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B-2016-2748 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS- CONTRACTOR: PERMIT NO:B-2016-2748 10205 SCENIC BLVD CUPERTINO,CA 95014-2724(357 09 009) HOMEOWNER BUILDER OWNER'S NAME: JONES RONALD E AND BARBARA M TRUSTEE DATE ISSUED:09/30/2016 OWNER'S PHONE:408-257-4478 PHONE NO: LICENSED CONTRAC'TOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic.# Contractor HOMEOWNER BUILDER 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 that my license is in full force and effect. JOB DESCRIPTION: PERMIT TO FINAL ORIGINAL PERMIT#0470: CONSTRUCT SINGLE I hereby affirm under penalty of perjury one of the following two declarations: STORY HOME(1204 S.F);ATTACHED GARAGE(242 S.E);REMOVE i. I have and will maintain a certificate of consent to self-insure for Worker's (E)RESIDENCEXOTTAGE(490 SQ FT). 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 for which this permit is issued. Sq.Ft Floor Area; Valuation:$50000.00 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 APN Number: Occupancy Type: and state laws relating to building construction,and hereby authorize 357 09 009 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 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 non-point source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 9/30/2016 Issued by:AbbyAyende Date:09/30/2016 OWNER-BUILDER DECLARATION T 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. I,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. e(Sec.7044,Business&Professions Code) z. I,as owner of the property;am exclusively contracting with licensed Signature of Applicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date: /201 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I I have and will maintain a Certificate of Consent to self-insure for Worker's C0* pensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the CaliforniaHealth&Safe Code,Sections 25505,25533,and 25534. I will ection 3700 of the Labor Code,for the performance of the work for which this tY permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 3. I 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 to the material. Additionally,should I use equipment or devices which emit hazardous air contaminants as definers by the Ba Area ty Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with upertin icip Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Sa Code,SecZ77 Labor Code,I must forthwith comply such provisions or this permit shall be deemed revoked, Owner or authorized agent: APPLICANT CERTIFICATION Date:9/30/2016 1 certify that I have read this application and state that the above information is CONSTRUCTION LENDA AGENCY correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction len ' 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.30 ,Civ C.) to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabilities, judgments,costs,and expenses which may accrue against said City in Lender's Address consequence of the gra oft is it.Additionally,the applicant understands and will comply a I non point ource egulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code,Secti .18. 1 understand my plans shall be used as public records. Licensed Signature Date 9/30/2016 Professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT� ARTMENT•'BUILDING DIVISION 10300 TORRE AVENUE•CUPER'TINO,CA 95014-3255 GUP)r1tTINtJ (408)777-3228•FAX(408)777-3333•buitdinq@cuperdno.ona Li N-&CONSTRUCTION ❑ ADDITION t-J ALTERATION 1 TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# a�i FR(JECT ADDRESS Apr((�NER NAME» n ]� �.s� Y lZ� L•� �Cw� PH6NE &MA IL x v S3REETADDRES7S �/te� i CITY,STATE,Z[P �# PAX CONTACT NAME E•MAIfr t } STREET ADDRESS CITY STATE FAX IR OWNER IYOWiVER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHrrECT i El ENGINEER © DEVELOPER Ci TENANT CONTRACTOR NA§W LICENSE NUMBER LICENSE TYPE BUS.LIC 0 COMPANY NAtM E-MAIL. FAX STREET ADDRESS CJTY,STATE,ZIP PRONE ARCHITECTIENGINEER NAME LICENSE NUMBER BUS.LIC# CO3APANYXAMII E-NIAIL FAX STREE7ADDRESS Crl'Y,STATE,ZIP PHONE DESCRIPTION OF WORK „_ 12W �50 EXISTING.USE PROPOSED USE - CONSTR.TYPE #STORIES D i USE TYPE OCC. SQ:FT. VALUATION($} Mam vY.. NEWFLOOR 13 DEMO TOTAL 1 AREA t Cj j�j W I AREA AREA NET AREA BAIRROOM RTICHEN OTIIER REMODELAREA REMODELAREA REMGDEL AREA PORg DECK AREA TOTAL DECKII'OR AREA OARAG£AREA• DET CH P.DWELLINGUNUS: ISASECONDUNIT ❑YEJ SECOND STORY ri1 3 BEING ADDED? P" ADDITION? �yi66 PRE-APPLICATION ©ITS IFYES,PROVIDE COPY OF 3STIIEBLDOAN 13,Kr6 RECEIVED Y: � - TC�� �1 ON: PLANNING APPL O E3-NO PLANNING APPROVAL LOT M- ELCI3LE I MNIE? - O � �J�,g�®„`�.. {{-,�!1�� By my signature below,I certify to each of the following: I am the property owner or authorized agent to lot on th property owner's behalf,YI have r Lea1d this application and the information I have e.i_correct,N have read the Descriptlon of Work and verify it is accurate. I agree to co m ly with all applicable local ordinances and state lawsreiating wtdingc tin , authorizers resenkrtivesofCupertlnotoenter the ab ve-ide' ifiedprope for inspection urposes. Signature of ApplicRm/Agent: hate: SUPPLEMENTAL INFORMAL' T-molition. QUIRED PLAN QWCK Ty ROUTING SLIP New SFD or Multifamily dwellings: Apply fo permit for 0 OVER-THE-COUNTER BUI nIIvc.PLAx xEvlz sv 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 O STANDARD © PUBLIC W.ORIGS form if any Hazardous Materials are being used as part of this project. O LARGE Cl rBEE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to El MAJORD SANITARY S1 wER DISTRICT submittal of Building Permit application. d ENVIRONatENTAL MAL-IV B1dgAPp 2011.doerevi.sed06121111 OWNER-BUILDER DISCLOSURE PORN! COMMUNITY DEVELOPMENT PtPARTMENT•BUILDING DIViSIO11 90300 TORRE AVENUE a CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333 d buildin cx.cu, oertinc.= 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 APN BP# oWNE ME a OWNERADDREySS DESCRIPTION OF WORK- We ORKWe 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 ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS.Please read and initial each statement below to signify you understand or verify this information.) l understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner- Bui d " Bui d "building permit that erroneously implies that the property owner is providing his or her own labor and material personally. 1, 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. 1 am willfully acting as an Owner-Builder and am aware of the limits of my ins nce coverage for injuries to workers on my property. I understand building permits are not required to be signed by property owners unless they are responsible for the struction and are not hiring a licensed Contractor to assume this responsibility. 3: I understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may pr ct myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her n e instead of my own. Iners . 1 understand Contractors are required by law to be licensed and bonded inl California and to list their license on permits and contracts. 1 understand if i employ or otherwise engage any persons,other than''California licensed Contractors, and the alue of my construction is at least five hundred dollars($500), including labor and materials, I may be co'sidered an"employer"under state and federal law. )tI understand if I am considered an"employer"under state and federal law, I must register with the state and feai government,withhold payroll taxes,provide workers'compensation disability insurance,and contributeto ployment compensation for each"employee."i also understand my fail re to',abide by these laws may subject m o serious financial risk. 1 understand under California Contractors'State License Law,an Owner-Builder who builds single-family ntial structures cannot legally build them with the intent to offer them for said, unless all work is performed by lice ed 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. V4) & I understand as an Owner-Builder if 1 sell the property for which this permit'is issued, I may be held liable for Inancial or personal injuries sustained by any subsequent owner(s)that result from any latent construction de ects in the workmanship or materials. OwnerBuilderFortn 2010.doc revised 04114110 j I understand Imay obtain more information regarding my obligations as an"ernployet"from the internal ev ue Service,the United States Small Business Administration,the California Department of Benefit Payments, and a California Division of Industrial Accident. i also understand I may contact the California Contractors'State License Board(CSLB)at 1-800-321-CSLB(2752)or www.esib.ca.gov for more information about licensed biors. 1 am aware of and consent to an Owner-Builder building permit applied for in,my name, and understand that I arty legally and financially responsible for proposed construction activity at the site address listed above. 1 agree that,as the party legally and financially responsible for this proposed construction activity, I will abide ll plicable laws and requirements that govern Owner-Builders as well as employers. 1 agree to notify the issuer of this form immediately of any additions,deletions,or changes to any of the on l have provided on this form. Licensed contractors are regulated by laws designed to protect the public. if ract 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 Pending 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 bylthe property owner and returned to the agency responsible for Issuing the permit. Note:A copy of the property owners dr'iver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to veri the roe owner' ature. Property Owner's Si.gnature: Date: 5, (NOTE: The following Authorization Four►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). i AUTHORIZATION OF AGENT TO ACT ON PROPERTY QWER'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 owner's signature. Property Owner's Signature: Date: OwnerSuilderForm 2010.doc revised 04114110 Anotary public orother officer completing this certittca4verifiiA6niythe CALIFORNIA ALL—PURPOSE of the individual who signed the document to which;thi ertiftcate is attached,and not the truthfulness,accuracy,or validity of that&cument. CERTIFICATE t?I` a State of California ACKNOWLEDGMENT County of. - On X302 1Gr� S before me, _ r I ll ri t:t.srvrr�and t,ir t } personally appeared who proved to me on the basis of satisfactory evidence to be the person((-whose namgW4s/#xe-subscribed to the within instrument and acknowledged to me that he/sJaeA*ey,executed the same in. his/heA40 air authorized capacity0o and that by-hls/ball*wk signature(emn the instrument the per=4a -or the.entity upon behalf of which the personcted,executed the instrument. , I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. - - ' RRCEl.IA A.ESTOESTA M. #2068265 z COMz Notary Public-Califomia WITNESS my hand acid official seal. 0.a Santa Clara County ° . ' M Comm Expires June 1©,20i$ t Signature (Seal) ' OPTIONAL INFORMATION Although else information in this section is not r0yired by law,it couldprevetit lroudulet)l romovcjt and rou"cichrnerrt of this acknowlerlyn7em'to on unat.ithorized docurrtent_opcl rrruy ptovr,(lielirl to per,iw75 reeving Or)the:flochetf chxutrre"L Description of Attached Document, _ The preceding Certificate of Acknowledgrtien is ate ehed to a document iMethod of'SitJner identification _ e f'tt3vc i,sreictlr�tlieb.3stsof atisfaciotyeviderrce titled/for the purpose o€ s '`'�},-r, �ic>ren[$�{rr+7•srl h,a,ettel Cerdtitrc Svslrt�.S,i.4t - NotItrial iwent t"dt�tatteti in natty iournal tiro; t-'r�(tt; f tltf� i containing pages,and dated t The signer(s)capacity or authority is/are as: h7r tart'=.,srildo ; til[#rvis:aitsl Other J Attorney-in-Pact . +4fctil u',ai�:�l�s itis �� �:c3n�.t�1?'nlar^,atrg;rtntt? _ n Colpotate_ofticer;s➢ ,. I t i>t„r�#r,3r1A?::tln<.rrvatcir ' i partnEl•tinlitedrGenerr3l . 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