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B-2016-3194 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3194 10709 CULBERTSON DR CUPERTINO,CA 95014-3554(375 36 035) OWNER/BUILDER OWNER'S NAME: ALAMDARI SEYED KAMALAAND MOTALEBI SlM[N V DATE ISSUED-01/26/2017 OWNER'S PHONE:408-446-0446 PHONENOz LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic.# Contractor OWNER/BUILDER Date X BLDG _ELECT —PLUM I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MICH 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 ENFORCEMENT CASE:REMOVE UN-PERMITTED I hereby affirm under penalty of perjury one of the following two declarations: LIVING SPACE AND CONVERT SPACE BACK TO A TWO CAR 1, 1 have and will maintain a certificate of consent to self-insure for Worker's GARAGE(414 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. 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. Sq.Ft Flo"Area: Valuation:$3000.00 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 APN Number: Occupancy Type- and state laws relating to building construction,and hereby authorize 375 36 035 representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save indemnity 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 WITIHN 180 DAYS OF PERMIT ISSUANCE OR source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED ECTION. Signature Date 011261=7 Issued by:MELIS Date:j01!26/2017 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RF ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 'Mi. 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. sale(Sec,7044,Business&Professions Code) 1 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date:01/26/2017 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"All OR BETTER 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 performance of the work for which this permit is issued. ' HAZARDOUS MATERIALS DISCLOSURE 2. 1 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. 1 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 material. Additionally,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 defined 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 Owner or authorized be deemed revoked. I agent-.,", APPLICANT CERTIFICATION Date:01/26/2017 77- I certify that I have read this applicationand state that the above information is CONSTRUCTIONLENDINGAGENCY 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 works 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, Lendees Address judgments,costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands ARCHITECT'S DECLARATION and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records. Code,Section 9.18. Licensed Date 01/26/2017 Signatu Professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT.BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 � � � (408)777-3228•FAX(408)777-3333•buildingCcDowertino org ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION!TI ❑ REVISION!DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS I b` j>L , �„ A ] APN# OWNERNAME �I� Y 1 [ B�+ P /01 J� E-1 AIL m k- �r fP_��t�►p 'C�„r- STREET ADDRESS 7 f1 C�����r .1p J CITY,STATE,ZIP G'V Y FAX CONTACT NAME W ki KO-TA-M tr 9 I PHONE C7 •C�y GI. a E-MAIL �a S SSI ntf��t 1h�t � 4n STREET ADDRESSCITY' C STATE,ZIP F C� fD�j 5 wl'�c�1t5 —cl l�ry ,��1��. J-� ❑ 7 OWNER LlOWNER-BUILDERElOWNMAGENT ❑ CONTRACTOR 11CONTRACTORAGE0NT ARCHr=T ❑ENGINEnR ❑ DEVELOPER 11 TENANT CO NTRACTORNAME H �r /� LICENSE NUMBER LICENSETYPE BUS.LIC# COMPANYNAME WW E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCEI TECTIENGEVEER NAMES 1 LIC- ENUMBER BUS.LIC 9 COMPANYNAME E-MALL FAX STREET ADDRESS CITY,STATE,ZIP PHONE /J �{ evig DESCRIPTIONOFWORK, �yflrnn6 r( C���•�-'"� C�ry cr�L��— � �-�v��- �P�c,�-� ��,t1"n Cr��(�-•��}z- 7"I��nJJ 5�1 •� EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION($} EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NEYAREA BATHROOM KITCItEN OTHER REMOMLAREA REMODELAREA REMODELAREA PORCHAREA DECKAREA TOTAL DECKIPORCHAREA GARAGEAREA: ©DETACH ❑ATTACH #DWELLING UNITS; IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEINGADDED? NO ADDITION? [:]NO PIE-APPLICATION E]YES IF YES,PROVIDE COPY OF ISTHEBLDGAN [3 YES CEIYED BY.:."i`._:'.;::;c�=;:_;=°'.';: i:'t.'i:=: ?; TOTAL VALUATION: PLANNINGAPPLB []NO PLANNING APPROVAL LEITER MCHLRRHOME? ❑NO4224-1 - __ n By my signature below,I ccitify to each of the.followi gg I ani the property owner or authorized agent lo act on the property owner's belle f. 1 have read this application and the information I have provided is coiT bt. 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 construct bn. I authorize representatives of Cupertino to enter the above-identified properly for inspection purposes. SigiiafuleofApplicant/Agent: .. J +w�Y ^� ^ ' Date; SUPPLEMENTAL INFORMATION Rr =-D ::7z;.ROU1'ING.511P:=:= _ or SPD or Multifamily y dwelfings: Apply for demolition permit f .:.-.:j.:.:.:Q::•U:.:N:.s..emT_. ..::-..::..:•.:.:.._.:;_.: ,.o'...-.:.i?.i.:PR_IU:AI.LD:\I:tN.I:-v G._--:.l.-:Y,a.L::-_-,-`W:-_Tk-R_:EV.S_-'I::-E___;:W existing building(s). Demolition permit is required prior to issuance ofbuldina : ` : permit for new building. RE _ Commercial Bldgs. Provide a completed-Hazardous aterials Disclosure '_° s Asti To—nn if any Hazardous s Materials are being used as part of this p roJ ect, - ... .... .. ........ :'�. ..LARGE:.'...`.;;5:::_':._:'..:::'_.:!,:`:,.::�i- - .F[RE DEPT"=t:i;i:...�;C::::;::..;:•:-`-.:.-: Copy of Planning Approval Letter or Meeting with Planning prior to ........: :� submittal of BuildingPermit application. _- _ -- _ - - -- .EN1D20NMCIV'I`IiL�IfEiII;TN.�:�'-'�'";.. BldgApp2011.c1oe revised 06121111 � � ^ W OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT~BUILDING DIVISION 1O3OOTORREAVENUE^CUPERTNO.CA 95014-3255 (408)77T3228~FAX(4V8)777'3333^ CUPERTINO | Dear Property An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: O-NERNAME WNER ADDRESS 1,3 "Lel 713 5 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 touosdour official address indicated. Anagent ofthe 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 (DK7fC77ON8:Please read and initial each statement below to signify you understand or verify this information.) . | underatandnknquentprooboeofun|icenaodpeneunaiobohavethepropertymwnnrnbtainon"Owner- 6�uiljer"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 sedous financial risk for any injuries sustained by onunlicensed person and his nrher employees whi|ewmdJngunmypno dy K4yhomeowner'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 toworkers onmyproperty. S. �AA 2. | understand building permits are not required to be signed byproperty owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. AA3. 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 ofmyown. S4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers onpermits and contracts. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the totalvalue of my construction is at least five hundred dollars($500), including labor and materials, I may be considered an"amp|oyer'understate and federal law. . | undorebandif| amoonoidnredon"emp|oyer" unduratoteandfedana| |avv | 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 me0ooehoum�nancia�hak. � | understand under California Contractors' Sbsb� License Law,an O�neBui/dervvho 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 ail of the work � iaperformed under contract with alicensed general building Contractor. � sell the property for which this permit is issued, | may be held liable for - any financial or perknal injuries sustained by any subsequent owner(s)that result from any latent construction . defects inthe workmanship ormaterials. ' 0x,77m-Bu&derFovn-2V28mhvrevised 041Y4D0 ' � � � ° pt 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(C8LB)ot1-8D8-321-CSLB(2752)nrvwxmv.on|b.na.guvfor more information about licensed contractors. '5-1A 10. 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. 51 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. neebonotify the issuer of this form immediately ofany additions, deletions, 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 3OQ7Ck/) 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 acceptable to the city may be required to be presented when the permit is issued ---------'-----'---'--------------------------- --------------------------' (NO7E. The following Authorization Form is required to be completed by the property owner only when designating an agent ofthe property owner boapply for aconstruction permit for the 0wme+Bu&ded. 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 toobtain an Owner-Builder Permit for myproject. Scope ofConstruction Project(or Description ofVVod6: Project Location orAddress: Name ofAuthorizedAgent: TelNo 'Address ofAuthorized Agent: I declare under penalty of perjury that I arn the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note:/4 copy ofthe 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: docmvised 0411410