150100974
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7449 STANFORD PL
CONTRACTOR: GRAND NEST
PERMIT NO: 15010097
CONSTRUCTION
OWNER'S NAME: YU LD{IN AND QUAN SA
13428 CHRISTINE DR
DATE ISSUED: 04/27/2015
OWNER'S PHONE: 6502153003
SARATOGA, CA 95070
PHONE NO: (408) 891-8059
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL ❑
CONSTRUCT 1 STORY SFDWL TO INCLUDE (LIVING 2459
/
License ClassLic. #D' ��
SQ FT, GARAGE 463 SQ FT, PORCH 38 SQ FT)
C�
Contractor ft S7 Date aV7,112,a]
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.
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
performance of the work for which this permit is issued.
Sq. Ft Floor Area:
Valuation: $455000
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 35932038.00
Occupancy Type:
ection 3700 of the Labor Code, for the performance of the work for which this
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
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM LED 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
Date: Z
granting of this permit. Additionally, the applicant understands and will complyY
with all non-point source regulations per the Cupertino Municipal Code, Section
RE-ROOFS:
9.18.
Signature �HSte d' S
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.
❑ 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. 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 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, Sections 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: - E�,4 :v Date:
permit is issued.Ir
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
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, after making this certificate of exemption, I
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
ARCHITECT'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
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
./I
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: 15010097
7449 STANFORD PL CUPERTINO CA 95014 (359 32 038)
GRAN NEST
CONSTRUCTION
13428 CHRISTINE DR,
SARATOGA, CA 95070
OWNER'S NAME: YU LDIIN AND QUAN SA
DATE ISSUED: 04/27/2015
OWNER'S PHONE: 6502153003
PHONE NO: 4088918059
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class 13 Lic. #985419
Contractor GRAN NEST CONSTRUCTION Date 3/9/2016
— BLDG —ELECT —PLUMB
MECH 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:
CONSTRUCT 1 STORY SFDWL TO INCLUDE ( LIVING 2459
I hereby affirm under penalty of perjury one of the following two declarations:
SQ FT, GARAGE 463 SQ FT, PORCH 38 SQ FT)
t. I have and will maintain a certificate of consent to self -insure for Worker's
REVISION #1 - INSTALL (N) TRELLIS IT X IT IN BACKYARD -
Compensation, as provided for by Section 3700 of the Labor Code, for the
ISSUED 3/9/2016
performance of the work for which this permit is issued.
z. I have and will maintain Worker's Compensation Insurance, as provided for
Section 3700 of the Labor Code, for the performance of the work for which
n
Sq. Ft Floor Area:
Valuation: $455000.00
U/ /yti� mit is issued.
ti
V 7
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
APN Number:
Occupancy Type:
ordinances and state laws relating to building construction, and hereby
359 32 038
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, costs, and
PERMIT EXPIRES IF WORK IS NOT STARTED
expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will
comply with all non -point source regulations per the Cupertino Municipal
180 DAYS FROM LAST CALLED INSPECTION.
Code, Section 9.18.
Issued by: PAUL O'SULLIVAN P
Signature,6 Pd�D , Date 3/9/2016
Date: 3/9/2016 aL
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
t. I, as owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered
for sale (Sec.7044, Business & Professions Code)
Signature of Applicant:
2. I, as owner of the property, am exclusively contracting with licensed
Date: 3/9/2016
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance, as provided for
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
by Section 3700 of the Labor Code, for the performance of the work for which
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
this permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
3. I certify that in the performance of the work for which this permit is issued, I
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
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Worker's Compensation laws of California. If, after making this certificate of
the Health & Safety Code, Sections 25505, 25533, and 25534.
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
n
Owner or authorized agent: IV ; -Yl d ee: �
be deemed revoked.
^
Date: 3/9/2016
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
certify that I have read this application and state that the above information is
I hereby affirm that there is a construction lending 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
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant
ARCHITECT'S DECLARATION
understands and will comply with all non -point source regulations per the
I understand my plans shall be used as public records.
Cupertino Municipal Code, Section 9.18.
Licensed
Professional
Signature Date 3/9/2016
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 REVISION #
' ' I (408) 777-3228 • FAX (408) 777-3333 • building(cDcupertino.org
CUPERTINO I`��
❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION / TI REVISION /DEFERRED ORIGINAL PERMIT # ``�` ' I��%
PROJECT ADDRESS r�(, /F,� h ^
APN # r� O �_ b (�
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OWNER NAME / / x / ! ( Y- / ' PHONE / L� "� D
E-MAIL
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STREET ADDRESS—
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CITY, STATE, ZIP
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FAX
CONTACT NAME
Milo c{4en
PHONE
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E-MAIL
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STREET ADDRESS1` A (� �� �u�^ V�1 e
CITY, STATE, P ^, �O
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FAX„ b n �4 or --&32,
1:1OWNER ❑ OWNER -BUILDER 13OWNER AGENT ❑ CONTRACTOR 11CONTRACTOR AGENT Mr ARCHITECT 11ENGINEER 11 DEVELOPER 11 TENANT
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAMELIC NSE NUMBER C _ 2' Z O
BUS. LIC #
me 0 ( 'j LtC�
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK I✓'AN1,r (
EXISTING USE
PROPOSED USE
CONSTR TYPE
# STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION (i)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: LJDETACH
❑ ATTACH
# DWELLING UNITS:
IS A SECOND UNIT YES
SECOND STORY ❑ YES
BEING ADDED? ONO
ADDITION? ONO
PRE -APPLICATION ❑ YES IF FES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RjErIVED BY:
TOTAL LUATION:
PLANNING APPL # [-]NO PLANNING APPROVAL LETTER
EICHLER HONTE? ❑ NO
1
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I)Ave read this
application and the information I have provided 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 building cons tion. I authorize representatives of Cupertino to enter the above -i enti ed property for inspection purposes.
Signature of Applicant/Agent: Date: 3
SUPPLEMENTAL INFORM ION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
OVER-THE-COUNTER
BUILDING PLAN REVIEW ULM
_ 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
1:1 STANDARD
E) 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
❑
I-]SANITARYSENVER DISTRICT
submittal of Building Permit application.
nIA.IOR
❑ ENVIRONMENTAL HEALTH
Bldg.4pp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 7449 stanford pl DATE: 01/1612016 REVIEWED BY: Mendez
APN: 72nd
ETYPE.
'VALUATION:*PERMIT TYPE: Building Permit PLAN CHNew Construction
PRIMARY Unit? Yes No PENTAMATION 1 R3SFDW
USE: SFD or Duplex PERMIT TYPE:
WORK construct 1 story sfdwl to include living2459 s ft garage 463 s ft porch 38 s ft
SCOPE
TYPE OF FLR AREA
OCCUPANCY TYPE: CONSTR. s.f.
R-3 (Custom) I II-B,III-B,IV,V-B 2,960
TOTALS: 1 2,960
PC FEES I PC FEE ID I BP FEES I BP FEE ID
$3,067.051 IR3PLNCK I $3,012.151 lR3INSP
$3,067.05
i,iec'..Viii C... :.
$3,012.15
SUBTOTALS: $7,242.511 $0.00 TOTAL FEr: $7,242.51
Revised: 01/06/2015
I aeec. Permit Fey
1't
/7>io.--
include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
NOTE: This estimate does not
These fees are based on the preliminary
information available and are only
an estimate. Contact the De t or addn'l info.
District, etc..
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/13)
FEE QTY/FEE j
MISC ITEMS
Plan Check Fee:
$3,067.05
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: Q Reg. Q OT 0.0 hrs
$0.00---F-=
PME Plan Check:
$0.00
Permit Fee:
$3,012.15
Suppl. Insp. Fee.S Reg. Q OT 0.0 hrs
$0.00
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$670.76
# new
Construction Tax: 1BCONSTAXR 1 units
r
•
Work Without Permit? 0 Yes (E) No
$0.00
Advanced Planning Fee_ IPLLONGR
$414.40
Select a Non -Residential
0
Building or Structure
0
$59.15
Select an Administrative Item
Strong Motion Fee: 1BSEISMICR
$19.00
Bldg Stds Commission Fee: IBCBSC
SUBTOTALS: $7,242.511 $0.00 TOTAL FEr: $7,242.51
Revised: 01/06/2015
CITY OF CUPERTINO
1 F.F. F.CTIMATnR — RIiII.nING DIVIRIMICInK1 .4 4 _
ADDRESS: 7449 STANFORD PL
iml
DATE: 03/08/2016 REVIEWED BY: PAUL
APN: 359 32 038
BP#: *VALUATION:
Iso
*PERMIT TYPE: Building Permit
Only? 0 Yes (D No
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE: p
Plan Check, Hourly
ISTPLNCK
PENTAMATION 1 GENRES
PERMIT TYPE: e
WORK
I REVISION #1 - INSTALL N TRELLIS 12'X 12' IN BACKYARD - ISSUED 3/8/2016
SCOPE
PME Plan Check:
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public worsts, rtre, ,3anuary,3ewer utstrict, actium
_ mz ___ [___ --- L_-1 .. sl .. ../...... rnntnrt thi, Dont for addn'l LIDO.
FEE ITEMS (Fee Resolution 11-053 Lo.7/11132
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee: Hourly
Only? 0 Yes (D No
$0.00
1 1 hours
$143.00
Plan Check, Hourly
ISTPLNCK
Suppl. PC Fee: (E) Reg. C) OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee: Hourly Only? C) Yes Q No
$0.00
Suppl. Insp. FeelD Reg.
Q OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
7
_T_T
Work Without Permit? 0 Yes (F) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
0
0
r)y
Strong Motion Fee:
$0.00
1.0 hrs
$143.00
Inspections
isTINsP 7Inspection, Hourly
Bidgy Stds Commission Fee:
$0.00
SUBTOTALS:
$0.00
$286.00
TOTAL FEE:
$286.00
Revised: 01/01/2016
CUPERTINO
CONSTRUCTION PERMIT APPLICATION V ��
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION V�
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 �f1�
(408) 777-3228 • FAX (408) 777-3333 • buildingta'�-cupertino.org
F1 -T , nnme-rDT jf` mn. F-1 enT-1T `Ir)M n AT TPR AT10N / TT n RF.VTSTON /DEFERRED ORIGINAL PERMIT #
I_J ivn yr u • - --
-- ----- --
PROJECT ADDRESS J,
7APN # 7s
(�
OWNER NAME / 1 ?( rI aC 616.17
l7
PHONE j [`D ..�'SS—�aa
&MAIL L
Ca "n J_ �' a Ab p0. 60 01
STREET ADDRESS- i I (� C ^' / n /� n/ A (l r
Y r J' f u�lJ I yJ` f=
CITY, STATE, ZIP C, IK n 9k7T/„ `U C� Q� /�
r
FAX
CONTACT NAME
I 1
PHOT _
/�D - -
E-MAIL
1Q �i
STREET ADDRESS
S�hh
CITY, STATE, ZIP
a'l a
FAX
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y .
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER 177
YPE
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
LA o
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
_
v
EXISTING USE
VZ
PRO OSED USE CONSTR.
�n �
TYPE
\/Tt,
# STORIES
�
USE TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG
AREA It'll
NEW FLOOR (L
AREA 2 v 2
DEMO
AREA ! y
V 7
TOTAL
NET AREA e 2
j
'l1 :`�rJ
��HH
BATHROOM
KITCHEN
IT
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
4-S h D �/•
V
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
I GARAGE AREA: DETACH
'ATTACH
j 00
u,
V
# DWELLING UNITS:
IS A SECOND UNIT ❑ YES
SECOND STORY []YES
BEING ADDED? PNo
ADDITION? []NO
PRE -APPLICATION []YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RECEIVED BY:
TOTAL VALUATION:
PLANNING APPL# []NO PLANNING APPROVAL LETTER
EICHLERHOME? []NO
eUfl
By my signature below, I certify to each of the following: I am the property owner or authorized agent to ac 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 Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bit ing c strut n. uthorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent Date: I — 10, 1 j
SUPPLEMENTAL INFORMATION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
❑ OVER-THE-COUNTER
UILDING 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
❑ NG PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials DisclosureNDARDUBLIC
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
ARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_201 1. doc revised 06/21/11
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS:
p PERMIT #
OWNER'S NAME:
PHONE #
GENERAL CONTRACTOR:
C p _ BUSINESS LICENSE #
ADDRESS:
CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
}
I am not using any subcontractors:
Sig . ate
Please check applicable subcontractors and complete the following information:
Owner / Contractor Signature
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner / Contractor Signature
Date