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B-2017-0244CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10649 FARALLONE DR CUPERTINO, CA 9501411407 (369 35 003) OWNER'S NAME: BAGARE VINAY KUMAR D AND LAKSHMI OWNER'S PHONE: 408-410-8237 LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor BAGARE VINAY KUMAR D AND LAKSHMI 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 Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I I have and will maintain Worker's Compensation Insurance, as prov�ded for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTMCATION 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 ordinan and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property inspection purposes. (We) agree to save indemnify and keep harmless City of Cupertino against liabilities, judgments, costs, and expenses whl may accrue against said City in consequence of the granting of this per Additionally, the applicant understands and will comply with all non-poin source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date 02/10/2017 I OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for o ie of the following two reasons: 1. I, 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)ffered for sale (Sec.7044, Business & Professions Code) I, as owner of the propert3; am exclusively contracting with license contractors to construct the project (Sec.7044, Business & Professio `ps Code). I h4reby 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. 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. 3' " I,certify that in the performance of the work for which this permit is Tissued, 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 cerltificate 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. CONTRACTOR: ' PERMIT_ NO: BAGARE VINAY KUMAR D AND LAKSHMI 10649 FARALLONE DR CUPERTINO, CA 95014-4407 02/10/2017 PHONE NO: BUILDING PERNHT'INFO: BLDG X ELECT _ PLUMB MECH X RESIDENTIAL _ ( JOB DESCRIPTION: REPLACE 100 AMP PANEL WITH 200 AMP, SAME LOCATION Sq. Ft Floor Area: 'I Valuation: APN Number: Occupancy Type: 369 35 003 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. by: All roofs shall be inspected prior to any rop6 g material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for Signature of Applicant: Date: 02/10/2017 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, 25533, and 25534. Owner or authorized agent: Date: 02/10/2017 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 jpublic records. Date 02/10/2017 1 Licensed GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 • building(d)cupertino.org. MMU CUPERTINO El f2<LF_CTPJCAL 0 Z' y D MECHANICAL [IMISCL�ANEOUS —7 PROJECT ADDRESS 106qq AP 'I N, :7647,� 003 OWNER NAME PHONE �og fre STREET ADDRESS CITY, STATE, ZIP CA- q56/0 FAX V L60 Rwaltw' 'by CONTACT NAME lids STREET ADDRESS CITY, STATE, ZIP FAX ❑ O'ANER <01R -BUILDER ❑ OWNERAGENT. 0 CON-MACTOR 13colrRACTORAGEIN-l' 1:1 ARCHITECT 11 EIN"GlINEER El DEVELOPER El TENTANIT CONTMACTORMAME LICENSE 1,aRqL3/q�T I LICENSE TYPE yryl BUS. LIC COMPANY NAlE- FAX STREET ADDRESS , q 5112- CITY, STATEZ�5 1 PHONE 4OSS970052 ARC111TECT/ENGINEERNAME LICENSE NUMBER V Bus, LIC ft COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF or DUPLEX PROJECT LN W11331-AIND ❑ YES f PROJECT 11 El YES URBANT INTERFACE AREA ❑ NO BLUDIING: Ej colE�'LTRukL FLOOD ZONE ❑ NO IS THE BLDG AN ❑ yEs EICHLERHOME? ❑ NO DESCRIPTION OF WORK +r j_ ry\ayl Wwd P_W'"CC-L MOAMAP C-Cxo YL AV TOTAL VALUATION: I am the property owner or authorized agent to act on the property dialf. I have By my signature below, I certify to,each of the following:re ' la cable I.cal application and the information I have provided is correct. I have read the Description of Work and verify itis accur.9e. agree to comply with all applicable relating �n. I authorize representatives Of Cupertino to enter the above -identified property for inspection purposes. ordinances and state laws to buildrWg cons uctl .% S iagnature of Applicant/Agent: Date: SUPPLEMENVA-L INTURMATION REQUIRED AlfEPARCAPP__Ml. doe revised 06121111 M Pte.. C3UPERTINO OWNER -BUILDER DISCLOSURE PORIA COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(Mcupertino.org Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the improvements specified at: of the property SITE ADDRESS l / q V K7 have / i -t 1� -T_/CPN,, 'tip /J s ��®� 3 3 3 i BP# OWNER NAME 1 �1 � & �_ OWNER E RE'Tf ®71 Y� DESCRIPTION OF WORK. cy l^° y x �� �e A ! q x�yL �v(�+ G 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 tows 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.) ' I . I understand a frequent practice of unlicensed persons is to have the property ow, rier 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. i 2. I 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. 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. v 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. 14C5. 1 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. i 6. 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. i 17. I 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. 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. OwnerBuilderForm 2010.doc revised 04114110 I I 4 r 9. 1 understand I may obtain more information regarding my obligations as an "employe" 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.esib.ca.gov for more information about licensed contractors. 10. 1 am aware of and consent to an Owner -Builder building permit applied forin my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. Aal 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide l applicable laws and requirements that govern Owner -Builders as well as employer$. 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 theP ublic. 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 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 acceptable to the city may be required to be presented :when the permit is issued to verify the orooerty owner's signature. A Property Owner's Signature: W.I7 Dater 2-1 t oI iW- --- - - -- --- --- ---- --- ---- --- -- -: --- --- - - -- - -- - ---- --- -- - ,'-- ---------------------------- (NOTE: The following Authorization Form is regwred 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 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. j Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: • Address of Authorized Agent: i 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. I Property Owner's Signature: Date: i OwnerBuilderForm_2010.doc revised 04114110 i I