B-2017-0376CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0376
10123 N WOLFE RD CUPERTINO, CA 95014 (316 20 100)
OWNER/BUILDER
OWNER'S NAME: VALLCO PROPERTY OWNER LLC
DATE ISSUED: 04/11/2017
OWNER'S PHONE: 408-777-3180
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class U6. #
Contractor OWNER/BUILDER Date
X BLDG —ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
MECH RESIDENTIAL X COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
CONSTRUCT TEMPORARY BARRICADE WALLS INSIDE MALL AT(7)
I hereby affirm under penalty of perjury one of the following two declarations:
LOCATIONS WITH PANIC HARDWARE EQUIPPED EGRESS
1. I have and will maintain a certificate of consent to self -insure for Worker's
DOORS - VALLCO
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: $5000.00
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
316 20100
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 of this permit.
Additionally, the applicant understands and will comply with all non -point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulati n per the Cup +t'no Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLEDANSPECTION.
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Signature + Date 04/11/2017
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Issued by: MiU& iNAMES
Date: 04/11/2017 ,..;, '-"==�""�.,,.'`
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
following two reasons:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
s. 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.
f sale (Sec.7044, Business & Professions Code)
i. J,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: 04/11/2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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.
HAZARDOUS MATERIALS DISCLOSURE
2. 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
aI certify that in the of the work for which this is issued, I
Health & Safety Code, Section 25532(a) should I store or handle hazardous
performance permit
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
Labor Code, I must forthwith comply with such provisions or this permit shall
the Health & Safety Code, Sections 2. 255 3, ,and 25534.
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be deemed revoked.
Owner or authorized.agent:/
APPLICANT CERTIFICATION
Date: 04/11/2017
1 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 ial.18.
I understand my plans shall be used as public records.
i
Licensed
Sign jufe� ! Date 04/11/2017
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300. TORRE AVENUE • CUPERTINO, CA 95014-3255
Ci3PER-rlNO
(408) 777-3228 • FAX (408) 777-3333 • building(acugertino.org 9,10 t *.-03- -1-
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❑ OWNER 11 WNEt BUILDER ElOWNERAGENT ❑ L'ONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANi,
CONTRACTORNAME n _f
LIC' SENUMBER
LICENSE TYPE
BUS. LIC#
COMPANYNAME"
E-MAIL
FAX
STR.EETADDRESS ..
CITY, STATE, ZIP
PHONE
ARCHITECTIENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANYNAME E-MAIL FAX
STREET ADDRESS CITY, STATE, ZIP PHONE
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_DESCRIPTION
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EXISTING USE
PROPOSED USE CONSTR,
TYPE
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USE TYPE
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VALUATION (S)
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DECK AREA TOTAL. DBCK/PORCH AREA
GARAGE AREA: ❑ DETACH
❑ ATTACH
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0 DWELLING UNITS:
ISA SECOND UNIT []YES
SECOND STORY ❑ YES
BEING ADDED? ❑NO
ADIITION? ❑NO
PRE APPLICATION ❑ YES F YES, PROVIDE COPY Or
1S THE BLDG AN ❑ YES'
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PLANNINGAPPL# []NO PLANNING APPROVALLETI•ER
EICHLERHOAIF.? [3 NO
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By my signature below, I certify to each of the following: I ani the property owner or authorized a ent to act an the property owner's' . I have read ibis
application and the information I have provided is corec . 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 b di g onst ct I. I ]IOlize representatives of Cupertino to enter the abov -ide tifred property for inspection purposrs.
9/71/17
Signature ofApplicanilAgent c Date:
SUPPLEMENTAL INFORMATION REQUIRED
YLALS CHECKTYPE .
ING5L1P.sr:`''%:'
New S -FD or Multifamily dwellings: Apply for demolition permit for
existingbuildin s. Demolition permitisrequired prior toissuance. ofbuilding
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permit for now building..............."
WGPLANREVIEW::-;:.;;::;
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosurc
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form if an Hazardous Materials are beat used as art of this project.
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FIRE DEPT:...:.::
Copy of Planning Approval Letter or Meeting with Planning prior to
I -:SAN -ARYSEIi`EkDiSTk CT":rc
submittal of Building Permit application.
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CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - building(@cupertino.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 ADDRESbi 9 8 R
APN f Z ,
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OWNER ADDRS�S
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DES RIPTION_OF WOR: a` P
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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.
8
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
( i surance coverage for injuries to workers on my property.
e
1 2. 1 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 Contractor to assume this responsibility.
,L_3. I understand as an "Owner -Builder" I am the responsible party of record on the permit. f 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.
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
n tubers on permits and contracts.
1 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
tota'1 value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
co idered an "employer" under state and federal law.
I 1 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
uneriiployment compensation for each "employee." I also understand my failure to abide by these laws may subject
�Tk serious financial risk.
a
7. 1 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 t erformed under contract with a licensed general building Contractor.
i� 8.1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
anytinancial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
Ow32erBllildeYFOrn1 2010.doc'revised 04114110
H l
Ag" 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 11-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed
I cl actors.
10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
&Teparty 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
blapplicable
laws and requirements that govern Owner -Builders as well as employers.
2. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
inforPnation 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 to the city maybe required to be presented when theermit'isissued
to verifv the property owner's sianature7.11 l r^
Property Owner's Signature: � If Cr S V116,1 -Ml U Date: !L1 ( C -H r % I
T- .
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(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):
Project Location or Address:
Name of Authorized Agent:,
Address of Authorized Agent:
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.
Property Owner's Signature:
Date:
OwnerBuilderFOrn2 2010.doc revised 04114110