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B-2016-3102CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR: PERMIT NO: B-2016-3102 18817 PENDERGASTAVE CUPERTINO, CA 95014-3620 (375 33 021) OWNER/BUILDER OWNER'S NAME: DE BLEECKER REGIEN D AND GIELENS MARIE C DATE ISSUED: 03/28/2017 OWNER'S PHONE: 408-398-05154 PHONE NO: LICENSED ONT A TOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic. # Contractor OWN R/BUILD R Date X BLDG X ELECT X 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: 1 (N) PERGOLA; ELECTRICAL -(19); PLUMBING -REPLACE (E) 1- I hereby affirm under penalty of perjury one of the following two declarations: SINK,1- SHOWER; 1. I have and will maintain a certificate of consent to self -insure for Worker's (N) DECK (355 SQ) 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. Sq. Ft Floor Area: Valuation: $50000.00 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 375 33 021 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 willl comply with all ll non -point WITHIN 180 DAYS OF PERMIT ISSUANCE OR source regulations per the Cupertino Municipal Code, Section 9.1 a. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 03-28-2017 Issued by: Kim Dunbar Date: 03/28/2017 OWNER-BUILDERDEC TION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE -ROOFS: foil * two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is 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. 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 (Sec.7044, Business & Professions Code). Date: 03-28-2017 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER s. 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. I will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the 3. 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 equipmen r devices which emit hazardous Worker's Compensation laws of California. If, after making this certificate of air contaminants as defined by the Bay a Air Quality Management District I will maintain compliance with the Cuper o Municipal Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety Code, Spc 'on 2550 , 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent: f APPLICANT CERTIFICATION Date: 03-28-2017 certify that I have read this application and state that the above information is T E GAGENCY correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construc ' ending agency for the performance relating to building construction, and hereby authorize representatives of this city of work's for which this permit is issue (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 penses which may accrue against said City in Lender's Address consequence of th granting of this permit. Additionally, the applicant understands and will comply wit all non -point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code, Section 9. 8: 1 understand my plans shall be used as public records. 6 Licensed Signature Date 03-28-2017 Professional /� CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPIrRTINO (408) 777-3228 • FAX (408) 777-3333 • bIII [ding CcDcupertino. orq b -[� !% VI(�j t `310 3 } © 2- ❑ NEW CONSTRUCTION El ADDITION ALTERATIO ! TI ❑ REVISION / DEFE (1 BldgApp 2t711.doe revised 06/21/11 RRED ORIGINAL PERMIT # /1 y %Y PROJECT ADDRESS F �I$,t)� � "'7 � � .� i J f��f'.iv1�y� OWNER NAtvIE' IL rF.N %1.GGlA-'6!"^�.,.. �jgCpN�#i r PHONE J U ®Jei y.� p�� '`�ly� E-MA1LZM 1P&&6& F_ I � STREET ADDRESSIS8gTgn7 rA.A �r )q lJ CITY, STATE, zip J�f�y D W rC�" v{`E-MI CONTACT NAME C�T ; PHONE AII_ STREET ADDRESS CITY, STATE, ZIP FAX OWNER -BUILDER Q OWNERAOENT ❑ CONTRACTOR M CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT rOWNER NTRACTORNAME LICENSENUMBER LICENSE TYPE BUS. LIC #) ANY NAME E•MAII, FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME 1 LICENSENUMBER �.�r�� BUS. LIC# COMPANYNAME � jw)� �tr777 E-MAIL ��1J1�s�,e� �4/�( f j + c�jiJ"V FAX STREET ADDRESS CITY, STATE,ZIPE`PI•IONE DESCRIPTION OF WORK ),,p1 p� -_ ..-- _ _--zArillr- lAl✓_�1s+c.vM--Vi.—L'_� :�f - -_-=� _ __:.n_ -1v-. I- t OWEN FWOX Ift6TCA • ��LJ�I'f� AxJ v EL G >��2 aGlZ �:ocJGr�b�'� „ i} irtop of ag-m m- Flkr1 M j t"L(JSABI0Q EXISTING USE �sft�aurf�iL PROPOSED USB CONSTR. S�Df�1 L� TYPE flSTORIES USE TYPE OCC. SQ.PT. VALUATION ($) aMiFM NEWFLOOR AREA DEMO AREA TOTAL NBTAREA OOM REMODEL AREA /j//A EN �j REMOREMODEL AREA /y� OTHER REMODEL AREA PORCHAREA DFCC(KAAREA TOTALDECWORCHARBA GARAGEAREA: DETACH JT�J %t 7 !jJr/�'L 0ATTACH # DWELLING UNITS: IS A SECON✓DUNITT [ YES BEINCADUED? WO SECOND STORY L ADDITION7 WESO - PRE -APPLICATION EIYES IF YES, PROVIDE COPY OF PLANNINGAPPLH I❑NO PLANNING APPROVAL LETTER ISTOEDI,DGAN [IES EICHLE� OME? [g'No V _E - _ TOTAL VALUATION: J� (900 By Iny signature below, I certify to eachof foltow I am the property owner or authorized agent to act on the property owner's behalf, I have read this ethe d is c application and the information I have provi orre l 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 •' ! tr tkcti6n au ze representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: —f1�/���Dt�J r SUPPLEMENTAL INFO! .1QN );QUIRED PLAN .CHECK TYPE aau rirsriP-_ :; :- [p ovEit=rxxr-eaurtTi R ❑ : situDlNG ri»ii REVIEW. _ New 3FD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. 11 EXPRESS- pLANNllIGPLANREVIEIV _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD - ❑ PUBLIC viGRics form if any Hazardous Materials are being used as part of this project. FIIREDEPT _ COPY of Aarnring Approval Letter or Meeting with Planning prior to [] rinaoR l]. sANITaxY SEWER DisT ircr submittal of Building Permit application. . 0 wm()NMEN_J'AIiM7 ALTR • BldgApp 2t711.doe revised 06/21/11 OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228 . FAX (408) 777-3333 - buildinaO=Dertino.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 1991 199Alb"414 tT 4V AP -. 2i - -�3to7z OWNER NAME t),r, gL6g (GI P_g 19KJ I OWNER ADDRESS J�� � Apl DESCRIPTION OF WORK: Or, 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. read and initial each statement below to signify you understand or verify this information.) C1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Bfider 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 "prance 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 struction and are not hiring a licensed Contractor to assume this responsibility. 3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may ct myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her instead of my own. I understand Contractors are required by law to be licensed and bonded in California and to list their license s on permits and contracts. 5. 1 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 idered an "employer" understate and federal law. understand if I am considered an "employer" under state and federal law, I must register with the state and f 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 to serious financial risk. Wns' 7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family entia) structures cannot legally build them with the intent to offer them for sale, unless all work is performed by d subcontractors and the number of structures does not exceed four within any calendar year, or all of the work s erformed under contract with a licensed general building Contractor. 8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for '48 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 04/14/10 49. 1 understand 1 may obtain more information regarding my obligations as an "employer"from the Internal R enue 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 ntractors. 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I 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 b i 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 in ation 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 issui a permit. Note: A copy of the property owners driver's license, form notarization, or other verification acc abl to the city maybe required to be presented when the permit is issued to veri the roe owner's si nater Property Owner's Signature: Date: dS (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). a 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, 1 hereby authorize the following petson(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: Tel No Address of Authorized Agent: 1 declare under penalty of perjury that I a the property owner for the address listed above and I personally filled out the above information .and certify its accurac . N "copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may b r quire to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: r OwnerBuilderForrn 2010.doc revised 04/14/10