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13070012CITY OF CUPERTINO BUILDING PERMIT l BUILDING ADDRESS: 1175 ELMSFORD CT CONTRACTOR: PO -FU HUANG PERMIT NO: 13070012 OWNER'S NAME: PO -FU HUANG 1 175 ELMS FORD CT DATE ISSUED: 11/18/2013 OWNER'S PHONE: 4086661371 CUPERTINO, CA 95014 PHONE NO: i { El LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL EJ COMMERCIAL IST & 2ND STORY ADDITION WITH 1,109 S.F. OF LIVING { License Class Lic. # SPACE TO CREATE I (N) BEDROOM & 1&1/2 (N) BATHS. REMODEL (E) 1,409 S.F. OF (E) LIVING SPACE i t Contractor Date DEFERRED #1- TRUSS CALCS - ISSUED 7/1/14 I hereby affirm that I am licensed under the provisions of Chapter 9 j(commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: 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 Sq. Ft Floor Area: Valuation: $350000 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by } I Section 3700 of the Labor Code, for the performance of the work for which this APN Number: 36208025.00 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 I correct. 1 agree to comply with all city and county ordinances and state laws relating WITHIN Igo D T ISSUANCE OR to building constructions and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgmen costs, and expenses which may accrue against said City in consequence oft" -- --� 1 granting of this permit.. Additionally, the applicant understands and will comply Issued ate: 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. Ira roof is installed without first obtaining an inspection, 1 agree to remove all new materials for inspection. OWNER- BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of _ j 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 I 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 1 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 J 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 Cu ino Municipal Code, Chapter 9.12 and 1 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 the Health & Safety Code, Secti s 25505 2553 nd 25534. ' / %(� ?1 Owner or authorized agent; Date:_ permit is issued. � 1 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, 1 must 1 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 I APPLICANT CERTIFICATION Lender's Address 1 certify that 1 have read this application and state that the above information is correct. 1 agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -poin • regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Date / o Signature/ - CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014 -3255 " (408) 777 -3228 • FAX (408) 777 -3333 • building (LDcuperdno.orq CUP RTIt�0 l I�6)-7W(2. ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/T1 REVISION /DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS }'- 5�,� :�:7E C• /n� / `/ OWNERNAME �j /� PHONE/�()E�_ I / E -NL4IL STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME PHONE E -MAIL ^ 34 r y��Q SQL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER- BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME � )/� •j� /. ^,��4 7C Yc 0 LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAMJ� /f `VL)a E -MAIL FAX ( % P- ?C STREET ADDRESS,/ CITY, STATE, ZIP PHONED ARCHITECTIENGTNEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK I Lt SS EXISTING USE PROPOSED USE CONSTR. TYPE ' k STORIES USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: MDETACH ❑ ATTACH # D\1BLLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? NO ADDITION? DNO PRE - APPLICATION DYES IF YES, PROVIDE COPY OF 1S THE BLDG AN ❑ YES RECEIVED BY - TION: PLANNING APPL# DNO PLANNING APPROVAL LETTER EICHLER HOME? DNO :' _ � r By my signature below, I certify to each of the following: I am the property owner or authorized agent to ac e 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 lavv,s relating to building construction. I authorize representatives of Cupertino to enter the above- identified property for inspection purposes. S ignature of Appl icant/Agent: Date: SUPPLEMENTAL INTFORMATION REQUIRED t h rLA1� cHECKT rE RoUTU.c slip m�2, ' '.. D New SFD or Multifamily d%v�ellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building O COITRTEA BUILDRgG PLAN REVIEW permit for new building. $?.PRESSr , +� q ; PI.AI,[g'Il G atv REVIEW 1.142 .:Z'y .xC � yw t� } a --i' y'a '..,Fng^ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure � N D = sTAI.Daiiv� t R....... �PUBLIGwbRxs ro _ form if any Hazardous Materials are being used as part of this project. Copy of Planning Approval Letter or Meeting With Planning prior to © AIAJOR� � SAI\TTARYSEI�ERDISTRICT c submittal of Building Permit application. D „`ENVTROAA4ENTAi HEALTHs ' B1dgApp_2011.doc revised 06121111 Wq. l I F-M-S CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 1175 elmsford ct DATE: 05/05/2014 REVIEWED BY: mendez APN: BP #: `VALUATION: $0 PERMIT TYPE: Building Permit 0.0 PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: PME Plan Check: PENTAMATION 1GENRE PERMIT TYPE: WORK revision #1- truss calcs $0.00 SCOPE f 0.07 hrs NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.)., These fees are based on the preliminary information available and are only an estimate. Contact the Deptfor addn'l info. FEE ITEMS (Fee Resolution 11 -053 Eff 7, 1. I3 FEE QTY /FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes No $0.00 1 3 hours Plan Check, Hourly $417.00 1STPLNCK Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee() Reg. Q OT f 0.07 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Work Without Permit? 0 Yes ) No $0.00 Advanced Planniii Fee: $0.00 Select a Non - Residential Building or Structure 0 Strong Motion Fee: $0.00 Select an Administrative Item Bldg Stds Commission Fee: $0.00 SUBTOTALS: $0.00 $417.00 TOTAL FEE: $417.00 Revised: 04/01/2014 ' CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1175 ELMSFORD CT CONTRACTOR: PO -FU HUANG PERMIT NO: 13070012 OWNER'S NAME: PO -FU HUANG 1175 ELMSFORD CT DATE ISSUED: 11/18/2013 OWNER'S PHONE: 4086661371 CUPERTINO, CA 95014 PHONE NO: j ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL License Class Lie. # 1ST & 2ND STORY ADDITION WITH 1,109 S.F. OF LIVING SPACE TO CREATE 1 (N) BEDROOM & 1 &1/2 (N) BATHS. l Contractor Date REMODEL (E) 1,409 S.F. OF (E) LIVING SPACE } I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions i 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 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 Sq. Ft Floor Area: Valuation: $350000 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 APN Number: 36208025.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT E IRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN YS 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 DAY M LAST CALLED INSPECTION. I i 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 3 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 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) , as owner of the property, am "elusively 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(x) should I store or handle hazardous i1 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 I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and 1 have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Secti 05, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Date: 1i f�? 3 permit is issued. 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 i Compensation laws of California. If, after making this certificate of exemption, l 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. work's for which this permit is issued (Sec. 3097, Civ C.) i Lender's Name APPLICANT CERTIFICATION Lender's Address jI 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 fupon the above mentioned property for inspection purposes. (We) agree to save ARCHITECT'S DECLARATION j indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records, granting of this permit. Additionally, the applicant understands and will comply with all non -point so regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date �c,T.tVSf\ • `V CONSTRUCTION PERMIT APPLICATION �O COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 V (408) 777 -3228 • FAX (408) 777 -3333 • buildinaCc cupertino.ong \ v ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS I %m ©ice It Y APN # _ OWNER NAME Fu ou4 1A PHONE li©g ^ 6 t 4-1 + E -MAIL b $ STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME r— nh Ra 5�0 PHONE E -M IL 409-0�- _ STREET ADDRESS , O1 Z CITY, STATE, ZIP ij -- C� . p GGW�� FAX ❑ OWNER ❑ OW!N'E'R- BUILDER ❑ OWA'ER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E -MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # �I � COMPANY NAME E -MAIL FAX STREET ADDRESS (1 CITY, STATE, ZIP ���� G1 �. 0 LQ PHONE DESCRIPTION OF WORK 6 � � i�-Ct. � tv W i'i F�i3wt / u; 2 - ^ � 5' r S � r-e-O i �� rt `�cCt�I C S f I �S 1 vL� � stGLeY L EXISTING USE I PROPOSED USE CONSTR TYPE : STORIES �� IGI.i��L1 cCJ(, , `� �7f b�.il'�n+ \(, �"�C � •Lr USE TYPE OCC. SQ.FT. VALUATION (S) EXLSTG NEW FLOOR DEMO TOTAL AREA Z 0 S " AREA ! 04_ 5. I AREA NET AREA BATHROOM CHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA /r �v9 i PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: DETACH E] ATTACH # DWELLING UNITS: is A SECOND UNrr ❑YES SECOND STORY OYES BELNG ADDED? ONO ADDITION? NO PPE- APPLICATION ❑ YES T YES, PROVIDE COPY OF PLANNLVGAPPI, NO PLANNING APPROVAL LETTER IS THE BLDG AN ❑ YES EICHLER HOME? ONO RECEI r � TOTAL VALUATION: 350 DOJO lJ 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 Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building const;;Tction. I authorize representatives of Cupertino to enter the above - identified property for inspection purposes. _ �z-',- 2 2 �� ° Signature of Applicant/Agent: - - - -�5- Date: SUPPLEMENTAL INF RMATION REQUIRED PLnivcl cx APE IiQVTINGSLIP New SFD or Multifamily dwellings: Apply for demolition permit for ❑ ovERrHE eounTER ❑ BUILDLNCPLAI�RE�'IEW _ existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EaPRESS ❑ P4Alt1LvG PLATS xRi vlEw Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ sTa�.�aRD K ❑ PvBLIC,oRxs _ form if any Hazardous Materials are being used as part of this project. ❑ FIRE LARGEF DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ ❑ SANITARY submittal of Building Permit application. MAJOR - _ SEwERDISTRICT ❑.:E'�'VIROn'41EIQTAT;HEALTH �' - B1dgApp_2011.doc revised 06121111 FM_7 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION 1AADDRESS: 1175 ELMSFORD CT DATE: 07102/2013 REVIEWED BY: MELISSA PC FEE ID APN: 362 08 025 BP #: , - *VALUATION: 1$350,000 %PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Du lex USE: P 2nd Unit? Yes No OTC? 0Yes (F) No PENTAMATION PERMIT TYPE• 1R3SFDADD woRK 1ST & 2ND STORY ADDITION WITH 1,109 S.F. OF LIVING SPACE TO CREATE 1 N BEDROOM & SCOPE 1 &1/2 (N) BATHS. REMODEL (E) 1,409 S.F. OF (E) LIVING SPACE OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID R -3 (Custom) II- B,111- B,IV,V -B 1,109 $2,617.06 1R3PLNCK $1,760.50 1R31NSP PME Plan Check: $0. 0 ` Permit Fee: $1,760.50 Suppl. Insp. Fee: Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 1,109 $2,617.06 $1,760.50 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, tire, sanitary Sewer District, school Dicfrirt otr ) Thoco foot nro hacod nn tho nroliminary infnrmatinn ovoilahle and nro nnly an estimate_ Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 11 -053 Eff.' 7/1/12) FEE QTY/FEE ISC ITEMS Plan Check Fee: $2,617.06 9 £ $4,638.00 Remodel, O her IREMItES2 Suppl. PC Fee: (F) Reg. 0 OT 1 0.0 1 hrs $0. PME Plan Check: $0. 0 ` Permit Fee: $1,760.50 Suppl. Insp. Fee: Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 V Work Without Permit? Q Yes No Advanced Planning Fee: IPLLONGR $144.17 t5 Select a Non - Residential Building or Structure 0 0 � 7i<�•-e! I1�>���trrcrt£r:riFt.: f'',cs: Strong Motion Fee: IBSEISMICR $35.00 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $14.0 URTOfiALS $4,570.73d$4,638.001 TOTAL FEE: $9,208.73 n �20,,8 LRevised: 07/01 /2013 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014 -3255 Telephone: 408 - 777 -3228 Fax: 408 - 777 -3333 JOB ADDRESS: 117 rp.5 r-4,d C1. PERMIT # % 00," OWNER'S NAME: ie T Fk /c �, PHONE # J' /D-^ ACP— 5'ey7 GENERAL CONTRACTO !16 ev e BUSINESS LICENSE # ADD s S .' pV.ej7r C/,¢ i`i� CITY /ZIPCODE: *Our municipal code requires all businesses workirt in'tV city to have a City of Cupertino business Iicense. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) AILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND A 0 ONTRACTORS HAVE TAINED A CITY OF CUPERTINO BUSINESS LICENSE. 14 I am not using any subcontractors: V1 r Signature Date Please check applicable subcontractors and complete the following information: Owner / Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date CUPERTINO OWNER - BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014 -3255 (408) 777 -3228 - FAX (408) 777 -3333 - building(- cupertino.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, I1 � VMS,/' I& n+ C J� APN BP# �� 2 OWNER NAME 4R6o OWNER ADDRESS DESCRIPTION OF WORK: 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 owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S APKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) 1. 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. 60 -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. �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. W4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. (�t5. I 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. W6. I understand if I am considered an "employer" under state and federal law, I must register with the state and fede r al 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. q7% 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. OwnerBuilderFonn 2010. doe remised 04114110 9. I understand I may obtain more information regarding my obligations as an "employer' from the Internal evenue 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 // contractors. 1Ww10. 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. A11. 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. 6x12. I 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. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verification accepta to the cit maybe required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: 111121113 ----------------------------------------------------------- ---------------------------------------------------------------------------------- (NOTE: The following 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 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: Address of Authorized Agent: Tel No 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: Oli�7ie7Builde7Fo777z 2010.doc revised 04114110