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B-2016-2466 CITY OF CUPE TINO BUILDING PERMIT CONTRACTOR: PERMIT NO:B-2016-2466 1B 4221DINGMARYAVE UNIT 10421 CUPERTINO,CA 95014-1344(326 52 053) HOMEOWNER/BUILD ER OWNER'S NAME: Sagar Shelke DATE ISSUED:08/31/2016 OWNER'S PHONE:408-242-.9453 PHONE NO: LICENSED CONTRACTOR'S DECLARATIONBUILDING PERMIT INFO: License Class Lic.# Contractor HOMEOWNE B 111 DER Date X BLDG —ELECT —PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL—COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Code and tb at my license is in full force and effect. JOB DESCRIPTION: I herebyaffirm under penalty of perjury one of the following 2ND FLR;(E)BATHROOM REMODEL&RECONFIGURE TO ADD(N) P tY P I ry llowing two declara ons: BATHROOM -M,E,P(150 S.F.) 1. I have and will maintain a certificate of consent to self-insure forVV Drker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work folr which this permit is issued. Sq.Ft Floor Area: Valuation:$5000.00 APPLICANT CERTIFICATION 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 es APN Number: Occupancy Type: and state laws relating to building construction,and hereby authorize 326 52 053 representatives of this city to enter upon the above mentioned property or inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs,and expenses whi oh PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally,the applicant understands and will comply with all ll non-poin source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS,FROM LAST CALLED INSPECTION. Signature Date 8/31/2016 Issued by:Abby Aygnde Date:08/3 U2016 OWNER-B ILD R DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1. 1,as owner of the property,or my employees with wages as their so a installed without first obtaining an inspection,I agree to remove all new materials for compensation,will do the work,and the structure is not intended or offered for inspection. j"ale(Sec.7044,Business&Professions Code) I as owner of the property,am exclusively contracting with license. Signature ofApplicant: contractors to construct the project(Sec.7044,Business&Professio s Code). Date: /$31/2016 I herebyaffirm under penalty ofperjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER P ty P l r'Y r. 1 have and will maintain a Certificate of Consent to self-insure for orker's Compensation,as provided for by Section 3700 of the Labor Code, or the 'performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE P2 I have and will maintain Worker's Compensation Insurance,as provpded for by I have read the hazardous materials requirements under Chapter 6.95 of the 'r Section 3700 of the Labor Code,for the performance of the work follk which this California Health&Safety Code,Sections 25505,25533,and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 3. 1 certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous shall not employ any person in any manner so:as to become subject o the material.Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If,after making this cei tificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534. Labor Code,I must forthwith comply with such provisions or this p rmit shall be deemed revoked. p ff Ownerne or authorized.agent: APPLICANT CERTIFICATION Date:8/31/2016 certify that I have read this application and state that the above.inform tion is CONSTRUCTION LENDING AGENCY correct.I agree to comply with all city and county ordinances and state I aws I hereby affirm that there.is a construction lending agency for the performance relating to building construction,and hereby authorize representatives of this city of work's.for which this permit is issued(Sec.3097,Civ C.) to enter upon the above mentioned property for inspection purposes. l e)agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabil ties, judgments,costs,and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino A lunicipal ARCHITECT'S DECLARATION Code,Section 9.18. 1 understand my plans shall be used as public records. / Licensed Signature 1 Date 8/31/2016 professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228•;FAX(408)777-31I333•building(ftupertino.org Mau-2q,6 CUP RTINO ❑NEW CONSTRUCTION ❑ ADDITION' ❑ ALTERATION/Ti ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT DRESS ®�j f Ave. � A 1� S,96-14R J*Il�Is%�J /F�I (UI,j ����, /T _%-V/�J APN# !— V� 77 OWNER NAME l',96 t4 R �ft?r L p e PHONE ?4 5 27 E-MAII C. STREET ADDRESS C _ 02 Z/ 111�R Vf=• op/=/ If li`l®. Gt r�iS 01 FAX CONTACT NAME PHONE H E-MAII ACl<lr2 IcI' -24 2 '� f.3 STREET ADDRESS ,STATE ZIP o®� Acl tI5 jS-VAf FAX OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE IUMBERT CENSE TYPE BUS.LIC# COMPANY NAME EMAIL FAX STREET ADDRESS CIIrY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE BER BUS.LIC# COMPANY NAME -1 TAH, FAX STREET ADDRESS CITY,STATE,ZIP PHONE ' DESCRIPTION OF WORK � ' l M6UA4 S46/ t-fa TING USE ED USE NSTR.TIEGt�!/l(Y�f g6I��dM bvav� #�TORIES USE TYPE OCC. SQ:FT. VALUATION($j E)USTG �dt // NEW FLOOR DEMO TOTAL AREA f`'�(/y�5 AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA -� - A GARAGE AREA) DETACH PORCH AREA DECK AREA TOTAL DECK/PORCH ARE ATTACH #DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY []YES BEING ADDED? ®'NO ADDITION? ANO PRE-APPLICATION ❑ S IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BYg, TO� VALLI ION: PLANNING APPL# O PLANNING APPROVAL LETTER EICHLER HOME? NO s (Z fff Af By my signature below,I certify to each of the following: I am the propert3 owner or authorized agent act onkhe 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 building construction. I authorize repre sentatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: V W Date: 0 t 0 f ' SUPPLEMENTAL INFORMATION REQUIRED Pii cxEcr iPE RciUTmirc siir _New SFD or Multifamily dwellings: Apply for demolition perf ift for ❑^OVER THE COUNTER ^ $ULhDIiVGP1iA1�REVIEVS� existing building(s). Demolition permit is required prior to issuance of building permit for new building, ❑ xPx>ss y ❑ r ININcPIANRE Ew Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑,SANDAi ❑ cisLic vvoixs To—mi if any Hazardous Materials are being used as part of this proje t. > LARc ❑` FIS DEPT Copy of Planning Approval Letter or Meeting with Planning pr or to ❑:iV1AJOR 42SANITARY SEr3'ERDISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL i01TH' BldgApp_2011.doc revised 06121/11 OWNER-BUILDER D1,53CLOSURE FORM COMMUNITY DEVELOPMENT DgPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE ENUE•CUPER INO,CA 95014-3255 '(408)777-3228-FAX(408)777-3-33•building(@cupertino.org +CUPERTIENO 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: SIT ADDRESS APN aB /0/471 �4RY /41/i:=,R UI�F T/T>o CI - � lei 326 —,1`2— OS.3EW2()1(v-LOW O NER NAME OWNER ADDRESS Sob ,q�R .SHELKE 1 101,12-1 MrdR`/__AA 14 145- v CU i0 64=?_"_Q1 . DESCRIPTION OF WORK: �p; l'l? UM ' ,, �Cyl� Sf7 f�J� I�iCI rAe , 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 t y having this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have rea , initialed your understanding of each provision,signed,and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the pr or approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION'OF INFORMATION (DIRECTIONS:Please read and initia each statemen below to signify you understand or verify this information.) I understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner wilder"building permit that erroneously implies t I at the property owner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held li ble and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees NAhile working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully e cting as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to1workers on my property. / understand building perm;its are not req u e cred to be signed by property owners unless they are responsible for construction and are not hiring a licensed Co tractor to assume this responsibility. I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may rotect myself from potential finar cial risk by hirin g a licensed Contractor and having the permit filed in his or her name instead of my own. . 1 understand Contractors are required by I aw to be licensed and bonded in California and to list their license umbers on permits and contracts. I I understand if I employ o`i otherwise eng-ge any persons, other than California licensed Contractors,and the al value of my construction is at least five hand ed dollars($500), including labor and materials, I may be considered an"employer"under state and federal law. '�'i6�1 understand if I am considered an"emplo, er" understate and federal law, I must register with the state and deral government,withhold payoll taxes,provi e workers' compensation disability insurance,and contribute to unemployment compensation for each"employe ."I also understand my failure to abide by these laws may subject me to serious financial risk. P. I understand under California Contractors State License Law, an Owner-Builder who builds single-family esidential structures cannot legally build them wi h the intent to offer them for sale, unless all work is performed by Licensed subcontractors and the Imber of structures does not exceed four within any calendar year, or all of the work is performed under contract with luicensed general building Contractor. 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 an l subsequent owner(s)that result from any latent construction defects in the workmanship or materials. OwnefBuilderForm 2010.doc revised 04/14/10 wVeven-uleLService, nderstand I may obtain more informatio regarding my obligations as an"employer"from the Internal ,, 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. . lam aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I the party legally and financially responsible forproposed construction activity at the site address listed above. agree that, as the party legally and finacially responsible for this proposed construction activity, I will abide all applicable laws and requirements that gove n Owner-Builders as well as employers. E 1Iiel agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the ormation I have provided on this form. License 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.lit is also importe nt 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. CONSTRUCTION LENDING AGENCY (DIRECTIONS:Please complete the following construction lending agency information.) 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: L.ender 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 thpermit. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to t e city may be required to be presented when the permit is issued to verifythe property owner's signature. Property Owner's Signature: �� t11/ _�--�` Date: 6,9110 P 2-01�'• --------------------------------------------------------------- ------------------------- ----------------------------------- (NOTE. The following Authorization Form is required I 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). 1 AUTHORIZATIONOF AGENT TO ACT ON PROPERTY OWNERS 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: I Tel No Address of Authorized Agent: I declare under penalty of perjury that I am the grope y owner for the address listed'above and I personally filled out the above information and certify its accuracy. Note:A co y 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: OwnerBuilderForm 2010.doc revised 04/14/10