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13080010CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11072 BEL AIRE CT CONTRACTOR'iPB� BE PERMIT NO: 13080010 DL,T-E�D OWNER'S NAME: PREM MALHOTRA pr.0 m 4 DATE ISSUED: 03/07/2014 OWNER'S PHONE: 4089963896 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL SFD ADDITION OF 1035 S.F. TO ADD (N) ENTRY, LIVING License Class Lic. # RM, GUEST ROOM & ENLARGE (E) MASTER BDRM. ADD 58 Contractor Date S.F. OF (N) FRONT PORCH AREA. REMODEL 400 S.F. TO 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. hereby affirm under penalty of perjury one of the following two declarations: 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 Sq. Ft Floor Area: Valuation: $182000 performance of the work for which this permit is issued. 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 APN Number: 35616057.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter DAY -ARR04 upon the above mentioned property for inspection purposes. (We) agree to save 180 LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the 7 granting of this permit. Additionally, the applicant understands and will comply Issued by: Dat with all non-point source regulations per the Cupertino Municipal Code, Section 9.18. RE-ROOFS: Signature_ Date All roofs shall be inspected prior to any roofing material being installed. if a roof is installed without first obtaining an inspection, l agree to remove all new materials for inspection. 1 OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1, 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 offered for sale (Sec.7044, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally, should l use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and 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 the Health & Safety Code, Sectio � 25505, 25533, and 25534. Owner or authorized agent: Date: 17N4 permit is issued. Iify that in the performance of the work for which this permit is issued, I shall of 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, 1 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, l must l hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct. l 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 ARCHI'TECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the l understand my plans shall be used as public records, granting of this permit. Additionally, the applicant understands and will comply with all non-point s rce regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date 61 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11072 BEL AIRE CT CONTRACTOR: PREM MALHOTRA PERMIT NO: 13080010 OWNER'S NAME: PREM MALHOTRA 11072 BEL AIRE CT DATE ISSUED: 03/07/2014 OWNER'S PHONE: 4089963896 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL F� COMMERCIAL E] SFD ADDITION OF 1035 S.F. TO ADD (N) ENTRY, LIVING License Class _ Lic. # RM, GUEST ROOM & ENLARGE (E) MASTER BDRM. ADD 58 S.F. OF (N) FRONT PORCH AREA. REMODEL 400 S.F. TO Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 Revision #1: Reroof existing residence and garage (2251 sq ft) (commencing with Section 7000) of Division 3 of the Business & Professions Issued 7/3/14 Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: 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 Sq. Ft Floor Area: Valuation: $182000 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 APN Number: 35616057.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 D MIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 D - 00� ED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, �� costs, and expenses which may accrue against said City in consequence of the L? J / granting of this permit. Additionally, the applicant understands and will comply ed b Date: with all non -point source regulations per the Cupertino Municipal Code, Se 9.18. RE -ROOFS: Signature Date _ All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, t agree to remove all new materials for inspection. OWNER -BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1, 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 offered for sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with t e M Cupertino unicipal Code, Chapter 9.12 and 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 the Health & Safety Code, Secti s 25505, 25533, and 25534. Owner or authorized agent: Date permit is issued.: 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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, ARCHITECT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non-po t source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date V I i 2 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11072 BEL AIRE CT CONTRACTOR: PREM MALHOTRA PERMIT NO: 13080010 OWNER'S NAME: PREM MALHOTRA 11072 BEL AIRE CT DATE ISSUED: 03/07/2014 OWNER'S PHONE: 4089963896 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL E] SFD ADDITION OF 1035 S.F. TO ADD (N) ENTRY, LIVING License Class Lic. # RM, GUEST ROOM & ENLARGE (E) MASTER BDRM. ADD 58 Contractor Date S.F. OF (N) FRONT PORCH AREA. REMODEL 400 S.F. TO I hereby affirm that I am licensed under the provisions of Chapter 9 REVISION #2 -OMIT PANEL UPGRADE; ADD SUB PANEL INSIDE (commencing with Section 7000) of Division 3 of the Business & Professions GARAGE- ISSD OTC 8/26/2014 Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: 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, foWON-lit- Valuation: $182000 performance of the work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance, as provi Section 3700 of the Labor Code, for the performance of the work for Occupancy Type: permit is issued.6057.00 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. 1 agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS F M L ST CALLED INSTION. 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 Issued by: Date: with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. RE -ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. F\F OWNER -BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1, as owner of the property, or my employees with wages as their sole compensation, wil I do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance wit the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Se 'ons 25505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner agent: Date: permit is issued. or authorized I rtify 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct. 1 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, ARCHITECT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the l understand my plans shall be used as public records. granting of this ermit. Additionally, the applicant understands and will comply with all non -poi source regulations per the Cupertino Municipal Cod , Section Licensed Professional 9.18. Date Signature \I v CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building6a cupertino.crg ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / Ti ❑ REVISION /DEFERRED ORIGINAL PERMIT # I� PROJECT ADDRESS � � ,(J � � y� APN # OWNER NAME Pilo E p E-MAIL STREET ADDRESS 1, U a . ^ -(/� CITY, STATE, ZIP FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE 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 2 ' to xv Nj EXISTING USE PROPOSED USE CONSTR TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: Lj DETACH ❑ ATTACH k DWELLING UNITS IS A SECOND UNIT ❑ YES SECOND STORY El YES BEING ADDED? ❑NO ADDITION? []NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES RECEIVED BY: T T ON: PLANNING ADPL 9 ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO By my signature below, I certify to each -the following: I am the property owner or authorized agent to act on the property owner's behalf. 1 have read this application and the information I have pr ided 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 buil i construe kon. I authorize re r Ives of Cupertino to enter the above- Identifie propertt for inspection purposes. Signature of A ppl icant/Agent: Date: SUPPLEMENTAL INFO MA REQUIRED PLAN CHECK TYPE ROUTING SLIP ❑ 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 ❑ STANDARD ❑ 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 ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH B1dgApp_201I.doc revised 06/21/11 CITY OF CUPERTINO FM__7 FEE ESTIMATOR - BUILDING DIVISION imADDRESS: 11072 BEL AIRE CT DATE: 08/01/2013 REVIEWED BY: MELISSA PC FEE ID APN: 35616 057 BP#: 3000 V "VALUATION: 1$182,000 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Duplex USE: 2nd Unit? 0 Yes . No OTC. 0 Yes 0 No PENTAMATION 1 R3SFDADD PERMIT TYPE: WORK SFD ADDITION OF 1035 S.F. TO ADD N ENTRY LIVING RM GUEST ROOM & ENLARGE E SCOPE MASTER BDRM. ADD 58 S.F. OF (N) FRONT PORCH AREA. REMODEL 400 S.F. TO p OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) II-B,111-B,IV,V-B 1,093 $2,597.03 IR3PLNCK $1,688.75 IR3INSP $0.00 PME Plan Check: $0.00 Permit Fee: $1,688.75 Suppl. Insp. Fee -0 Reg. 0 OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: TOTALS: 1,093 $2,597.03 $1,688.75 NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District ote-L Thomo teem are hamod an the nreliminary infarmatian available and are only an estimate. Contact the DeDt for addn'l info. FEE ITEMS (Fee Resolution 11-053 Ef: 7/1/12) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,597.03 = s.f. $488.00 Remodel, Other 1REMRESOTH Suppl. PC Fee: 0 Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $1,688.75 Suppl. Insp. Fee -0 Reg. 0 OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Con'Owcfion i�;x Jdmhfistrativ f',,c: 0 E) Work Without Permit? 0 Yes 0 No $0.00 Advanced Pianniniz Fee: 1PLLONGR $153.02 Select a Non -Residential Building or Structure 0 0 7'i-elvcl 1)0"Il entctJie,r=. Strong Motion Fee: 1BSEISMICR $18.20 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $8.00 CTBT'U'ALS:'` $4,465.001 $488.00 , T(STAI, F.EEt $4,953.00 Revised: 07/01/2013 CITY OF CUPERTINO FM -7 FEE ESTIMATOR - BUILDING DIVISION NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School Dictrirt atr ) Thoco fooc nra hacod nn tho nraliminary infarmatian availahla and nra anh� nn octimato_ Cantart tho Dont far addn'I info_ FEE ITEMS Fee Resolution II -053 Eff' 7/1%73 ADDRESS: 11072 Bel Aire Ct DATE: 07/03/2014 REVIEWED BY: Sean Plan Check Fee: APN: 35616057 BP#: 12)Noo M Suppl. PC Fee: Q Reg. Q OT 'VALUATION: Iso PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or DuplexT USE: PME Plan Check: �PENTAMATION 1 SFDWLROOF PERMIT TYPE: WORK Revision #1: Reroof existing residence and garage 2251 sq ftIssued 7/3/14 SCOPE Suppl. Insp. Fee -E) Reg. Q OT0,0hrs NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School Dictrirt atr ) Thoco fooc nra hacod nn tho nraliminary infarmatian availahla and nra anh� nn octimato_ Cantart tho Dont far addn'I info_ FEE ITEMS Fee Resolution II -053 Eff' 7/1%73 FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 2,251 s. f. Re -roof $368.00 /REROOFREs Suppl. PC Fee: Q Reg. Q OT F0.0 I hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee -E) Reg. Q OT0,0hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 0 E) Work Without Permit? 0 Yes No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential 0 Building or Structure A Strom Motion Fee: $0.00 Select an Administrative Item Bldg Stds Commission Fee: $0.00 SUBTOTALS: $0.00 $368.00 TOTAL FEE: $368.00 Revised: 07/01/2014 Ly'GiFrt �:: OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building EDcupertino.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 tit. 6ri(�� APN . BP# , 16 _o% 13 b800 10 `I OWNER NAME OWNERE ALI- C, -L- & i- AVE C-1- (.()PW'-rJ7rUG Gly -'i1-UlLf DESCRIPTION OF WORK: n a 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.) V1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- uilder' 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 understand building permits are not required to be signed by property owners unless they are responsible for t construction and are not hiring a licensed Contractorto assume this responsibility. �_t2.,-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. &��I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the Noilvalue 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. �l 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. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family ��7, ential 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. Z. I 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. OwnerBuilder F07771 2010.doc revised 04114110 9. I 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.csib.ca.gov for more information about licensed contractors. �0 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the parry legally and financially responsible for proposed construction activity at the site address listed above. 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by allapplicablelaws 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 acceptable o 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: --------------------------------------------------------------------------------------------------------------------------------------------- (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). AUTHORIZA"PION 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 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: OwnerBuildeiFonri 1010.doc revised 04114/10 11072 BEL HIRE CT ommy,mil, SCANNED BOX #570 z Q oO `�Y _ g s o �W 3 LL O 5 g 7 w LLI W LL- ID0 w z O WCW.. UoaF C o 4 W / F (II L� C cr W y w '�L' (n W ( V I V^ W CG G Q C� — W O C 4 4 Q < Q 4 Z �� II 'aa H$3a3I HINds � � 'ia a�d Asa 6 i � LSI m � M@ ITJ= a U L..J j_��, U bQ dWWdHd 4 � � h w o t 'aa HISIA daND a s c. _.. h' O O 4 El M-Iffi ji-nnfliffikimm m. 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