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B-2017-0289CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10214 NILE DR CUPERTINO, CA 95014-2144 50 022) CONTRACTOR: PERMIT NO: B-2017-0289 (369 HOMEOWNER BUILDER OWNER'S NAME: TOTH KEVIN S AND ANDREA W DATE ISSUED: 02/21/2017 OWNER'S PHONE: 714-488-2826 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic. # Contractor HOMEOWNER BUILDER Date X BLDG —ELECT _PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing — MECH X RESIDENTIAL — COMMERCIAL with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: I hereby affirm under penalty of perjury one of the following two declarations: REMODEL MASTER BATHROOM (80 S.F.) 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. . z. 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. APPLICANT Sq. Ft Floor Area: Valuation: $15000.00 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 369 50 022 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 this permit. Additionally, the applicant understands and will comply with all ll 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 2MI2017 Issued by: Abby Avende Date: 02/21/2017 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 i. 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 A inspection. f sale (Sec.7044, Business & Professions Code) Gz�I, as owner of the property, am exclusively contracting with licensed Signature ofApplicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 2/21/2017 I hereby affirm under penalty of perjury one of the following three declarations: t. 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 performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE z% 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 theperformance 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 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 authorized agent: APPLICANT CERTIFICATION li Date: 2/2112017 I 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 9.18. 1 understand my plans shall be used as public records. c Sig an ture Date 2!21/2017 Professional— CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - bufld1no(o�cugerflno.orq 11 NTE 'WCO"NSTRUCTIO! � AT)-1)TTTn,T,T FV/A T TL7) A -MnT I IT F -I - — ii UFLIGINAL PERMIT ft' PROZCT.ADDRESS 0jZX4,t AP # �um - SO -01? OWN-EP,\A-k-1E PHONZE'1\4_qt�,I�Z� F -I\, . A �kjL STREFTADDRESSCIT, Ax Wzlq 7t& Y. STATEC V e # F CONTACT NAME PHPN--E L N r q Z -o & STREE�WSS ZIP Lia L C, E 3 OWIN-- R 13 OV,'\,-RBT--MDER 2/ 0'111R A GENT ❑ COI\'T'P-ACTOR El CONTRACTORAGE-E1.7 DEVELOPER ❑ —='ANT CONTR&CTORNAME LICENSE. 7U IvIEBER I LICENSE TYPE BUS. LIC; COA/PARYNA 4E E-MAJL FAX STREET -ADDRESS CITY, STATE, ZIP PHONE -kRCH1TF-CT,SI`:;G1N,EE-R N.4UIE I fICEN*SE1\L1\IBER BUS. LTC Cc h1p.-UNTY Muls2'IL RAX STREFTAJ)DRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK EXIST-UNGUSE PROPOSED USE C0NSTR i1TE eSTORIES I USE TYPE OCC. SQ.FT. NtALUAno\, (S) EXISTG MEW FLOOR DEMO TOTAL A22.EA AREA AREA NET AREA BATHROOM KTfCHEN OTHER REMOVEL.AREA R.EMODELAREA PORCH.L,REA DEECKAl-UA IOTA TOTAL DECKTORCH.�.Rllk GARAGE ARIIA: E] DETA ❑ ATTACH DIA TILLING T,\, -TS: .TS.. IS A SECOND UNIT [] YES SECOND STORY EINGADDED? [D\ --O BEING ADDITION? E] NO PRE-A.°PLICATION' )7S IF YES, PROVIDE COPY OF P1-ANNI2\G.A0PL NO ING APPROVAL LETTER 1STHE BLDG .k-, E]YES EICELERHOME? ED NO J TOT --LL ALUATION: 5"e By any signature below, I ccertii}, to each of the follow-ine: I am the property owner or authorized agent 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'W'ork and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relatffis . to buil m'sr const action. I a pr-CSCUtativeS Of Cupertino to enter the ab iden ed property for inspection purposes. S i _cmature OfAppIicant�kgent: Date: SUPPLEMENTAL rKFORMATIONIT REQUIRED s**,'!i.----.-...-T*, PLZN 9 CH TiT New SFD or -Muhifai-nib7 &-vellings: Apply fior demolition pernlit for •DemolitIO-1-1pCITITTI 7 _j existl-ngbuilding(s). t is required nrior to issuance ofbuildina perinit for new building. Commercial Bldgs: Provide a completed Hazardous Materials Disclosure form i L7 sT�- .... ........ II any Hazardous are being L sed as par, ofthis pioject. j Copy of Planning A 'pproval Letter Or lvle�tirilg with Planning prior to submittal of Building Perri-ift application. )R 6,2,- N BIdg1p.p_2011.doc revised 06/21/11 3PL 5� [_ zw_114� CU'PERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(cDcupertino.ora 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, a1d02M- LE i>pYs e� BP# OWNER NAME AvT>P -C 1 k YiTa i�T1 OWNER ADDRESS 10214 At ME Dr-kVa y �eSOrnnt®, CA 9s'iI DESCRIPTION OF WORK: Gi1I+r--Q i k?-e4Lt01>e-(_ v.,( .JPg `i- STNWn+ P. 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.) _-1. 1 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. ft�_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. X 3. 1 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. P6- 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. P�i"5. I 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. PT -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. K-7. 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. 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 any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. Oii'72e7Blfilde7F07711 2010.doc revised 04114/10 `f 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 wvvw.csib.ca.gov for more information about licensed contractors. AT' 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. K 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. K 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: M I )PI, Lender Address: 9 Before a building permit can be issued, this form must be completed and signed bythe 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 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): Ptyme-om r.-e.kwi>,_k„ i,,J ,���• sft-Wp�.e. c -m vaes,aP4 Project Location or Address: Ir -214 Ale Dr -Ave eA ga'Q14 FL;--gP Name of Authorized Agent: 1111&r� Tel No J 4-7 Z --Lt( L Address of Authorized Agent: i declare under penalty of perjury that 1 am tl e 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: C' ---,j J _ Date: 014-77e7B2iilde7Fo7-777_2010.doc revised 04/14/10 IwX m m a U n" 05 ud J Na @ mE Fc`v c X `m ...E E IwX a U n" 05 ud J �3 c X I' z CL m$ L3� � is-' 0 0 J LL G 0 0 Q m 0 W 0 0- 0 Er - L1 Z Q J 0 0 0 J L c G 0 0 Q m ^G X W a U m$ �a m -- rz T, Sr o m v d _ FF Of m �U v E _ _ o a A- c m m 3 3 R m 'o�a U n mE v 8 m E m EIc0 0000`o `o .E E �EE — @ Eco io m U 0 '^E� 45 WE Q L3� � is-' 0 0 J LL G 0 0 Q m 0 W 0 0- 0 Er - L1 Z Q J 0 0 0 J L c G 0 0 Q m ^G X W