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13120071I A, CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21842 GRANADA AVE CONTRACTOR: R MACHANDRAN PERMIT NO: 13120071 BALASUBRAMANIAN AND PH OWNER'S NAME: RAMACHANDRAN BALASUBRAMANIAN AND PH 21842 GRANADA AVE DATE ISSUED: 03/19/2014 OWNER'S PHONE: CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL CONSTRUTCT A ONE STORY ADDITION (457 SQ FT); License ClassLic. # INTERIOR REMODEL (325 SQ FT); KITCHEN REMODEL (130 Contractor Date ____ SQ FT) I hereby affirm that 1 am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions REVISION#2- RAISE ROOF; ISSD OTC 8/11/2014 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 Sq. Ft Floor Area: Valuation: $70000 performance of the work for which this permit is issued. l 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 APN Number: 35716026.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPI.RES 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 LAST CALLED 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 granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. RE -ROOFS: Signature_Date All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, 1 agree to remove all new materials for inspection. ❑ Q� OWNER -BUILDER DECLARATION Signature of Applicant: Date: 1 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) I, 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. I 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 1 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 5533,d 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: !� ' Date: permit is issued. 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 Compensation laws of California. If, after making this certificate of exemption, 1 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must 1 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 1 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 1 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. r Signature Date CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21842 GRANADA AVE CONTRACTOR: RAMACHANDRAN PERMIT NO: 13120071 BALASUBRAMANIAN AND PH OWNER'S NAME: RAMACHANDRAN BALASUBRAMANIAN AND PH 21842 GRANADA AVE DATE ISSUED: 03/19/2014 OWNER'S PHONE: CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL CONSTRUTCT A ONE STORY ADDITION (457 SQ FT); License Class Lic. # INTERIOR REMODEL (325 SQ FT); KITCHEN REMODEL (130 Contractor Date SQ FT) 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: $70000 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 .CPN Number: 35716026.00 Occupancy Type: 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 18 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 F L T CALLED 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 , Issued by: Date: granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. RE -ROOFS: Signature Date 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: 1 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 I, 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) I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE c nsuct 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 l ereby 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(x) 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 1 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: Date: permit is issued. _ I certify that in the performance of the work for which this permit is issued, I shall 1 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 sour a regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(&cupertino.org ❑ NEW CONSTRUCTION ® ADDITION 1,31 � ❑ ALTERATION/ TI ❑ REVISION / DEFERRED ORIGINAL PERMIT # •! ��� �� AV PROJECT ADDRESS it e, APN # OWNER NAME I�AIC U , PHONE �y� I _ n / (� (y E-MAIL STREET ADDRESS C V ' na FAX CONTACT NAME t!I� I' S 11 PHONE�O 1 - CM / -w E-MAIL ki C 141 6) A0 6 L t �T Yw f<v STREET ADDRESS IN. CITY, STATE, ZIP n Jose( FAX ❑ OWNER ❑ OIVNER-B=ER ❑ OWNER AGENT ❑ CONTRACTOR $1 CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME D LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORKI Me �►'1� ' n , LdtjLJ i ' P 6roa►-�A411" N G, �. EXISTING USE PROPOSED USE CONSTR. TYPE # STORIES I USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG AREA NEW FLOOR AREA 1 J S '�% / DEMO AREA TOTAL NET AREA BATHROOM REMODEL AREA 44 KITCHEN OTHER REMODEL AREA REMODEL AREA &A, PORCH AREA DECK AREA TOTAL D K/PORCH AREA GARAGE AREA: DETACH I ATTACH # DWELLING UNITS: IS A SECOND UNrr ❑ YES SECOND STORY ❑ YES BEING ADDED? []NO ADDITION? []NO PRE -APPLICATION ❑YES IF YES, PROVIDE COPY OF PLAATNINGAPPL# []NO PLANNING APPROVAL LETTER IS THE BLDG AN ❑ YES EICHLERH0111E? ❑NO RECEI TOTAL VALUATION: „` 006 By my signature below, I certify to each of the following: I am the property owner or autholiz age o a opelty owner's behalf. I have read this application and the information I have provided is correct. I]lave read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relator* building cons on. authorize representatives of Cupertino to enter the property for inspection purposes. Signature of Applicant/Agent: /above-iiddentitified Date:/ 2 -7`t -/r -- I7 SUPPLEME TAL INFORMAT REQUIRED PLAN CHECK TYPE ROUTING SLIP ❑ OVER-THE-COUNTER ❑BUILDING 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. - XPRESS PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure El STANDARD El 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 submittal of Building Permit application. ❑ nIAJOR��EJEIV.RONIIIENTAL Y SEWER DISTRICT HEALTH BIdgApp_2011.doc revised 06/21/11 WPM CITY OF CUPERTINO ������,� 1�►M TIFF TQTiMATnR—RITILDING DIVISION 121 ADDRESS: 21842 granada ave DATE: 12/09/2013 REVIEWED BY: Mendez PC FEE ID APN: BP#: Q *VALUATION: $70,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Duplex USE: 2nd Unit? 0 Yes No7UNTAMATION OTC. O Yes ONoPERMIT 1R3SFDADD TYPE: WORK 1457 sa ft addition to rear of sfdwl to include master suite quest bedroom and bath remodel existing SCOPE I dining and kitchen area OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) 11-8,111-B,IV,V-B 457 $1,579.00 IADDPLCK $1,284.00 1ADDINSP PME Plan Check: $0.00 Permit Fee: $1,284.00 Suppl. Insp. Fee:O Reg. O OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 457 1 $1,579.00 $1,284.00 MECH, HOURLY O Yes G No PLUMB, HOURLY O Yes 0 No ELEC, HOURLY O .Yes 0 No - - MISC ITEMS Plpmb. Plun Cheri, /-lee. Plan Check �Mech =s.f. $626.00 Elec. Permit Fee. Other bfech. Insp. Other Plumb Insp. Other Elec. Insp, Alech. Insp. Fee: $0.00 PME Plan Check: $0.00 NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public works, fire, Junuury .server -11— __ _ _ �_ __ _ _ L,.. J .L,... „/:»,:......, ;-f--do" avail-hle and are anly an estimate. Contact the Dept for addh 7 info. Dlstrici,eic1. ..... FEE ITEMS j ee Resolution 11-053 Eff, 7f ,1!13) FEE -- QTY/FEE - - MISC ITEMS Plan Check Fee: $1,579.00 =s.f. $626.00 Remodel, Kitchen (<=300 sf) IREMRESKIT Suppl. PC Fee: 0 Reg. O OT 0.0 1 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $1,284.00 Suppl. Insp. Fee:O Reg. O OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Consttziction Tax: Fa ,ldtninistratity FCc,. O 0 Work Without Permit? O Yes 0 No $0.00 Advanced Planning Fee: IPLLONGR $63.98 Select a Non -Residential Building or Structure 0 O Trm,el Docionentation Fees.' Strong Motion Fee: IBSEISMICR $7.00 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $3.00 SUBTOTALS:$2,936.98 $626.00 TOTAL FEE: $3,562.98 Revised: 10/01/2013 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21842 GRANADA AVE CONTRACTOR: RAMACHANDRAN PERMIT NO: 13120071 BALASUBRAMAN IAN AND PH OWNER'S NAME: RAMACHANDRAN BALASUBRAMANIAN AND PH 21842 GRANADA AVE DATE ISSUED: 03/19/2014 OWNER'S PHONE: CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ CONSTRUTCT A ONE STORY ADDITION (457 SQ FT); License Class ....... Lic. tl INTERIOR REMODEL (325 SQ FT); KITCHEN REMODEL (130SQ Contractor _ Date FT) I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions 5/20/14 - REV t1 I - ADD WINDOWS AND RAISE CEILING IN ADDITION Code and that my license is in full force and effect. AREA FROM 8' TO 10'-ISSD 6/9/2014 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 Sq. Ft Floor Area: Valuation: $70000 performance of the work for which this permit is issued. 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 APN Number: 35716026.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above information is PERMIT IRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 0 D YS 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 DAY LAST CALLED INSP ION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the �iC granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. RE -ROOFS: Signature __-_ Date All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, 1 agree to remove all new materials for inspection. OWNER -BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that 1 am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I, 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(x) should I store or handle hazardous 1 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: Date: `]� permit is issued. I certify that in the performance of the work for which this permit is issued, 1 shall r' not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY become subject to die 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 APPLICANTCERTIFICATION 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 so cc regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date J w' Q 1rill LAI L, 47 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21842 GRANADA AVE CONTRACTOR: RAMACHANDRAN PERMIT NO: 13120071 BALASUBRAMANIAN AND PH OWNER'S NAME: RAMACHANDRAN BALASUBRAMANIAN AND PH 21842 GRANADA AVE DATE ISSUED: 03/19/2014 OWNER'S PHONE: CUPERTINO, CA 95014 PHONE NO: LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL EJ CONSTRUTCT A ONE STORY ADDITION (457 SQ FT); License Class s�� Lic. 9 INTERIOR REMODEL (325 SQ FT); KITCHEN REMODEL (130 SQ FT) Contractor ,� Date REV # 3 - RAISE CEILING HEIGHT - ISSUED 9/4/14 I hereby affirm that 1 am licensed under the provisions o Cha ter 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 Sq. Ft Floor Area: Valuation: $70000 performance of the work for which this permit is issued. 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 APN Number: 35716026.00 Occupancy Type: 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. 1 agree tocomply with all city and county ordinances and slate laws relating WITHIN 180 ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter IT upon the above mentioned property for inspection purposes. (We) agree to save 18TU0,I . +ROM LAST C D INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments,�u costs, and expenses which may accrue against said City in consequence of the D granting of this permit. Additionally, the applicant understands and will comply e"', e: with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. YE Signature Date _L( -ROOFS: All roofs shall be inspe or 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 I, 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) I, 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(x) should I store or handle hazardous 1 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: Date; � permit is issued. I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY 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 1 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 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTIN0 I (408) 777-3228 • FAX (408) 777-3333 • building cupertino.or ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION I TI JKREVISIO 1 DEFERRED ORIGUNIAL PERMIT R L�1'Z03-7/ PROJECT ADDRESS APN 4 OWNERNAME PHONE" , 7 I E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX Cr CONTACT NAME PHONE E-MAIL , lw—. STREET ADDRESS CITY, STATE, ZIP I �/ /�LCu` ,� ir�c-� Cry e2�rr/o � So Itf FAX 14�--fwF' OWRMR ❑ OVNER-BG-ILDER ❑ OWNER AGENT C�-1 O1."IRACTOR ❑ CoNTRACTORAGENT ❑ ARCH[rrECT ❑ ENGP.'FMR ❑ DEVELOPER ❑ TENANT CONIRACTORNAME A f �j�'t �I � D� /i [/L/(r l/ I LICENSE9U1,f,BER I LICENSE TxPF� L� L jf BUS.LICR COMPANY NAME EMAIL FAX STREET ADDRESS 2/ 31 L�� e CITY, STATE, ZIP C�rOc�2 ,r�r ��.�ti PHONE 4 ')'- 3 ARCMTECT/ENGINEER NAME LICENSE NUMBER I BUS. LIC d' COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR TYPE : STORIES USE TYPE OCC. SQ.FT. VALUATION (i) EXI57G NEWFLOOR 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: LJ DETACH.,,„ 11 ATTACH R D\ rTLUNG UMTS: .4 SECOND UiIT ❑YES SECOND STORY ❑ YES y ° -�'-"'""^ "° TIS BEING ADDED? []NO ADDITION'. NO ,., w P3�E-A�PLICa�tON } S IF ES.� 01+IDEro11AF PLANTRNGAPPL" ONO PLAN'N� G APPROVAL LETTER I STH ,HAG Vin_._..O7FS EICHLER HOE'.NO M R> rill° q ^P Sw Tfhe dry 4 w TOTALV.vLUATION: " '5` °" -- By my Signature below, I certify to each of the following: lam the property owner or authorized" nTfo "acton 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 agee to comply with all applicable local ordinances and State)?,WS relating to building Donstruction. I authorize remes ntatives of Cupertino to enter the above -identified opert�y for inspection purposes. Signature of Appl icant/Agent: /� Date: R//�y SUPPLEN4E14TAL INFORMATION REQUIRED 01a _Neta+ SFD or Multifamily dwellings: Apply for demolition permit for Demolition is issuance buifdmQ �� � +� � '✓ �� ,�"<1��wtr,�+yz� ���i� caunxalR��� I t `� '�, r.i��1��� r �i� DJd��Tnxeut� �x existing building(s). permit required prior to of permit for new building. Hazardous / Disclosure ! Materials _Commercial Bldgs: Provide a completed form if an Hazardous Materials are being used as art of this project. Y P P J —Copy of Planning Approval Letter or Meeting with Planning prior to ° Building Permit application. 2C4A i T2 t' ��jk•����,' >77E� z` ] kR] S i R DIST �wb, submittal of P P iu t Bldo 4pp_2011. doc revised 06/21/11 CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISIO 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(c-cupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI [:1REVISION / DEFERRED ORIGINAL PERMIT # I , 12-003-1 PROJECT ADDRESS ,,, APN k OWNER NAME PHON���0 E-MAIL " V a V, STREET ADDRESS "^ ^ ! CITY, STATE, ZIP S .o ( FAX -Q I' CONTACT NAME '�` +l PHONEAJ E -MA VV (�[ ' , I y STREETADDRESS 4-- CITY, STATE, ZIP FA71, 04-233 ❑ OWNER ❑ OWNER -BUILDER D -OWNER AGENT ❑ CON'TRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC k COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEERNAMEt LV LICENSE NUMBER BUS. LIC k COMPANY NAME 2� �" EMAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK Jav Q EXISTING USE PROPOSED USE CONSTR- TYPE k STORIES USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG NEW FLOOR DEMO TOTAL AREA AREAAREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REN40DEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: FIDETACH ❑ ATTACH k DWELLING UNrrS. IS ASECOND UNIT ❑YES SECONDSTORY ❑YES BEING ADDED? ❑ NO ADDITION? ❑ NO PRE APPLICATION ❑ 1'ES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑YES TOTAL VALUATION: PLANNING APPL k ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO 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 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 157 i Ing construe n. I a or e representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent Date: SUPPLEMENTAL INFORMATION REQUIRED RE Q ��" "",PLAN CHECT{IYE „ �,`,;,,,,° ROUTInG SLIP ; ❑ ❑ New SFD or Multifamily dwellings: Apply for demolition permit for — OVERTkJFCOiIN�ER BUILDJNGPLAAItEVIEW existing building(s). Demolition permit is required prior to Issuance of building permit for new building. ❑ E),.hrtSS, ' ' 'i ❑ PLANIsiNG 'LANEYIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ $TANDA1tD ❑ PU>II IQwO ° aa'i form if any Hazardous Materials are being used as part of this project, ,. LAIz ❑ Ftii1 Copy of Planning Approval Letter or Meeting with Planning prior to % ✓ JzrErx ;';1 ! „' ;/, ❑ A2AJOR' ' ❑ SAfYJTARY SEVIrER DISTkICT % submittal of Building Permit application. �r ENVIPLONi14ENTA1, HEALTH'? B1dgApp_2011.doc revised 06/21/11 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINrO (408) 777-3228 • FAX (408) 777-3333 • buildina(dbcuDertino.org ❑' NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI 0 REVISION / DEFERRED ORIGINAL PERI`4IT �./ 3` /2 "v PROJECT ADDRESSV APN 4 ER NAME, PHONEE-MAIL 12��'C STREET' ADDRESS - CITY, STATE - . CONT CT NA?JiE PHONE E•?,AIL t ( v%10\ STRE6 ADDRESS C17Y, STATE, ZIP FAX ❑ O-AQaR ❑ ORRNE.R-BUILDER ❑ OWNERAcizNrr ❑ CONTRACTOR ❑CO).TR4CTORAGENT, ❑ ARCn-Lrr-Ecr ❑ENGLN'EER ❑ DE\'ELOPER ❑ TZNP?\*r CON7RACr0RNA,\,ELICENSENU),lBER 41"1)(5-V /L)0 LICENSE TYPE ,7 BUS. LIC COMPANY NAME r E-MAIL FAX STREET ADDRESS / / v CrrY, STATE, ZIP y t 7 '° r d/�� �}��'7,�G�IL+ PHONEVIOS',;)IJQ'S;✓q4 ARCHITEC IENGWEER NAME fUL LICENSE NUA�ER BUS. LIC COMPANY NAME P u (°° E-MAIL STREET ADDRESS CITY, STATE, ZIP- IPDESCRIPTION DESCRIPTIONOF WORK iP� r 4-;A7'W1't /'J k EXISTINGL'SE PROPOSED USE CONSTR-nTE ISTORIES USE TYPE I OCC. I SQ.FT. VALUATION (S) EXISIG NE\V FLOOR DEMOTOTAL AREA AREA AREA I NET AREA BATHROOM KITCiaN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ ATTACH I DWELLING UNITS: IS A SECOND UNIT ❑YES SECONDSTORY El -'ES BEING ADDED' ❑ NO ADDITION" ❑NO PLA,YMNTG APPL & ❑ NO PLANRQII�'G APPROVAL LEITER EICHLER HOME? ❑ N TOTAL VALUATION: '� "" " 'i}. "" ' r 61 By my signature below, I certify to each of the fallowing: I am the property owner or uthorized agent to act on the property ow'ner'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 building const ion. I authorize representatives of Cupertino to enter the above- identified Property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL II\rFORMATION REQUIRED tr New SFD or Multifamily d%vellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building"t:r permit for new building, p Bldgs: Provide a completed Hazardous Materials Disclosure �4%, _Commercial form if any Hazardous Materials are being used as part of this project. _ Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. t ISG 3 AR S) ii' R ISI FfIC " Bldg.9pp_2011.doc revised 0 612 1/11 CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 1 /) (408) 777-3228 • FAX (408) 777-3333 • building(Dcupertino.org NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT M PROJECT ADDRESS 2i Z � 2 F1r�A0h � u� APN H O ER NAMEPHONE SLA V ARAMArJi4q-d �'�^^/�C�1Ar�7C'�Ar' (4q ._& TZ -Z) E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC k COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC k COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR. TYPE tl 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 DETACH ❑ ATTACH N DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES ,r ._.,... BEING ADDED? NO ADDITION? ONO .� '•� PRE- APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN [-]YES RECEIVED �} �„� """ TOTAL VALUATION: PLANIMNGAPPLN r1NO PLANNING APPROVAL LETTER EICHLERHOME? ONO By my signature below, I certify to each of the following: 1 am the property owner or authorizKagent to at -6n the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description ofWort and,yerfl'y it Is accurate. I agree to comply with all applicable local ordinances and state laws relating to buildin construction. I authorize representatives of Cupe Ino to enter the above -identified property for inspection purposes. Signature ApplicantlAgent: Date: of 1AA--1L SUPPLEMENTAL, INF RMATION REQUIRED PLAN CHECK ITE ROUTING SLIP AVER -THE canlvTeR ❑ BUILDING PLAN RrvlEw 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. Q EXPRESS ❑ PLANNING PLAN RLN IEw _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure El STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. 11 ❑ LARGE; >:I". DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to El ArArpR' SANITARY SEwERDISTRICT submittal of Building Permit application. ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District_ etc-)- These fees are based on the nrelinunary information available and are only an estimate. Contact the Dent for addn'l info. FEE ITEMS (/,'cc Resolution 11-053 Eff 7/1113) 21842 granada ave DATE: 09/04/2014 REVIEWED BY: melissa jigADDRESS: APN: 357 16 026 BP#: 13120071 'VALUATION: $0 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: I PENTAMATION PERMIT TYPE: WORK rev # 3 - raise ceiling height - issued 9/4/14 SCOPE PME Plan Check: NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District_ etc-)- These fees are based on the nrelinunary information available and are only an estimate. Contact the Dent for addn'l info. FEE ITEMS (/,'cc Resolution 11-053 Eff 7/1113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Mise Bldg/Structure or Element of a Building Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? 0 Yes Q No $0.00 Suppl. Insp. Fee:0 Reg. Q OT0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 7T 0 0 Work Without Permit? 0 Yes (j) No $0.00 Advanced Planninc Fee: $0.00 Select a Non -Residential Building or Structure G i Strong Motion Fee, $0.00 1.0 hrs $143.00 Inspections /ST/NSP Inspection, Hourly Bldg Stds Commission Fee: $0.00 SUBTOTALS: $0.00 $143.00 TOTAL. FEE: r $143.00 Revised: 08/20/2014 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn7 info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/13) ADDRESS: 21842 GRANADA AVE DATE: 05/20/2014 REVIEWED BY: MELISSA E17- APN: 35716 026 BP#: 13120071 *VALUATION: Iso PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex USE: Suppl. PC Fee: (F) Reg. 0 OT PENTAMATION PERMIT TYPE: WORKREV # 1 -ADD WINDOWS AND RAISE CEILING IN ADDITION AREA FROM 8' TO 10' SCOPE NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn7 info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/13) FEE QTY/FEE . a . E17- E3_L_ $0.00 NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addn7 info. FEE ITEMS (Fee Resolution 11-053 E . 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: (F) Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Work Without Permit? Yes ,• No $0.00 Advanced Planning Fee. $0.00 Select a Non -Residential Building or Structure r) i tnj, c t f{ tr r f r in r Strong Motion Fee: $0.00 0 # $834.00 Revisions IREVSFDWL SFDWL Bldg Stds Commission Fee: $0.001 SUBTOTALS: $0.00 $834.001 TOTAL FEE: 1 $834.00 Revised: 04/01/2014 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: g)+Alfi 0 PERMIT # OWNER'S NAME: Ram s[4VAan ; PHONE # 40;-3f47—,5Y-?7- D"SS-?GENERAL __. GENERAL CONTRACTOR: ''6,5 GAJ BUSINESS LICENSE # 967 ADDRESS: 1 W;) At,,07,44_ pW Ctr e4'y,o CITY/ZIPCODE: G,4#S`-or ''Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signat re ate Please check applicable subcontractors and complete the following information: Signature -21/v1-�- Date 4w �m r n— SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork .-,S Lin Cement Finishing 17 S d -A jl- Electrical 3 0, Excavation dxf, Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation C.� Landscaping Lathing C�t1 Masonry Painting / Wallpaper fj s G Cnf Paving Plastering ev Plumbing .f Roofing 6-V5,- . Septic Tank ' Sheet Metal. Sheet Rock a - Tile '^ P�"i,�f Signature -21/v1-�- Date 4w �m r n— N CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildino(a cuoertino.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: �C7 1(, Oz� SITE ADDRESS ,r 2 C r9 �1 BPS e. ,Ca PNADAv RRA A OWNER NAI ✓E 'XALASuRQLtAAfJ1 Al- OWNER ADDRESS A-LAAfaQJl Q n) DESCRIPTION OF WORK: � D dJ 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 of-�icial 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.) 13�Q 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. &-L2. I 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. 9. 12- 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. A•Q4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. e5. 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. 94.1 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 unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. A-27. 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 performed under contract with a licensed general building Contractor. -VS 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,rne7BuildeiFonn ?010.doc remised 04/14/10 { L�. 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 1-800-321-CSLB (2752) or %,Nm.cslb.ca.gov for more information about licensed contractors. 610. 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. L -i11. 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. � —9- 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.) hereby a firm 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 si nat e Property Owner's Signature: Date: arc 15 2-o%y --------------------------------------------------------------------------------------------------------------------------------------------- (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 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: Ou,77erBiuilde7For7n 2010.doc revised 04114110