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12120042
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20118 FOREST AVE CONTRACTOR: AP AMERICAN PERMIT NO: 12120042 CONSTRUCTION OWNER'S NAME: RAMALINGAM SUBRAMANI AND VENKATACHA 5632 VAN NUYS BLVD STE 367 DATE ISSUED: 07/30/2013 OWNER'S PHONE: 6508145368 VAN NUYS, CA 91401 PHONE NO: (818) 301-5354 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL LJ COMMERCIAL License Class_ Lic. # 513 i'Le 2ND STORY ADDITION & 1ST FLOOR ADDITION(1,555 c0h,,,��10,1 Contractor , h1.e1J2Y _L'� D'ate -7-10-2- l3 SQFT) REMODEL ON 1ST AND 2ND FLOOR(BATHROOM(186 I hereby affirm that I am licensed under the provisions of Chapter 9 SQFT),KITCHEN(198 SQFT)& LIVING ROOM/FAMILY (commencing with Section 7000) of Division 3 of the Business & Professions ROOM Code and that my license is in full force and effect.. 1 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: $115000 performance of the work for which this permit is issued. 1 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. APN Number: 31623002.00 Occupancy Type: 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 DA 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 Issued by: Date: granting of this pernit. Ad ''o ally, th applicant understands and will comply with all non-point source r gul ions p the Cupertino Municipal Code, Section 9.18. RE-ROOFS: Signature Date © _—YW& 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 al 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 construct the project (Sec.7044, Business & Professions Code). 1 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 Cupertin unici al Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505 533, a 2 34. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent: Date: 7--�z� permit is issued. f I certify that in the performance of the work for which this permit is issued, l 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION 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 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20120 FOREST AVE CONTRACTOR: SUBRAMANI & VENKA PERMIT NO: 12120044 RAMALINGAM OWNER'S NAME: SUBRAMANI & VENKA RAMALINGAM 20118 FOREST AVE DATE ISSUED: 07/30/2013 OWNER'S PHONE: 6508145368 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL CONVERSION OF A DETACHED ACCESSORY STRUCTURE License Class Lic.# TO A 640 SQ FT 2ND LIVING UNIT (BATH 48 SQFT), (KITCHEN Contractor Date 80 SQFT) & OTHER (512 SQFT) 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: 1 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: $30000 performance of the work for which this permit is issued. 1 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: 31623002.20120 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 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 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 1 granting of this permit. Additionally, the applicant understands and will comply /,(� Issued by: Date: V , 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: 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) 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 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 Cu a tino Municipal Code, Chapter 9.12 and 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 the Health & Safety Code, Sections 2 5, 25533, and 25534. (g I S 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 ompensation 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 I understand my plans shall be used as public records. granting of this pt. Additionally, the applicant understands and will comply with all non-point o rce regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date—34-81 S CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20118 FOREST AVE CONTRACTOR: RAMALINGAM PERMIT NO: 12120042 SUBRAMANI AND VENKATACHA OWNER'S NAME: RAMALINGAM SUBRAMANI AND VENKATACHA 20118 FOREST AVE DATE ISSUED: 07/30/2013 OWNER'S PHONE: 6508145368 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL E] 2ND STORY ADDITION & IST FLOOR ADDITION(1,555 License Class Lic. # SQFT) REMODEL ON 1ST AND 2ND FLOOR(BATHROOM(186 Contractor Date SQFT),KITCHEN(198 SQFT)& LIVING ROOM/FAMILY I hereby affirm that I am licensed under the provisions of Chapter 9 ROOM (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: $115000 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: 31623002.00 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 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 F ST 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 �/8�� 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, I agree to remove all new materials for inspection. OWNER -BUILDER DECLARATION Signature of Applicant: Date: 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) 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 vill 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 a Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupe t'no Municipal Code, Chapter 9.12 and 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 the Health & Safety Code, Sections 255 ' 25533, and 25534. $ ��/ 4 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, 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 ay accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. A itionally, the applicant understands and will comply with all non -point sourctulabons per the Cupertino Municipal Code, Section Licensed Professional 9.18. �j J Signature Date % / 2— (2_o(- Ld �- CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO (4018) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.org 1-1 8) NEW CONSTRUCTION I I ADDITION I I ALTERATION / TI F1 REVISION /DEFERRED ORIGINAL PERMIT # :1 PROJECT ADDRESS �C) ` k r,FO n G ��� A U c iA-M APING# / ^ �7 3 (bye dEC-MAIL OWNER NAME S � � �7 A f-)C_ I 1 J� +_ 11V 6 // PHONE 6S 0 :1 1 4 � � M o N L y � IQ NI w I T M fI I �' C✓ STREET ADDRESS j iNC N A Ail CITY, STATE, ZIP P C P_ T l FAX � 3 0 '5-v6 ' 7 v 1 L 5" 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 �SH�Iz (_ �� LICENSE NUMBER S J ) s � LICENSE TYPE BUS. LIC # COMPANY NAMED /}M F ! i C AN (vNS f I�iie . l' i DN/ �f E-MAIL / 1 ICVr=J C�•tI FAX J- d'8 It Ol _ 322_.& STREET ADDRESS 6- � 3 VAA 2_ j V) ys 4_V YY 1V N CITY, STATE, ZIP J PHONE D q JI 3zZ Y l� I ARCHITECTIE G EER NAM E17 LICENSE NUMBER BUS. LIC # 95f I S - zba —1"i COMPANY NAME E-MAIL FAX STREET ADDRESS%� (�/_ (s l� ZGM (/� / (� rfi�� / / C CITY, STATE / DESCRIPTION OF WORK I�'� �- S+vN i S� �L0'✓)t �C.1�r�1�1 Stv1\J / MODE-lr EXISTING USE PROPOSED USE CONSTR. TYPE ✓. # STORIES USE TYPE OCC. SQTT. VALUATION (S) EXISTG 1 ARE/ ,J p NEW FLOOR AREA p t'J DEMO AREA (�•� TOTAL ,r NET AREA BATHROOM - REMODEL AREA KITCHEN REMODEL AREA O RC1 REMODEL AREA V PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: EET`ACH ATTACH # DWELLING UNITS: IS A SECOND UNIT YES SECOND STORY XflYES BEING ADDED? • ❑NO ADDITION? []NO PRE -APPLICATION OYES IF YES, PROVIDE COPY OF 1S THE BLDG AN I -]YES RECEIVED BY: OTA- "A r DATION: # NO LETTER EICHLER HOME? PLANNING ADPL ❑ PLANNING APPROVAL -Ea,-NO ( i „ , /0 V By my signature below, I certify to each of the foing: I am the property owner or authorized agent to act on the property owner's b alf. I have read this application and the information I have provided ' co ect. 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 c ctign. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: 2 SUPPLEMENTAL INFO TION REQUIRED PLAN CHECK TYPE ROUTING SLIP RTHE-COUNTER 1-1BUILDINGPLAN REVIEW New SFD or Multifamily dwellings: Apply for demolition permit forZEXPRESS existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ .PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ 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 El MAJOR ❑ SANITARY SEWER DISTRICT: submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06121/11 1 CITY OF CUPERTINO FM'_7 FEE ESTIMATOR - BUILDING DIVISION OCCUPANCY TYPE: ADDRESS: 20118 Forest Ave. DATE: 12/10/2012 REVIEWED BY: jsg PC FEE ID APN: BP#: 'VALUATION: 1$115,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY SFD or Duplex USE: 2nd Unit? 0 Yes 0 No OTC. 0 Yes 0 N PENTAMATION 1 R3SFDADD PERMIT TYPE: WORK Addition/remodel add second floor, remodel first floor SCOPE OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) II-B,111-B,N,v-B 1,555 $2,583.08 IR3PLNCK $1,961.38 IR3INSP $0.00 PME Plan Check: $0.00 = s.£ $600.00 Remodel, Kitchen (<=300 sf) IREMRESKIT Permit Fee: $1,961.38 Suppl. Insp. Fee:Q Reg. Q OT 0,0 hrs $0.00 462 s.f. Remodel, Other $467.00 IREMRESOTH PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 1,555 1 $2,583.08 1 1 $1,961.38 MECH, HOURLY 0 Yes F) No: PLUMB, HOURLY Q Yes ) No ELEC, HOURLY O Yes (F)No �ifuc;1_n0<Lrr 1717cihEcK T'in7 = s.f. $600.00 Remodel, Bath (<=300 so IREMRESBAT Lik(i7. /np' P"!(", tiz'1' $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 nreliminary information available and are only an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 6ff 711112) FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,583.08 = s.f. $600.00 Remodel, Bath (<=300 so IREMRESBAT Suppl. PC Fee: (j) Reg. 0 OT 1 0.0 1 hrs $0.00 PME Plan Check: $0.00 = s.£ $600.00 Remodel, Kitchen (<=300 sf) IREMRESKIT Permit Fee: $1,961.38 Suppl. Insp. Fee:Q Reg. Q OT 0,0 hrs $0.00 462 s.f. Remodel, Other $467.00 IREMRESOTH PME Unit Fee: $0.00 PME Permit Fee: $0.00 (Ionso-11ction TLV. :Jd1n_iuiw1-atitiv Fee: 0 Work Without Permit? 0 Yes E) No $0.00 Advanced Planning Fee: IPLLONGR $202.15 Select a Non -Residential Building or Structure E) Strong Motion Fee: IBSEISMICR $11.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $5.00 SUBTOTALS: $4,763.11 $1,667.00 TOTALFEE: $6,430.11 Revised: 10/01/2012 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: 2-011& A V F— 1 PERMIT # j '2- 1 OWNER'S NAME: jo?-v A t'-ikN rN 61 A M, PHONE # 9 I t4 -S 3 6 GENERAL CONTRACTOR: 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 INSRECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRA ORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. XI am not using any subcontractors: Si ature Date Please check applicable subcontractors and complete the following information: V 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 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: .:10 j 1= s ; A V PERMIT OWNER'SNAME: L.GrAM PHONE# �,D spy 3i, 1S GENERAL CONTRACTOR: 0 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 INSPXCTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRAC ORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. XI am not using any subcontractors: 4 46t�'- Signatwre ---Ie Date 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 Mandatory Measures Summary 7W -1R Residential 1 of 3 Site Addis: Eafor�t smart Agenerr Date NOTE: Low-rise residential buildings subject to the Standards must comply with all applicable mandatory measures listed reganffess of the compliance approach used More stringent energy memo es listed on the Cerilfwde of Comphawe (CF -1 R, CF -JR -ADD, or CF -1 R -ALT Form) shall supersede dee items marked with are asterisk(*) below. This Mandatory Measures Summary shall be incorporated into the permit documents and the applicable features shall be considered by all parties as minimum componentperformance specifrcadons whether they are shown elsewhere in the documents or in this summary. Submit all appUcable sections ojrthe W --IR Form with PI=. DESCP"TION Building Envelope Measures: 116(a)l: Doors and windows between conditioned and unconditioned spaces ace mamafaetmed to limit air §116(a)4: Fenestration products (except field -fabricated windows) have a label listing the certified U Factor, certified Solar Heat Gain Coefficient SH and infiltration that s the of §10-111(a). §117: Exterior doors and windows are weather—stripped; all ' rots and penetrations —caulked and sealed. p ls(a): insolation or installed meets Standards for Insulating Material. Indicatetype and include on CF -6R Foam. §118(1): Tire thermal emittauce and solar re9ectenoe values of the cool roofing material meets the requirements of §118(1) when the iaslallation of a Cool Roof is specified on the CF -1 R Form. *§150(a): Minimum R-19 insulation in wood -home ceiling or equivalent U -factor. §150(6): Loose fill insulation shall conform with manuf wturces installed desi labeled R Value. *§150(c): Mmimum R-13 insulation in wood-6ame wall or equivalent U -factor. *§150(d): Minimum R-13 insulation in raised wood -frame floor or equ ivalem U -factor. §1S0( . Air retarding wrap is tested, labeled, and installed according to ASTM E1677-95(2000) when specified on the CF -1R Form. 150(8): Mandatory Vapor harrier installed in Climate Zones 14 or 16- §150(1): 6.§150(1): Water absorption rate for slab edge insulation material alone without facings is no greater than 03%a, water vapor permcaam rate is no than 20 rah and shall be protected firm gttcal damage and UV light deterioration. Fireplaces, Decorative Gas Appliances and Gas Log Measares: §150(e)IA: Masomy or fictory-built fireplaces have a closable metal or glass door covering the entire opening ofibe firebox § 150(e)1B: Masonry or factory4mitt fireplaces have a combustion outside air brake, which is at least six square inches in area and is equipped with a with a readily accessible, operablc, and ti - and or a combustion -air control device_ §150(e)2: Continuous burning pilot lights and the use of indoor air for cooling a firebox jacket, whoa that indoor air is vented to the outside of the building, are Space Condition' Water Heattin and Pimabing System Measures: §110-§113: HVAC equipimexit water heaters, slowerheads, fincets and all ether regulated appliances are certified by the Commission. §113(c)5: Water heating recirculation loops serving multiple dwelling units and lfigh Rise residential occupancies meet the air release valve, backflow, prevention, pump isolation valve, and recirculation Imp connection requirements of §113(c)5. §115: Coetimrously burning pilot fights are probibited for natnrai gas: flan -type central furnaces, household cooking appliances (appliances with an electnrel voftW ootmemion with pilot ligbts that consume less than 150 BbA r are exempt),and pool and sM heaters. § 15oao Heating and/or cooling loads are calculated to accordance with ASHRAE, SMACNA or ACOA. §150(1): Heating systems we equipped with thermostats that meet the setback requhmcm of Section H1 c . §1 so( )iA-- Storage gas water beaters rated with an Energy Factor no greater than the federal minimal standard are externally wrapped with insulation having an itstalled thermal resistance of R-12 or greater- §150(i)IB: Unfired storage tanks, such as storage tanks or backup tanks for solar water heating system, or other indirect hot watertanks have R-12 emernat insulation or R-16 internal insulation ahwe the internal insultrtioa R -value is indicated on the exituior of the tank. §150(1)2: First 5 fed of hat and cold water pipes closest to wear heater tank, non-rec¢ailating systems, and entire length of recirculating sections of hot water Pipa are insulated per Standards Table 150-B. §150(1)2: Coaling system piping (sib, chilled weber. or brine lines).and piping insulated between heading source and indirect hot water tank shall be insulated to Table 150-B and Equation 150 -A- -§150(j)2: Pipe insulation for steam hydrvnic beating systems or hot water systems >15 psi, meets the requirements of Standards Table 123-A. §150( )3A: Inculation.is protected from damage, including that due to-nligbk moisture, equipment—tonsace, and wind §150G)3A. Insulation for chilled water piping and refrigerant suction lines includes a vapor retardant or is enclosed entirely m motioned space. 2008 Residential Compliance Forms August 2009 MandaWry Measures Summa W -1R Residential 2 of 3 Site Address: Enforcement Agency: Bate: §1500)4- Solar water and/or collectors are certified by the Solar Raft and Certification on Ducts and Fans Measures: §150(m)1: All air -distribution system duds and plenums installed, we sealed and insulated to meet the requirements of CMC Sections 601, 602, 603, 604, 605 and Standard 6-5; supply -4 it and return -air ducts and plenums ate insulated to a minimum installed level of R-4.2 or enclosed entirely in conditioned space. Openings shall be sealed with mastic, tape or other duct-closum system that meds the applicable requirements of UL 181, UL 181A, or UL I81B or aerosol sealant that meets The requirements of UL 723. If mastic or tape is used to seal openings greater than 1/4 inch, the chombination ofmastic and either mesh or tape shalt be used § 150(m)1: Building cavities, support platforms for air handlers, and plenums defined or constructed with materials other than seated sheet metal, duct board or flexible duct shall not be used for conveying conditioned air. Building cavities and support plaii'orm may contain ducts. Duds installed in cavities and support pladbrms shall not be compressed to cause reductions in the cross-sectional area of the duds. § i 50(m)21D: Joins and seams of dud systems and ore's components shall not be sealed with cloth back rubber adhesive dud tapes unless such tape is used in combination with mastic and draw bands. § t m)7: Exhaust fan systems have back draft or automatic § 1 m)8: Gravity, ventilating systems serving conditioned spaw have either automatic or readily accessible, manually operated dam § 150(m)9: Insulation shall be protected from damage, including that due to sunlight, moisture, equipment maintenance, and wind Cellular foam insulation shall be protected as above or painted with a cog that is water retardant and provides shielding from solar radiation that can cause degradation of the material. §150(m)10: Flexible duds cannot have porous inner cores §150(o): All dwelling units Mall meet the requuEmems of ANSIIASHRAE Standard 62-2-2007 Ventilation and Acceptable Indoor Air Quality in Low Rise Resideatiat Buildings Window operation is not a permissible method ofproviding the Whole Building Ventilation requited in Section 4 of that Standard Pool and Spa Hwting Symtems and Equipment Measures: §114(x): Any pool or spa heating system shall be certified to have: a thermal efficiency that complies with the Appliance Efficiency Regulations; an on-off switch mounted outside of the heater, apexmanent weatherproof plate or card with operating instructions; and shall not use electric resistance heating ora pilot fi §114(b)l: Any pool or spa heating equipment snail be installed with at least 367 of pipe between filter and heater, or dedicated suction and return Imes, or built-up connections for future solarbeatin §1 14(b)2: Outdoor pools or spas that have a heat pump or gas hear shall have a cover. §114(b)_3: Pools shall have dbectional inlets that adequately mix the pool water, and a time switch dial will allow all pumps to be set or programmed to run only off- electric demand 'ods. §150(p): Residential pool systems or equipment meet the pump sizing, flow rate, piping, fibers, and valve requirements of §150(p). Residential Lighting Measures: §150(k)l: High efficacy luminaires or LED Light Engine with Integral Beat Sink has an efficacy that is no lower than time effigies contained in Table 150-C and is not a low efficacy luminaire as specified by §150(k)2. §150(k)3: The wattage ofpetmanemily installed luminaires shall be determined as specified by §130(d). §150(k)4: Ballasts for fluorescent lamps rated 13 Watts or greater shall be electronic and shell have an output firequency no Iess than 20 kHz. §150(k)5: Permanently installed night lights and night lights integrA to apmmumeatly installed luminaire or exhaust fan shall contain only high efficacy lamps meeting the minimum efficacies contained in Table 150-C and shall not min a lino -voltage sodmt or tine -voltage lamp hold.; OR shall be rated to consume no more than five watts of power as determined by §130(d), and shall not contain a medium screw -base socket §150(k)6: Lighting integral to exhaust fans, in rooms other than kitchens, shall meet the applicable requirements of § 150(k). §150(k)7: All switching devices and controls shall meet the requirements of §150(k)7. §150(k)8: A muimmumm of 50 percent of the total rated wattage of penanently installed lighting in kitchens shall be high efficacy. EXCEPTION: Up to 50 watts for dwelling units less than or equal to 2,500 a or 100 watts for dwelling units IaW than 2,500 ft2 may be exempt from the 509b high efficacy mqunement when: all low efficacy luminaires in the kitchen are eoatrolled by a manual on occupant sensor; dimmer, energy management system (EMCS), or a multi programmable control system; and all permanently installed luminaries in gam ages, laundry moms, closets greater than 70 square feta; and utility rooms are high efficacy and controlled by a manual -on occupant sensor. §150(k)9- Permanently installed Iighting that is internal to cabinets shall use no more than 20 watts of power per linear foot ofillaminated cabinet. §150(k)10: Permanently installed luminaires in bathrooms, attached and detached garages, laundry rooms, closets and wMay rooms shall be high efficacy, 2008 Residential Compliance Forms August 2009 Mandatory Measures Summa MF -1R Residential 3 of 3 Site Address: Enforcement Agency: Date: EXCEPTION 1: Permanently installed low efficacy luminaires shall be allowed provided that they are controlled by a manual -on occupant sensor certified to comply with the applicable requirements of § 119. EXCEPTION 2: Permanently installed low efficacy luminaires in closets less than 70 square feet are not required to be controlled by a manual -on occupant sensor. §150(k)ll: Permanently installed luminaires located in rooms or areas other than in kitchens, bathrooms, garages, laundry rooms, closets, and utility rooms shall be high efficacy luimnaires. EXCEPTION 1: Permanently installed low efficacy luminaires shall be allowed provided they are controlled by either a dimmer switch that complies with the applicable requirements of § 119, or by a manual -on occupant sensor that complies with the applicable requirements of §119. EXCEPTION 2: Lighting in detached storage building less than 1000 square feet located on a residential site is not required to comply with I50(k)l L §150(k)12: Luminaires recessed into insulated ceilings shall be listed for zero clearance insulation contact (IC) by Underwriters Laboratories or other nationally recognized testing/rating laboratory; and have a label that certifies the lumiunaire is airtight with air leakage less then 2.0 CFM at 75 Pascals when tested in accordance with ASTM E283: and be sealed with a gasket or caulk between the luminaire housing and ceiling. 150(k)13: Luminaires providing outdoor lighting; including lighting for private patios in low-rise residential buildings with four or more dwelling units, entrances, balconies, and porches, which are permanently mounted to a residential building or to other buildings on the same lot shall be high efficacy. EXCEPTION 1: Permanently installed outdoor low efficacy luminaires shall be allowed provided that they are controlled by a manual on/ofIrswitch, a motion sensor not having an override or bypass switch that disables the motion sensor, and one of the following controls: a photocontrol not having an override or bypass switch that disables the photocontrol; OR an astronomical time clock not having an override or bypass switch that disables the astronomical time clock; OR an energy management control system (EMCS) not having an override or bypass switch that allows the luminaire to be always on EXCEPTION 2: Outdoor luminaires used to comply with Exceptionl to § 150(k)13 may be controlled by a temporary override switch which bypasses the motion sensing fimction provided that the motion sensor is automatically reactivated within six hours. EXCEPTION 3: Permanently installed luminaires in or around swimming pool, water features, or other location subject to Article 680 of the California Electric Code need not be high efficacy luminaires. I50(k)14: Internally illuminated address signs shall comply with Section 148; OR not contain a screw -base socket, and consume no more than five watts of power as determined according to 13 150(k)15: Lighting for parking lots and carports with a total of for 8 or more vehicles per site shall comply with the applicable requirements in Sections 130, 132, 134, and 147. Lighting for parking garages for 8 or more vehicles shall comply with the applicable requirements of Sections 130, 131,134, and 146 § 150(k)16: Permanently installed lighting in the enclosed, non -dwelling spaces of low-rise residential buildings with four or more dwelling units shall be high efficacy luminaires. EXCEPTION: Permanently installed low efficacy luminaires shall be allowed provided that they are controlled by an occupant sensor(s) certified to comply with the applicable ents of § 119. 2008 Residential Compliance Forms August 2009 CUPERTINO PURPOSE: 2010 CALGREEN RESIDENTIAL CHECKLIST — MANDATORY ITEMS COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-32.28 • FAX (408) 777-3333 uIch!ir (_llru.n r1.ir1r..orq The 2010 CalGreen Code applies to all newly constructed hotels, motels, lodging houses, dwellings, dormitories, condominiums, shelters, congregate residences, employee housing, factory -built housing and other types of swellings with sleeping accommodations and new accessory buildings associated with such uses. Existing site and landscaping improvements that are not otherwise disturbed are not subject to the requirements of CALGreen. Project Name: Project Address: 20118 Forest Ave. 20118 Forest Ave., Cupertino, CA 95014 ii Project Description: Convert accessory building to 2nd unit detached Instructions: 1. The Owner or the Owner's agent shall employ a licensed professional experienced with the 2010 California Green Building Standards Codes to verify and assure that all required work described herein is properly planned and implemented in the project. 2. The licensed professional, in collaboration with the owner and the design professional shall initial Column 2 of this checklist, sign and date Section 1 - Design Verification at the end of this checklist and have the checklist printed on the approved plans for the project. 3. Prior to final inspection by the Building Department, the licensed professional shall complete Column 3 and sign and date Section 2 - Implementation Verification at the end of this checklist and submit the completed form to the Building Inspector. I F -' C.Opl, Column 2 Column 3 MANDATORY FEATURE OR MEASURE Project Verification Requirements A4.1 PLANNING AND DESIGN Planning and Design - Site Preservation 4.104.1 A site plan and inventory of the site is developed and used to minimize site disturbance in order preserve desirable existing natural resources and QX minimize future adverse effects on the proposed structure. Planning and Design - Site Development 4.106.2 A plan is developed and implemented to manage storm water drainage during construction. 4.106.3 The site shall be planned and developed to keep surface water away from buildings. Construction plans shall indicate how site grading or a drainage XQ system will manage all surface water flows. Page I of 5 CnlGreen_2010.doc reused 08 2' 11 ENERGY General 4.201.1 Low-rise residential buildings shall meet or exceed the minimum standard design required by the California Energy Standards. A4.3 WATER EFFICIENCY AND CONSERVATION Indoor Water Use 4.303.1 Indoor water use shall be reduced by at least 20 percent using one of the follow methods. Q Water saving fixtures or flaw restrictors shall be used per Table 4.303.2. 13A 20 percent reduction in baseline water use shall be demonstrated per As of 7/0112011 Table 4.303.1. 4.303.2 When using the calculation method specified in Section 4.303.1, multiple showerheads shall not exceed maximum flow rates. As of 7/01/2011 4.303.3 Plumbing fixtures (water closets and urinals) and fittings (faucets and showerheads) shall comply with specified performance requirements. As of 7/0l/2011 Outdoor Water Use 4.304.1 Automatic irrigation systems installed at the time of final inspection shall be weather -based. A4.4 Enhanced Durability and Reduced Maintenance 4.406.1 Joints and openings. Annular spaces around pipes, electric cables. conduits, or other openings in plates at exterior walls shall be protected against the passage of rodents by closing such openings with cement mortar, concrete masonry or similar method acceptable to the enforcing agency. Construction Waste Reduction, Disposal and Recycling 4.408.2 Where a local jurisdiction does not have a construction and demolition waste management ordinance, a construction waste management plan shall X❑ be submitted for approval to the enforcing agency. Building Maintenance and Operation 4.410.1 An operation and maintenance manual shall be provided to the building occupant or owner. Page 2 of 5 ColGreen 2010.doc reused 08 1' /1 'A4.5 ENVIRONMENTAL Fireplaces 4.503.1 Install only a direct -vent sealed -combustion gas or sealed wood - RX burning fireplace, or a sealed woodstove. Pollutant Control 4.504.1 Duct openings and other related air distribution component openings RX shall be covered during construction. 4.504.2.1 Adhesives, sealants and caulks shall be compliant with VOC and RX Q other toxic compound limits. 4.504.2.2 Paints, stains and other coatings shall be compliant with VOC limits. 4.504.2.3 Aerosol paints and other coatings shall be compliant with product weighted MIR Limits for ROC and other toxic compounds. 4.504.2.4 Documentation shall be provided to verify that compliant VOC limit 0 finish materials have been used. i 4.504.3 Carpet and carpet systems shall be compliant with VOC limits. i ❑X 4.504.4 Fifty (50) percent of floor area receiving resilient flooring shall comply I with the VOC-emission limits defined in the Collaborative for High Performance MX Schools (CHPS) Low -emitting Materials List or be certified under the Resilient Floor Covering Institute (RCFI) FloorScore program. 4.504.5 Particleboard, medium density fiberboard (MDF), and hardwood plywood used in interior finish systems shall comply with low formaldehyde ❑X emission standards. Interior Moisture Control 4.505.2 Vapor retarder and capillary break is installed at slab on grade foundations. 4.505.3 Moisture content of building materials used in wall and floor framing is checked before enclosure. Page 3 of 5 C'alGreen 2010.doc revised 0827 l I Indoor Air Quality and Exhaust 4.506.1 Exhaust fans which terminate outside the building are provided in every bathroom. l✓6 Environmental Comfort 4.507.1 Whole house exhaust fans shall have insulated louvers or covers which close when the fan is off. Covers or louvers shall have a minimum ❑X Q insulation value of R-4.2. 4.507.2. Duct systems are sized and designed and equipment is selected using the following methods: 1. Establish heat loss and heat gain values according to ACCA Manual J or equivalent. ICJ 2. Size duct systems according to ACCA 29-D (Manual D) or equivalent. 3. Select heating and cooling equipment according to ACCA 36-S (Manual S) or equivalent. - INSTALLER AND SPECIAL ' QUALIFICATIONS Qualifications 702.1 HVAC system installers are trained and certified in the proper installation LN of HVAC systems. 702.2 The Licensed Professional responsible to verify CALGreen compliance is qualified and able to demonstrate competence in the discipline they inspect []X 0 and verify. Verifications 703.1 Verification of compliance with CALGreen may include construction documents, plans, specifications, builder or installer certification, inspection reports, or other methods acceptable to the enforcing agency which show substantial conformance. Implementation verification shall be submitted to the Building Department after implementation of all required measures and prior to final inspection approval. Pagc 4 o('5 Col'Green 2010.doc revised 08 27 11 CALGREEN SIGNATURE DECLARATIONS Project Name: 20118 Forest Ave. Project Address: 20118 Forest Ave., Cupertino, CA 95014 Project Description: Convert accessory building to 2nd unit detached SECTION 1 — DESIGN VERIFICATION Complete all lines of Section 1 — "Design Verification" and submit the completed checklist (Columns 1 and 2) with the plans and building permit application to the Building Department. The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and certify that the items checked above are hereby incorporated into the project plans and will be implemented into the project in accordance h the requirements set forth in the 2010 California Green Building Standards Code as adopted by the City otCbpertino. Email Address for License Professional responsible for CalGreen compliance SECTION 2 — IMPLEMENTATION VERIFICATION Complete, sign and submit the competed checklist, including column 3, together with all original signatures on Section 2 to the Building Department prior to Building Department final inspection. I have inspected the work and have received sufficient documentation to verify and certify that the project identified above was constructed in accordance with this Green Building Checklist and in accordance with the requirements of the 2010 California Green Building Standards Code as adopted by the City of Cupertino. Signature of License Professional responsible for CalGreen compliance Date Name of License Professional responsible for CalGreen compliance (Please Print) Phone Email Address for License Professional responsible for CalGreen compliance Page 5 of 5 CalGreen 2010.doc revised W2? -11 06/17/2013 Owner's Signature Date Subramaill Ramalingam Owner's Name (Please Print) 06/17/2013 Design Professional's Signature Date Asher Ecleri Design Professional'Name (Please Print) 06/17/2013 Signature of Liceinse Professional responsible for CalGreen compliance Date Asher Ederi 408-404-3227 Name of License Professional responsible for CalGreen compliance (Please Print) Phone info@apamerican.com Email Address for License Professional responsible for CalGreen compliance SECTION 2 — IMPLEMENTATION VERIFICATION Complete, sign and submit the competed checklist, including column 3, together with all original signatures on Section 2 to the Building Department prior to Building Department final inspection. I have inspected the work and have received sufficient documentation to verify and certify that the project identified above was constructed in accordance with this Green Building Checklist and in accordance with the requirements of the 2010 California Green Building Standards Code as adopted by the City of Cupertino. Signature of License Professional responsible for CalGreen compliance Date Name of License Professional responsible for CalGreen compliance (Please Print) Phone Email Address for License Professional responsible for CalGreen compliance Page 5 of 5 CalGreen 2010.doc revised W2? -11 March 61 2015 Building Department, City of Cupertino 1030o Torre Avenue Cupertino, CA 95014 To whom it may concern: This letter is in regards to the remodeling project at 2o2.2.8 Forest Ave in Cupertino. The permit numbers are 2-22-20044 and 2-2120042. The contractor on record is AP American Construction with whom we are no longer working. We terminated the contract on February, 25th, 2015, due to Asher Ederi's inability to work neither cooperatively with us nor with the City of Cupertino's Building Department, and his intentional slowing of the project. Our lawyer, David Bicknell, sent Asher Ederi a letter on February 25th stating that the contract is terminated, effective immediately, as the result of his material breaches of contract and his violations of California law. We provided the Building Depart a copy of the termination notice in October of 2010. We are now directly taking ownership of finishing up the project. Please update your records accordingly. Thankyou. [Sincerely,] i Subrama Zmalin gam 20118 Forest Cupertino CA 95014 Ph: 650-83.4-5368 f, i , 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(a)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 ADDRESS ,-. (I r -O RF S i P J E- APN BP# 2 j 2POLl 2 OWNER NAME ,J9,RP,rnPON LiN,�AM OWNER ADDRESS ©1\g F�i�E 'i Naf CJ 7'ri?--Tt )'JJ iy DESCRIPTION.OF WORK: 2-NpS�fz`1 AD 1T1O�J I COrJ VERSI0Ij 0►= A-CCFSSof_y S71�UC iJK� 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. Please read and initial each statement below to signify you understand or verify this information) L1, 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 k ce coverage for injuries to workers on my property. 1 understand building permits are not required to be signed by property owners unless they are responsible for struction and are not hiring a licensed Contractor to assume this responsibility. 43. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may ppotect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 1--4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. J,--5. 1 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. E. I understand if I am considered an "employer" under state and federal law, I must register with the state and ederal 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 rrr1� to serious financial risk. 7. I 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 i performed under contract with a licensed general building Contractor. 8. 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. OwnerBuilderForn7 2010.doc revised 04114110 -9.1 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 Paymantc, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed c tractors. 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I a the party legally and financially responsible for proposed construction activity at the site address listed above. J, _11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by II 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 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.) 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 r issuing the permit. Note: A copy of the property owners driver's license, form notarization, or other verificatioceptable to the city may be required to be presented when the permit is issued to verify the property owners sign r Property Owner's Signature: Date: -------------------------------------------------------------------------------------------------------------------- — ----------------------- (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). AU"fHORIZATION 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 owners signature. Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revised 04/14/10 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(cDcupertino.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 ADDRESS > ,- 1 To �r- C T J APN BP# (21 2004 2 2-00 �j OWNER NAME UF.KAMAN) J:ZAMA L\N6AM OWNER ADDRESS \\ FTE i" RAF C�t'rIZ7i>vo CA 1) 5-0 1 DESCRIPTION OF WORK: 2N ,SiORy D 1Tt(DrJ CDrJ VE Iz,ot') Oi= kccFSSos�_Y S rt uc -)JKE 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. S: Please read and initial each statement below to signify you understand or verify this information.) LJ!L1. I 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 in rance 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 e construction and are not hiring a licensed Contractor to assume this responsibility. may4. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may ppo�tect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. k4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. L-5. 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. 6. I understand if I am considered an "employer" under state and federal law, I must register with the state and ederal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject to serious financial risk. 7. I 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 iAperf"ormed under contract with a licensed general building Contractor. I/ 8. I understand as an Owner -Builder if I sell the property for which this permit is issued I may be held liable for P P Y P Y any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 9.l 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 (CS LB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed afctors. 0. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I t e party legally and financially responsible for proposed construction activity at the site address listed above. 1. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by II applicable laws and requirements that govern Owner -Builders as well as employers. 12. I 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.) 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 responsibl r issuing the permit. Note: A copy of the property owner's driver's license, form notarization, or other verificatio ceptable to the city may be required to be presented when the permit is issued to verify the property owner's sign 11yJ Property Owner's Signature: Date: 3 9 It --------------------------------------------------------------------------------------------------------------------------------------------- (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: OwnerBuilderForm 2010.doc revised 04/14/10