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B-2016-2786CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2786 20568 SUNRISE DR CUPERTINO, CA 95014 (359 10 042) OWNER BUILDER OWNER'S NAME: TIEMANN PETER DATE ISSUED: 12/14/2016 i OWNER'S PHONE: 831-435-8734 PHONE NO: i LICENSED CONTRACTOR'S A ATION BUILDING PERMIT INFO: License Class Lic. # Contractor OWNER BUILDER Date X BLDG X ELECT _ PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing X 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: TO CLEAR CODE CASE; RE -OPEN EXPIRED PERMIT (15000085 IN I hereby affirm under penalty of perjury one of the following two declarations: BIN A1.5); LEGALIZE ATTACHED 2ND UNIT (594 S.F.); ADD 2 WALL 1. I have and will maintain a certificate of consent to self -insure for Worker's FURNACES; UPGRADE 200 AMP PANEL FOR SERVICE FOR NEW Compensation, as provided for by Section 3700 of the Labor Code, for the UNIT /performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by REV#1 - CHANGE LOCATION OF FIRE RATED WALL; REVISE Section 3700 of the Labor Code, for the performance of the work for which this MECHANICAL AND ELECTRICAL - ISSUED 4/25/2017 permit is issued. Sq. Ft Floor Area: Valuation: $1000.00 APPLICANT CERTIFICATION I certify that I have read this application and state that the above APN Number: Occupancy Type: information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize 359 10 042 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. Additionally, the applicant understands and will comply with all non -point WITHIN 180 DAYS OF PERMIT ISSUANCE OR source regulations per the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. .' -:Signature Date 4/25/2017 Issued by: ABBY AYENDE Date: 12/14/2016 OWNER -BUILDER 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. 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. 0/1'sale (Sec.7044, Business & Professions Code) -211 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: 4/25/2017 I 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 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER Compensation, as provided for by Section 3700 of the Labor Code, for the of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE �.rperformance 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 Section 3700 of the Labor Code, for the performance of the work for 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 s. 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' Worker's Compensation laws of California. If, after making this certificate of air contaminants as defined by the Bay Area Air Quality Management District I exemption, I become subject to the Worker's Compensation provisions of the will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and Labor Code, I must forthwith comply with such provisions or this permit shall the Health &Safety Co ,Sections 05, 25533, and 25534. be deemed revoked. := ner or authorized agent: APPLICANT CERTIFICATION Date: 4/25/2017 1 certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY correct. I agree to comply with all city and county ordinances and state laws 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. (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 granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code, Section 18. I understand my plans shall be used as public records. F ,, B Signature �W Date 4/25/2017 Licensed Professional CONSTRUCTION PERMIT APPLICATION. COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTiNO (408) 777-3228 - FAX (408) 777-3333 • buildinaCo)cupertino.orqf ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/ TI ® REVISI / DEFE D ORIGINAL PERMIT # PROTECT ADDRESS 2-/i (`'-70 APN# p- /; to.- 041 OWNER NAME PHO E-MAIL Zoa 12 �Gr STREET ADDRESS PO 60-t � 0t�o 9. CITY, STATE, ZIP Cl� 6 2 I Rf 1) n 9 E 61 fv1 FAX CONTACT NAME 6am® fr PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACT R NAMELICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME- LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK �W 11��,, L � 'C y 1s � �� �� rl C.. `-�' Wrl Fes, t �D u�� �; ✓1 C f � EXISTING USF -� G c PROPOS USE CONS X, TYPE jVj # STORIES USE TYPE OCC. - SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO FTOTAL AREA AREA AREA NETAREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH I ❑ ATTACH # DWELLING UNITS: ISA SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? []NO ADDITION? ❑ NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER IS THE BLDG AN ❑ YES EICHLER HOME? E] NO RECEIVED BY:_ TOTAL VALUATION: 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 co tion. ILA4orize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: f Date:G` j7 SUPPLEMENTAL INFO TION REQUIRED PLAN CHECK TYPE . ROUTING BLIP ❑ OVER-THE-COUNTER " ❑ BUILDING PLAN REVIEW _ New SFD or Multifamily dwellings: Apply for demolition permit for 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 ❑ STAATDARD ❑ PUBLIC WORKS 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 1:1 MAaok EJ SANITARY SEWER DISTRICT" submittal of Building Permit application. .❑ ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06121/11 f -0 OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building0cupertino.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 2_00r --7C) :5&q",r4dejl_ #� APN ? ii;_" j� BP# �y_4gst� - �� i n °��a�C�j OWNER NAME - �^,p fJ I Vl-10 �'l OWNER ADDRESS Ov (�� c=� V s ( ��nr\oJ V 1 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 ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) f 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. 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. K-3. I 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. Or4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license fiu'mbers onP ermits and contracts. Val 5.I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the 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. 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. 7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family esidential 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. k 8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for ny financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwneYBuilderForm 2010.doc revised 04114110 9-9. 1 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 contr actors. 0. 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.. 11. 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. , 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 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 acceptab/ to the ci y be required to be presented when the permit is issued to verify the property owner's signature. ! Property Owner's Signature: Date: -_------------------------------------------------------------------------------__------------------------------------------------------- (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: OWneYBuilderForm 2010.doc revised 04/14/10 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2786 20568 SUNRISE DR CUPERTINO, CA 95014 (359 10 042) OWNER/BUILDER OWNER'S NAME: TIEMANN PETER DATE ISSUED: 12/14/2016 OWNER'S PHONE: 831-435-8734 PHONE NO: LICENSED CONTRACTOR'S DECLARATION ' BUILDING PERMIT INFO: License Class Lic. # Contractor OWNER/BUILDER Date X BLDG X ELEC _ PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing X MECH X RES ENTIAL _COMMERCIAL' with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: TO CLEAR CODE ASE; RE -OPEN EXPIRED PERMIT (15090085 IN I hereby affirm under penalty of perjury one ofthe following two declarations: BIN A1.5); LEGAL ZE ATTACHED 2ND UNIT (594 S.F.); ADD 2 WALL 1. I have and will maintain a certificate of consent to self -insure for Worker's FURNACES; UPGI ADE 200 AMP PANEL FOR SERVICE FOR NEW Compensation, as provided for by Section 3700 of the Labor Code, for the UNIT 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 Sq. Ft Floor Area: Valuation: $1000.00 permit is issued. ' APPLICANT CERTIFICATION 1 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 "N Number: Occupancy Type: and state laws relating to building construction, and hereby authorize 359 10 042 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 E IRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 18 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 MOM LAST CALLED INSPECTION. Signature Date 12/14/2016 Issued by: MELIS N Date: 12/14/2016 OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the Allroofs shallbe ins RE -ROOFS: ected prior to any roofing material being installed. If a roof is following two reasons: 1. ' I, as owner of the property, or my employees with wages as their sole installed without first btaining-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. sale (Sec.7044, Business & Professions Code) 2. ,' I as owner of the property, am exclusively contracting with licensed Signature of Applicant contractors to construct the project (See.7044, Business & Professions Code). Date: 12/14/2016 I hereby affirm under penalty of perjury one of the following three declarations: ALL • ROO COVERINGS TO BE CLASS "A" ORBETTER 1. 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 performance of the work for which this permit is issued. HAZARDOUS MATER AL DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the ha2 ardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code, for the performance of the work for which this California Health &Safety Code, Sections 25505, 25533, and 25534. I will permit is issued. maintain complianc with the Cupertino Municipal Code, Chapter 9.12 and the 25532(a) I handle hazardous % 3. 1 certify that in the performance of the work for which this permit is issued, I v Health & Safety material. Additionally, ode, Section should store or should I use equipment or devices which emit hazardous shall not employ any person in any manner so as to become subject to the air contaminants as leflned by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If, after making this certificate 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 permit shall be deemed revoked. Owner or authoriz d agents "" APPLICANT CERTIFICATION Date: 12/14/20.16 certify that I have read this application and state that the above information is CONSTRUCTION i hereby affirm that t LENDING ere is a construction lending agency for the performance correct. I agree to comply with all city and county ordinances and state laws of work's for which tl ils permit is issued (Sec. 3097, Civ C.) relating to building construction, and hereby authorize representatives of this city 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 granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal I understand my pla ARCHITECT'S be used as s shall be used as public records. Code, Section 9.18. /,� �G�----�� Licensed Signature Date 12/14/2016 professional r � • 1 ,re�rcov s can t ssu P bas CONSTRUCTION PF-RMiT APPLICATi [ N COMMUNITY DEVELOPMEK "ANT • BUILDING DIVISION 10300 TORRE AVENUE '" _ / 5014-3255 _ � ,�,�� (408) 777-3228 • FAX (4`: ; ;77 .:;33 - builGinciOcupertlno,org ^ r^ry �^7 (3- Z vt 6.. 2� Np.Wr--nNCTDTir—TiQw 1 1. AT)T)TTTfIN '1 I ATTF'RATinmrTT . I RT:\rTCTf'M/T1T:F RDFT) n1?Tr-Tk1AT DrDT,ATT4+ PROJECT 215&, n i475 APN# �gV - �V 1 vU 1 \ ` ` .9 OWNERNAME 1401 rPHONE t E-I%WL STREET ADDRESSwp� aID VrrY { ��y1J CITY, STATE, 71P[ FAX CONTACT NAME j� j{ 1 YHQNE [ J E-MAIL )''/h L J' STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑OWATERR DUILDER El OWNER AGENT ❑ CONTRACTOR 0 CONTRACTOR AGENT CHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANr CONTRACTORNAME LIC£NSENUNMER LICENSETYPE BUS. LIC# COMPANY NAME E•h AIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECTIENGINEER NAME LICENSE NUMBER BUS. LIC: tr COMPANY NAMEEMAIL FAX STREET ADDRESS CITY, STATE,ZIP PHONE �f (J�l ii%1+G T �rn� ccQ.t�ed � =° a-dd�d r:...svv��cl�l►�� EXISTING USE 1PROPOSED USECONSTE. TYPF. 9 STORIES . USE TYPE OCC, SQ.FT. - VALUATION() EXISTO NEW FLOOR DEMO TOTAL ARFA AREA AREA NETAREA BATHROOM KITCHEN OTHER-- REMODELAREA REMODELAREA REMODELAREA PORCH AREA DECK AREA TOTAL DECK/PORCH. AREA GARAGE DETACH ATTACH I #DWELLING UMITS:. ISASECONDUNIT [DYES SECOND STORY E] YES - - -- BEING ADDED? ❑ No ADDITION? ❑NO ,. PR%-APPLICATIoN []YES IPYES, movi ECOPY of IS THE BLDG AN El YES RE ; _ '` : ".• TOTAL VALUATION: PLANNING APPL 2 F-1 NO PLANNING APPROVAL LETTER NICHLERIIOME? ❑NO _ _ __ By my signature below, I certify to each of the following: I am the propert awnor or author: _ agent to Hie paArty owner's behalf. I ]lave read this , application and the information I have provided is correct. I have read Description of Work and ve ' it is e. I agree to covlply with all applicable local ordinances and state laws relating to build' no- wrshu 'on. I atttllol' e representatives of Cupe:. t r th above -identified property forms ction purposes, Date: O Signature of AppUcantlAgent: SUPPLEMENTAL R\TP'ORMATION REQUIRED:- PI:A CHH ...:. - ., ROUTIAG SLIP.`......• -. O� CRI>Irc JtRUTD\ GPLAh REVIETV Now SFD or Multifamily dwellings: Apply for demolition peen it for required e�istmabuilding(s). Demolition ernitis rior to issuance ofbuilding Pei mit for new bui]ding. ❑ PLAIv'hINGYLAlI REVIEIV Commercial Bldgs: Proidde a completed Hazardous Materials Disclosure Ci sTar<IIARD _. ❑ rilsLle t�orcxs _'' Ton -ii if any Hazardous Materials are being used as part of this project. �= = ❑FIRE ,.� LARGE�i .._ DEPT - ..;.. Copy of Planning ApproN al Letter or Meeting with Planning prior to _:Q hIAJOR ©S9itiTARYSERERDISTRICT SlIbmitial of Building Pei application. _ ' - - - - - ❑. �ENVJROIYlYiEA'T'Ali.IIEAi:'I'ii BldgApp_MJ.doc revised 06121111 OWNER -BUILDER DISCLOSURE FOR COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building cDcupertino.( Dear Property Owner(s): An application fora building permit has been submitted in your name listing improvements specified at: X No as the builder of the property SITE ADD SS 205.66 I 10j 70 51AVAca M. APN � J � ' ♦ � v `!2 BP# t3 - 2 0 � 6 - Z� OWNER OWNER ADDRESS DESCRIPTION OF WORK: We are providing you with an Owner -Builder Acknowledgment and Information your responsibilities and possible risk you may incur by having this permit issu( will not issue a building permit until you have read, initialed your underst returned this form to us at our official address indicated. An agent of the 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 una 1. 1 understand a frequent practice of unlicensed persons is to have th ulder' building permit that erroneously implies that the property owner is I personally. 1, as an Owner -Builder, may be held liable and subject to seriou an unlicensed person and his or her employees while working on my prope provide coverage for those injuries. I am willfully acting as an Owner-BuildE insurance coverage for injuries to workers on my property. Ar _i-=-2. I understand building permits are not required to be signed by prop( the construction and are not hiring a licensed Contractor to assume this re: 3. I understand as an "Owner -Builder" I am the responsible party of re protect myself from potential financial risk by hiring a licensed Contractor a name instead of my own. ��4. 1 understand Contractors are required by law to be licensed and bol numbers on permits and contracts. ;rification Form to make you aware of in your name as the Owner -Builder. We ding of each provision, signed, and ner cannot execute this notice unless or verify this information.) property owner obtain an "Owner- oviding his or her own labor and material financial risk for any injuries sustained by y. My homeowner's insurance may not and am aware of the limits of my owners unless they are responsible for isibility. d on the permit. I understand that I may having the permit filed in his or her ded in California and to list their license 5. I understand if I employ or otherwise engage any persons, other th n 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.: OG6. 1 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. E7. 1 understand under California Contractors' State License Law, an C ntial structures cannot legally build them with the intent to offer them licensed subcontractors and the number of structures does not exceed fou i is performed under contract with a licensed general building Contractor. 8. 1 understand as an Owner -Builder if I sell the property for which thi., a y financial or personal injuries sustained by any subsequent owner(s) th defects in the workmanship or materials. vner-Builder who builds single-family or sale, unless all work is performed by within any calendar year, or all of the work permit is issued, I may be held liable for t result from any latent construction Owne3BuilderFonn 2010.doc revised 04114110 Keve 9I understand I may obtain more information regarding my obligation as an "employer"from the Internal nue 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. CIM I am aware of and consent to an Owner -Builder building permit applied form my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. 11. 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. 12. 1 agree to notify the issuer of this form immediately of any addition information I have provided on this form. Licensed contractors are regulate) you contract with someone who does not have a license, the Contractors' assist you with any financial loss you may sustain as a result of a complain Contractors may be in civil court. it is also important for you to understand 1 employee of that individual or firm is injured while working on your property you obtain a permit as Owner -Builder and wish to hire Contractors, you will those Contractors are properly licensed and the status of their workers' cor CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency info I hereby affirm that there is a construction lending agency for the performancE (Sec 3097 Civ.). / Lender Name: Lender Address: deletions, or changes to any of the by laws designed to protect the public. If .ate License Board may be unable to Your only remedy against unlicensed iat if an unlicensed Contractor or you may be held liable for damages. If )e responsible for verifying whether or not pensation insurance coverage. of the work for which this permit is issued Before a building permit can be issued, this form must be completed and 5ligned 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 acceptable to the city may be required to be presented when the permit is issued to veri the property owner's si nature. Property Owner's Signature: Date: VNIMA ------------------------------------------------------------- ----_----------------- -- -- (NOTE: The following Authorization Form is required to be completed by the p o� agent of the property owner to apply for a construction permit for the Owner -Bu Ic Excluding the Notice to Property Owner, the execution of which I understand is authorize the following person(s) to act as my agent(s) to apply for, sign, and fil Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Z Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: ------------------------------------------ y owner only when designating an personal responsibility, I hereby e documents necessary to obtain an Me I declare under penalty of perjury that t 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' driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the pe mit is issued to verify the property owner's signature. Property Owner's Signature: Owne7BuilderForm 2010.doc revised 04/14/10