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11080099-F CITY OF CUPERTINO BUILDING PERMIT S BUILDING ADDRESS: 20630 CLEO AVE CONTRACTOR:HABITAT FOR PERM T No 80099 HUMANITY SILICON V /� OWNER'S NAME: HABITAT FOR HUMANITY SILICON VLLY 513 VALLEY WAY ODATE ISSUED:01/27/2012 OWNER'S PHONE: 4089426444 MILPITAS,CA 95035 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT PLUMB License Class Lic.# Ir I- r— MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: NEW TWO-STORY SFDWL-LOT 1(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. 7/12/12 DEFERRED SUBMITTAL-TRUSSES-1SSD 7/19/12 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:$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:36231004.20630 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+ WORT{IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN Igo 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 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: 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 1 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 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: Dat permit is issued. e: 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,t 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. V Signature 'S — `� Date [ 1? 91t-i I CITY OF tCU PICflgTINO BUILDING G IPIERiMIIT BUILDING ADDRESS: 20630 CLEO AVE CONTRACTOR:HABITAT FOR HUMANITY PERMIT NO: l 1080099 SILICON VLLY OWNER'S NAME: HABITAT FOR HUMANITY SILICON VLLY 513 VALLEY WAX DATE ISSUED:01/27/2012 OWNER'S PHONE: 40894264.44 MILPITAS,CA 95035 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BI:IILIIDIIIVG I'Ell8lalllT IllliF®: BLDG ELECT PLIrJM16 License Class Lie.# IbIIECH RESIDENTIAL r COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:NEW TWO-STORY SFDWL-LOT I(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 Workers 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:36231004.20630 Occupancy Type: I certify that I 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 IF 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 IIO®DAYS OF PERMIT IT IISSUANC E (DR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. ON. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued by: ]Date: �� 7 Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I 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,I 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(Sec.7044, Business&Professions Code) Signature of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(See.7044,Business&Professions Code). ALI,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,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& Section 3 700 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 y 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 mariner so as to become subject to the Worker's Health& afety Code,Sections 25505,25533,and 25534. Compensation laws of Califomia. If,after making this certificate of exemption,t become subject to the Worker's Compensation provisions of the Labor Code,l must forthwith comply with such provisions or this permit shall be deemed revoked. Date: APPLICANT CERTIFICATION CONSTRUCTION FENDING 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's correct.I agree to comply with all city and county ordinances and state laws relating I for which this pennit 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address cysts,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 non-point source regulations per the Cupertino Municipal Code,Section 9.13. I understand my plans shall be used as public records. Signature Date Licensed Professional CONSTRUCTION PERMIT APPLICATION aa.... COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION ' 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228•FAX(408)777-3333- building(8cupertino.org GUPERTINO i ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS �� J� �' $ 6 OWNER NAME q,,b I,+ _` ,, 1TREETADD1E1S.5•,) OYII ��a C17 C. STATE �h P 8 � <4- so:( y F y�� CONTACT NAND IL_ �®N� PHONE(61®�*?W E MAILAy I"'+r e& s� STREETADDRESSSr@OI�� !L C17Y.STATE IIPA14 �, / TroFAX( 1& y Piny ❑OWNER OWNER-BUITD�ER ❑ OWNERV�AGGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ CA ❑ENGINEER l❑ DEVELOPER dt❑TENANT CONTRACTOR CONTRACTOR N LICENSE NUMBER LICENSE TYPE BUS.LIC N dfikbwe J COMPANY NAME E-MAEL FAX STREW ADDRESS CITY,STATE,ZIP PHONE ARCHTTECTIENOWEER NAME pIy eJ J. LICENSE NUMBER S 6 BUS.LIC 43)-3 .5 COMPANY NAME � E MAII. @Q",M 0 1/l SS e COW\ FC�Ib J�C�`v_1�l c STREET ADDRESS/ r CITY.STATE,ZIP PHO �,,� FTI- Clair `rs6 � 110-536-�/�� DESCRIFRON OF WORK EXLS71NGUSE PROPOSEDUSE CONSTF-TYPE #STORIES USE TYPE OCC. SQ-FT. VALUATION(S) EXLSTG NEW FLOOR DEMO TOTAL AREA AREA AREA NETAREA - BATHROOM KITCHENOTHER REMODELARFA REMODEL AREA REMODEL AREA PORCHAREA DECK AREA TOTAL DECK/PORc'AREA GARAGE AREA: DETACH ATTACH #DWELLING UNTrS: ISA SECOND UNrT ❑YES SECOND STORY ❑YES BEING An ❑NO ADDITION? ❑NO PRE-APPLICATION []YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: TOTAL VALUATION_ PLANNING APPL A ❑NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO 1 2 1 1 0 By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prterty 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 4tdihng constrncoon. I autho,V=representatives of Cupertino to enter the above-identified property far inspection purposes. Signature of Applicant/Agent Date. 0 11 Q SUPPLEMENTAL RNTOFMATION REQ D PLAN CBECICTYPE ROUTING ST.2 New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-TBE-COUNTER ❑ BUMI)MG PLAN a>rV W existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REvIEw Commercial Btdgs: Provide a completed Hazardous Materials Disclosuas re ❑ STANDARD ❑ PLIC WORxs 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 ❑ hIAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH Blda 4ppjOl Ldoc revised 06121/11 I I I oA ou CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTlO (408)777-3228• FAX(408)777-3333 ° building(cDcupertino.org NEW CONSTRUCTION ❑ ADDMON ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROIECr ADDRESS Iw . APN � 6�q r�8{ %15t7 1 OWNER NAME (1Y 1 '� \ PHO � ` � IL ST= RE EMAILn ��PiO'� 171��SM.®� STADDSS 5I 3 RILL e i Y� � L� s OA ` oas +a-�►� CONTACT NAME (� S PH 3Ib-(a�� E (i Wemie rp, STREEC ADDRESS CrVATE.ZIP :Ll ❑OWNER OWNER-BUILDER ❑ OWNEAAGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARC=CT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME I1-4T IR 44MA0110SWCOV� EMAL &il Wei.\1er_& W� 9\1-,ON `6q+& STREET ADDRESS 513 �A� V� = L r 1 ARC1UT1iCT/ENft -I Cp/�,,_ LICENSE NUMBER BUS.LIC# COMPANY NAME�n jy E MAm rf-sh LACI k� .'yO. F (_6g0q STREETADDRESS CITY, , gs -AI VI DESCRIPTION OF WORK MCA) PP 11 C17O w` OF �5i^`! I` I EKLSTING USE PROPOSED USE CONSTR.TYPE #STORIES BIOME rmq REs r7(� USE TYPE OCG SQ.FT. VALUATION(5) AREA AREA AREA G AAR �OOR 1 DEMO TCTAL NETAREA �o�Q 0��-- BATHROOM KITCHEN OTHER REMODELAREA REMODEL AREA REMODELAREA PORCH AREA DECKAREA TOTAL DECYJPORCHAREA GARAGE AREA H DETACH 2A �„ � 3-7 Sf „'^6(� ATTACH DWELLING( NG^UNITS: IS A SECOND UNIT C]YES SECOND STTORYYES BEING ADDED? It"ZO ADDITION? 010 PRE-APPLICATION IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED Y TO �4I.UATION: PLANNING APPL# []NO PLANNIN�NPRO�V 4L LETTER EICHI.ER HOME? �NO fl �, By my signature below,I certify to each of the following: I am the property owner or authorized agent to ct Un the prrperty owner's behalf. I ha read this application and the information I have provide s correct I have read the Description of Work and veri it is accurate. I agree to comply with all applicable local ordinances and state laws relating to b nstruction. I au orize representatives of Cupertino to enter the above-id Sed perty for inspection purposes. Signature of ApplicandAgent: Date: SUPPLEMENTAL INFORMATION REQ=D PLATT CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER- -COUNTER BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building I{� permit for new building. ❑ HESS PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STANDARD PUBLTcwORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE � FIRE DSI, _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ NWOR SANITARY SEWER DISTRICT submittal of Building Permit application. ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06/21/11 liJ � o1) gq ADDRESS: lot 9 DATE: 08/12/2011 RIEYIIEWEIID BY: bobs APN: CIZVUJO WAILUATUON: 1$170,000 ''PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY SFD Or Duplex 2nd Unit? 0 Yes 0 No PENTAMATIION 1 R3SFDW USE: PERMIT TYPE: woRK construct new 2 story sfd SCOPE OCCUPANCY TYPE: TYPE OF FLR AREA PC]FEES PC FEE ID B?]FEES B?]FEE ID CONSTR. s.t R-3(Custom) II-B,111-B,IV,V-B 1,046 $2,438.81 IR3PLNCK $1,586.38 IR3INSP TOTALS: 1,046 $2,438.81 $1,586.38 F,_,, .'iiYirl%1 t•`n.,. ''Et77ii'.."le;'T .Fee t.)%c'�. !'Ci i7:i!F%e. t'.)•°ili'i''gi'i7;.f18x:, (}.lilii'�'Eilli7l';,r'iY: f °i.'' � :. � . f'Ce f- ir.cp, 1::'0"' NOTE. These.fees are based on thepreliminag information available and are on! an estimate. Contact the I)e t or addn'l in o. FELE ITEMS (Fee Resolution I I-053 L_'ff. 7'11"111 FEE QTS'/FEE Iy ISC ITEMS Plan Check Fee: $2,438.81 Select a Misc Bldg/Structure Suppl. PC Fee: r:° Reg. COT 0.0 hrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: $1,586.38 Suppl.Insp. Fee-E) Reg. COT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Constr.Tax: IBCONSTAXR 1 new $579.61 units Acoustical Fee: 0 Yes 0 No $0.00 Work Without Permit? Q Yes 0 No $0.00 Planning PLLONGRNGR $135.98 Select a Non-Residential :1 ir:1:%rrerarfrirrl.l ce. : Building or Structure Strong Motion Fee: IBSEISMICR $17.00 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $7.00 SUBTOTALS: $4,764.78 $0.00 T®TA><,FEE:- $4,764.78 Revised: 07/0412011 Bufidipg City Of Cupertino 10300 Torre Aven,..1- Cupertino,CA 95014-3255 Telephone: 408-777-32?,'� CUPERTINO Fax: 408-777-333'1 CONTRACTOR SUBCONTRACTOR BEST JOB ADDRESS: /* PERMIT OWNER'S NAME: , GENERAL CONTRACTOR: ... .. BUSINESS L[CL,NSE 4 ADDRESS: CITY/ZIPCODF: *Our municipal code requires all 6a,5inemes-vvurklng 5'n the city to have 2 C,'-\v -_T CU-C,-TVn(G b:w5!T'e�15 NO BUILDING FINAL OR FINAL OCCUPANCY TNS?ECT1,0N1 ,j'5) '7_`E' SzCH E DULZ GENERAL CONTRACTOR AND ALL 5UHC(0N-fRAC70R9 THAVE OD7A.:N'E'; A C17 CJ`"_':-,�71"�: BUSINESS LICENSE. R am not using any subcontractors: signblure uahe Please check applicable subcontractors nud complete the fiGEOW-ng V SUBCONTRACTOR BUSINESS NAME BUSITNIESIS __i_7C1_TNT5-7 Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring /Carpeting Linoleum /Wood Glass/Glazing Heating Insulation Landscaping Lathing Mason Painting Wallpaper Paving Plastering Plumbing Roofing r Septic Tank Sheet Metal Sheet Rock Ti le --,Owner Contractor Signature Date r OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DNISION 10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 OOP1=E3TIPdO (408)777-3228^FAX(408)777-3333-buildino(a cuoertino.oro 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 , q VCC AP%5bg 1� BP# /Id 910V O R hAfJl 1� �I/� 0V ng DO /&�y 6/ // DESCRIPTIDN OF WORK:'tt" G ai mal m 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 otivnE7-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 in,'ormation.) (k)_1. 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. OA�2. 1 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. (W-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. W-L .- - - -- -- - - - - - -- --- -- . _ ...-- 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license nu bers or permits and contracts. 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 considered an "employer' under state and federal law. (W-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. W7. 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. 8.11 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. OwnerBuilderForm ?010.doc revised 04114/10 LTJ-9. I understand I may obtain more information regarding my obligations as an °employer"from the Internal Revenue Service, the United States Small Business Administration,the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed co tractors. 610. 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. do)-11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by II 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 information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone v✓ho 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 Wsh to hire Contractors,you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers'compensation insurance coverage. CONSTRUCTION LENDING AGENCY (D_IRFGIONSLP_lease complete_th.e_following_constr-uction_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: D 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 drivers license, form notarization, or other venficatio acceptable to the city maybe required to be presented when the ermi is issued to verify the property owner's sin ' Property Owner's Signature: Date: --------------------------------------------------------------------------------------------------------------------------------------------- (NOTE: The following Authorization Form is required to be completed by the property ov✓fief only when designating an agent of the property owner to apply for a construction permit for the Owner-Builder). AUTHORIZATION OF AGENT TO AOT 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: Oi+77erBui7der•Forr7t_2010.doc revLse-d04114110