B-2017-0739CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0739
10161 LEBANON DR CUPERTINO, CA 95014-2645 (342 14 007)
HOMEOWNER
BUILDER
OWNER'S NAME: HSU TRACY TRUSTEE
DATE ISSUED: 05/10/2017
OWNER'S PHONE: 408-464-5030
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lic. #
Contractor HOMEOWNER BUILDER Date
X BLDG X ELECT —PLUMB
MECH X RESIDENTIAL COMMERCIAL
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.
JOB DESCRIPTION:
(N) TEMPORARY POWER POLE (100 AMP)
I hereby affirm under penalty of perjury one of the following two declarations:
t. 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
Sq. Ft Floor Area:
Valuation: $300.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
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
34214 007
342
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.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply with all non -point
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 5/10/2017
Issued by: Abby Aygnde
Date: 05/10/2017
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RF -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
1. 1, 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)
z. 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:/15 0/2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
r. 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
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
maintain compliance with the Cupertino. Municipal Code, Chapter 9.12 and the
permit is issued.
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
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
the Health & Safety Code, Sections 25505, 25533, and 2 34.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION
Date: 5/10/2017
I certify that I have read this application and state that the above information is
CON
I hereby affirm that there is a construction len ' g agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
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
DECLARATION
and will comply with all non -point source regulations per the Cupertino Municipal
ARCHITECT'S
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date 5/10/2017
Professional
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GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 1
CUPERTINO
❑PLUMBING ❑MECHANICAL ❑ELECTRICAL FJMISCELLANEOUS
(408) 777-3228 •FAX (408) 777-3333 • buiidino(a)cunertino.orcl
PROJECT ADDRESS G t I �N
b Le li a „ o
OWNER NAME - PHONE �
E-MAIL r
tic' ._h soca .'.-
STREET ADDRESS �.. CITY, STATE, ZIP l
FAX
CONTACT NAME _
PHONE
E-MAIL
STREET ADDRESS 77 /
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CITY, STATE, ZIP 7
CA 1
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ElOWNER 11OWNER-BUILDERE3OWNER AGENT ❑ C0117RACTOR ElCONTRACTOR AGENT ElARCHITECT 1:1ENGINEER 1:1DEVELOPER 11TENANT
CONTRACTOR NAME LICENSE NUMBER
LICENSE TYPE
BUS. LIC 9
COMPANY NAME
E-MAIL
FAX
STREET .ADDRESS
CITY, STATE, ZIP
PHONE
.ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC r
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
- USE OF SFD or DUPLEX ❑ MULTI -FAMILY PROJECT INW ILDLAND [I YES
BUILDING: ElCOMMERCIAL, URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ElNO
IS THE BLDG AN El YES
EICHLER HOME? ElNO
DESCRIPTION OF WORK
TOTAL VALUATION:
✓✓✓two
RECEIVED
By my signature below, I certify each of the following: I am the propertyowner or authorized agent to act on the property owner's b ial£ I have read this
application and the information I have provided is correct. I have read the Description of \�7ork and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building constructioW I authorize represeyriat' 'es of Cupertino to enter the above -identified property for inspection purposes.
Signature of App]icandAgent: - --` G%L2Z i. Date:
SUPPLEMENTAL INTFORMATIt REQUIRED
OFFICE USE ONLY .
OWER -THE -COUNTER
f'
❑ EXPRESS
U
U.
STANDARD.
LARGE':
]1LAJOR
A1EPAlliscApp_2011.doc revised 06121/11
NO
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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 • buildinq(c1cupertino.orq
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 IV ( L -e be-LWe'ys, r•
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OWNER NAME �
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DESCRIPTION OF WORK:
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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.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
_rAl. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
u der" 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.
2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
th construction 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
pr tett myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
nl4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
ubnu bers on permits and contracts.
5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
tot I 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.
6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and
fe ral 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.
7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family
reidential 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.
f8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for
inancial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
ts in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04/14/10
9. I understand I may obtain more information regarding my obligations as an "employer" from the Internal
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.csib.ca.gov for more information about licensed
contractors.
7/10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
e 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
by all 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
ation I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
7
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 may be required to be presented when the permit is issued
to verify the property owner's signature. _ 11/%
Property Owner's Signature: / Date: _�5/7o //'7
-- -- - ---- ----- --- ------------------------------------------------
(NOTE: The- following- Authorization- - Form is -r-e- 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:
OwnerBuilderForm 2010.doc revised 04/14/10