yes 0 No $0.000 Planning Fee: PLLONGRNGR $135.98 Select a Non-Residential Building or StructureUj Strong Motion Fee: 1BSEISMICR $17.00 Select an Administrative Item BId,&T Stds Commission Fee: IBCBSC $7.0011$3,583.90 $0.00 '>c®'Fi�l[ FEE: $3,583.90 Revised: 07/04/2011 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CQ.DPERTINO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR UST JOB ADDRESS: o6�y 20(, 6 �c6 1a63e C/ro �4„p_ PERMIT# 99 005 OWNER'S NAME: Fos- a3� S,`I,rc VIAS HONE# 5-10 — a 5 - 6,3e`/ GENERAL CONTRACTOR: FRSV BUSINESS LICENSE# ADDRESS: X619 a�-ond CITY/ZIPCODE: 6-,Y-l" *Our municipal code requires all 6usinesses 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 CITY OF CUPERTINO BUSINESS LICENSE. ]I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LTCIENSE # Cabinets & Millwork Cement Finishing /�'n qh Coxc ��•-}� ( 57P �� 1 L Electrical Excavation Fencing Flooring/Carpeting Linoleum/ Wood Glass /Glazing Heating Insulation Landscaping Lathing Masonry Painting/ Wallpaper Paving Dv 31= 0-7 Plastering Plumbing Ir''ro-F�c-4 �o�.� Roofing v%c v cl �4b„w� Septic Tank Sheet Metal a c o,-}- M-e-}-e' _S S"/`7 k Sheet Rock a� ;� �� 3 8 7 0 Tile \ ' Z-7 113 caner/Contractor Signature is 'Ii+ 3"7�- C° vy�k7 1 Date J � � OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 103D0 TORRE AVENUE ,CUPERTINO, CA 95014-3255 CUPERTIMO (408)777-3228- FAX (4D8)777-3333 - buildina aQcuDertino.orq Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE.ADDRESS fiv)k 'c/ .4PN _��,/� I �j BRA D �pA�� N R NAM g I'. �GN� I� l�l/hlE W,4q Al /!T, 64 ?JM3_1;' DESCRIPTION OF WORK: IVW WV0771) 6"7 _2A&,-'9 /L 1_MAWL-,— 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-farm-to-us-at our official-address-indfcated An-agent-of-the owner cannot-execute this notice uhldss you,the property owner,obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECT/ N5:Please read and initial each statement below to signify you understand or verily this information.) I understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner- Builder'building permit that erroneously implies that the property owner is providing his or her own labor and material personaily. 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 forthose injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my insu ance 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. &iIN 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 nam instead of my own. 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. /W..._5. 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 yc�o��ns�idered an "employer"under state and federal law. (W)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 nmetoserious financial risk. ( A1 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 erformed under contract with a licensed general building Contractor. W-, 8,;*[ 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. 0wnerBvi7dzrForm 2010.doc revised 09/14/10 C9. 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 www.csib.ca.gov for more information about licensed contractors. &_J10. 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. 6k11. 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. W-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 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 verifying whether or not those Contractors are properly licensed and the status of their workers'compensation insurance coverage. CONS-rRUCTIONI LENDING AGENCY _ _(DIRECTIONS:_P_lease.complefe_th.e_follo�Ning_construcfion_lending_agency_in;ormation.) -. _ _ __ _._ ___ .___ ._ _ I I hereby afnrm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) I Lender Name: kyn 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 verifrcan accepTble to the city may be required to be presented when the ermi'is issued to vert the rope owner's i t e. Property Owner's Signature Date; ---------- -------------------------------------------------------------------------------------------- ------------------ --------------- (NOTE. The following Authorization Form is required to be completed by the property owner only when designating an agent of the properly 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: 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 owners signature. Property Owner's Signature: Date: a i,77erBuilderForm 2010.doc revised 04/14/10