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B-2016-0416CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10790 MINETTE DR CUPERTINO, CA 95014-3615 (375 31 034) CONTRACTOR: PERMIT NO: D-2016-0416 OWNER -BUILDER ( OWNER'S NAME: KELKAR UMESH AND PREETI U I I DATE ISSUED: 09/28/2016 OWNER'S PHONE: 408-891-5772 LICENSED..CONTRACTORIS DECLARA110N License Class Lia # Contractor OWNER -BUILDER Date I hereby affirm that I am licensed under the provisions of Chapter 9 (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. I. have and will maintain a certificate of consent to self -insure for Worker's PHONE NO: BUILDING PERMIT INFO: BLDG —ELECT —PLUMB MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: DEMO EXISTING HOME (1127 S.F.); ATTACHED GARAGE (264 S.F.) 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 permit is issued. Sq. Ft Floor Area: Valuation: $6000.00 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 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, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date 09/28/2016 APN Number: Occupancy Type: 375 31 034 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS D^M T A T CALLED INSPECTION. Issued by: Date: 09/2 I hereby affirm that I am exempt from the Contractor's License Law for one of the I 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 sole 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. le (See.7044, Business & Professions Code) 2:1'' I, as owner of the property am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). hereby affirm under penalty of perjury one of the following three declarations: 1. 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. 2. 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 )permit is issued. a�/)�I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 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, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date 09/28/2016 Signature of Applicant: Date: 09/28/2016 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER ,HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505,2555333, and 25534. Owner or authorized agent:;' Date: 09/28/2016 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed OWNER -BUILDER DISCLOSURE FORME COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING 'DIVISION 10300 TORRE AVENUE CUPERTINO, CA 95014-3255 CtIPERTIN© (408) 777-3228 • FAx (408) 777-3333 • buildina(a cupertino.org 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+. AP '91 ' 7t/ U FBP# 7� M �-rte OWNER NAME C �s lit �-_faocAf, OWNER ADDRESS I(3 0 A SV14-- 4DESCRIPTION DESCRIPTION OF WORK: ^ We are providing your with a your responsibilities and po: will not issue a building pi returned this form to us ai you, the property owner, obi (DIRECTIONS. Please rear Owner -Builder Acknowledgment and Information Verification Form to make you aware of ible risk you may incur by having this permit issued in your name as the Owner -Builder. We mit until you have read, initialed your understanding of each provision, signed, and )ur official address indicated. An agent of the owner cannot execute this notice unless in the prior approval of the permitting authority. T AND VERIFICATION OF INFORMATION initial each statement below to signify you understand or verify this information.) . I understand a fr eluent practice of unlicensed persons is to have the property owner obtain an "Owner - Builder" building permit I 1 at erroneously implies that the property owner is providing his or her own labor and material personally. 1, as an Ow er-Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person a ed' his or her employees while working on my property. My homeowner's insurance may not provide coveragefor se injuries. l am willfully acting as an Owner -Builder and am aware of the limits -of my insurance oovera.9 for injuries to workers on my property. W�-2. 1 understand bu the construction and an V� I understand as protect myself from pot name instead of my ow 4. I understand Cc numbers on permits an VY74 -5. I understand if I total value of my constr considered an "employ( iM—Z--6. I understand if I federal government, wii unemployment comper me to serious financial 7. I understand un residential structures c� licensed subcontractor: is performed under con 8. 1 understand as any financial or person, defects in the workman per are not required to be signed by property owners unless they are responsible for hiring a Licensed Contractor to assume this responsibility. "Owner -Builder" I am the responsible party of record on the permit. I understand that i may al financial risk by hiring a licensed Contractor and having the permit filed in his or her are required by law to be licensed and bonded in California and to list their license 1ploy or otherwise engage any persons, other than California licensed Contractors, and the ion is at least five hundred dollars ($500), including labor and materials, I may be under state and federal law. considered an "employer" under state and federal law, I must register with the state and Id payroll taxes, provide workers' compensation disability insurance, and contribute to on for each "employee." I also understand my failure to abide by these laws may subject California Contractors' State License Law, an Owner -Builder who builds single-family A legally build them with the intent to offer them for sale, unless all work is performed by d the number of structures does not exceed four within any calendar year, or all of the work t with a licensed general building Contractor. Owner -Builder if I sell the property for which this permit is issued, I may be held liable for injuries sustained by any subsequent owner(s) that result from any latent construction iip or materials. O1T772e7Bzfilde7Fo7-717 2010.doc revised 04114/10 9. 1 understand I m Revenue Service,, the U and the California Divisi License Board (CSLB) contractors. 10. 1 am aware of y�am the party legally anc 1tY 11. 1 agree that, as by all applicable laws ar 12. I agree to notifi information I have provil you contract withsomec assist you with any finar Contractors may be in c employee of that individ you obtain a permit as C those Contractors are pi (DIRECTIONS: Please core I hereby affirm that there is (Sec 3097 Civ.) Lender Name: f obtain more information regarding my obligations as an "employer" from the Internal ted States Small Business Administration, the California Department of Benefit Payments, r of Industrial Accidents. I also understand I may contact the California Contractors' State 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed consent to an Owner -Builder building permit applied for in my name, and understand that ancially responsible for proposed construction activity at the site address listed above. e party legally and financially responsible for this proposed construction activity, I will abide requirements that govern Owner -Builders as well as employers. ie issuer of this form immediately of any additions, deletions, or changes to any of the d on this form. Licensed contractors are regulated by laws designed to protect the public. If B who does not have a license, the Contractors' State License Board may be unable to al loss you may sustain as a result of a complaint. Your only remedy against unlicensed I court. It is also important for you to understand that if an unlicensed Contractor or 1 or firm is injured while working on your property, you may be held liable for damages. If 'ner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not )erly licensed and the status of their workers' compensation insurance coverage. the following construction lending agency information.) construction lending agency for the performance of the work for which this permit is issued Lender Address: Before a building permit c �h be issued, this form must be completed and signed by the property owner and � returned to the agency res form notarization, or other v onsible for issuing the permit. Note: A copy of the property owner's driver's license, �,ification acceptable to the city may .be required to be presented when the permit is issued to verify the property owner si nature. Property Owner's Signature: Date: 64 1 2,V ^ 'LO --------------------------------- I---- ~f --- --- - - ------------------------------------------------------------------------- (NOTE: The following Auth dization Form is required to be completed by the property owner only when designating an --- agent of the property owner o apply for a construction permit for the Owner -Builder), AUTHORIZALTION OF AGENT TO ACT ON PROPERTY ' OWNER S BEHALF Excluding the Notice to Prop . rty Owner, the execution of which I understand is my personal responsibility; I hereby authorize the following pers n(s) to act as my agent(s): to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my Droject. Scope of Construction Proje it (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agen' I declare under penalty of pe above information and certifi verification acceptable to the signature. Property Owner's Signature: Tel No that 1 am the property owner for the address listed above and I personally filled out the accuracy. Note: A copy of the property owner's driver's license, form notarization, or other may be required to be presented when the permit is issued to verify the property owner's Date: Oi4l7ze7Bzrilde7Fonn 2010.doc revised 04/14110