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12010176 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19056 TILSON AVE CONTRACTOR:KRISHNAMURTHY PERMIT NO:12010176 VASANTH AND SWAMY SEE OWNER'S NAME: KRISHNAMURTHY VASANTH AND SWAMY SEE 10828 ALDERBROOK LN DATE ISSUED:01/22/2013 OWNER'S PHONE: 4083946769 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIALD COMMERCIAL License Class Lic.# CONSTRUCT I STORY SFDWL,2756SQFT LIVING SPACE& 554SQFT GARAGE,71SQFT PORCH Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 RE SIO 1-REVISE FLOOR PLAN LAYOUT-ISSD 3/5/13 (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. j�r I hereby affirm under penalty of perjury one of the following two declar ��ii I have and will maintain a certificate of consent to self-insure for Worke Compensation,as provided for by Section 3700 of the Labor Code 0r 0Z performance of the work for which this permit is issued. q.Ft Floor Area: Valuation:$280000 I have and will maintain Worker's Compensation Insurance,as pr ' ed for by. Section 3700 of the Labor Code,for the performance of the work for which APN Number:37509005.00 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 80 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 DAYF OM LAST CALLED INSP C 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 (3. 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 I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: 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 I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectiolrs 25505,25533 and 25534. Section 3700 of the Labor Code,for the performance of the work for which this //C- permit is issued. Owner or authorized agent: .,� w Date: I certify that in the performance of the work for which this permit is issued,I shall f 3 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 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. 4 *"t'=,1ate Signature CONSTRUCTION PERMIT APPLICATION 94 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333•buildingCc cupertino.org 11(67 ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION!TI ❑ REVISION!DEFERRED ORIGINAL`PERMIT# PROJECT ADDRESS/L�!.� TI/ !J, A 1 i��'j ( , � �T�1 , API!,,i ,L/ 7 /L ,c J OWNER NAME , L. (� / (/ / �/j j��y PHONE.,��ti (L/ 1/ E-MAIL _5(•Cp lit ��C SUIT( l/n �'� Clil STREET ADDRESS U Z C P�:f 2/31 c 1./V CITY,STATE,ZIP �.11 Y ]r�VC v` 7AX 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# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHTTECTIENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK — / )' i t �tO_� EXISTING USE PROPOSED USE CONSTR TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA I DECK AREA TOTAL DECK/PORCH AREA I GARAGE AREA: DETACH I]ATTACH #DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? []NO ADDITION? []NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES rEE�i TOTAL VALUATION: PLANNING APPL# ❑NO PLANNING APPROVAL LETTER EICHLER HOME? []NO 0 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. 1 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 buildin 'egnstruction. I aut ze representatives of Cupertino to enter the above-identified property for inspection purposes. n Signature of ApplicanUAgent: Date: 19 _ t , f SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure 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 MAJOR 11 SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ❑ ENVIRONMENTAL HEALTH BldgApp 2011.doc revised 06/21/11 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19056 TILSON AVE CONTRACTOR:KRISHNAMURTHY PERMIT NO: 12010176 VASANTH AND SWAMY SEE OWNER'S NAME: KRISHNAMURTHY VASANTH AND SWAMY SEE 10828 ALDERBROOK LN DATE ISSUED:01/22/2013 OWNER'S PHONE: 4083946769 . CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class Lic.# CONSTRUCT I STORY SFDWL,2756SQFT LIVING SPACE& 554SQFT GARAGE,71SQFT PORCH Contractor Date 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:$280000 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:37509005.00 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 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: /V c! 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 I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. 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 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 agen ti' 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,l 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. Date Signature CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228•FAX(408)777-3333• building(c1i_cupertino.org CUPERTINO NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFEE�RRED ORIGINAL PERMIT# PROJECT ADDRESS 1 Q 5/R I�O l` 4F/. �# / 01 �-'c� OWNER NAME ! /[I`F,r, ` G9' �'r PHONE .h C 64 -61 1 EMAIL STREET ADDRESS ©�(i 1 n r co L �Y, ',, I! , (J `0 14 FAX CONTACT NAME TG' G rL PHONES J�O _ E-MAIL V i-, r�T STREET ADDRESS CITY, T TE ZIP FAX ❑OWNER ❑ OWNER-BUILDER OWNER AGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER c,5 TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHTTECTAl� ER NAME LICENSE NUMBEr BUS.LIC# COMPANY NAME E-MAIIoo,CpM FAX STREET ADDRESS 5 _ CITYS P 3O CA n PHONE Q . 9115 DESCRIPTION OF WORK L �l r �ZJ o -- 5To(Q-y EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES wn y � � M t / 1 USE TYPE OCC. SQ.FT. VALUATION(S) E)aSTG IC NEW FLOOR DEMO �! TOTAL AREA, AREA �6 AREA NET AREA c 'F P v' C� 3 ® K BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH I' 5 ATTACH #DWELLING UNITS: IS A SECOND UA7T YES SECOND STORY ❑YES BEING ADDED? f�'NO An 'G1'NO PRE-APPLICATION []YES IF YES,PROVIDE COPY OF IS THE BLDG AN []YES RECEIVED BY: TOTAL VALUATION: PLANNING APPL# gNO 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 prrperty 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 toj!� . g con traction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: �! 3 SUPPLEMENTAL INFORMATION REQUIRED PIAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ sTANDARD ❑ PUBLIc woRxs form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE bEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENvTRoNMENTAL HEALTH B1dgApp 2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 19056 tilson ave DATE: 0113012012 REVIEWED BY: larry s 1 7 — APN: BP#: I '17-11.11ATION: 1$280,000 PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY SFD or Duplex 2nd Unit? 0 Yes 1@ No PENTAMATION I R3SFDW USE: PERMIT TYPE: WORK I new construction 1 story 2756 sq ft living,554 sq ft garage, 71 sq ft porch SCOPE OCCUPANCY TYPE: TYPE OF FLR AREA PC EEE987___- PC FEE ID BP FEES BP FEE H) CONSTR. (s.f.) R-3(Custom) 11-B,111-B,1V,V-B 3,381 71C2,871.11 IR.3PLNCK $2,919.78 IR31,YSP TOTALS: 3,381 $2,871 $2,91 Lj NOTE.- This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These.Lees are based on theLimina infortnation available and are 22Ly an estimate. Contact the Pff 1,Lor addn 7 info. FEE ITEMSFEE QTY/FEE MISC ITEMS . ....................... Plan Check Fee: $2,871.11 Select a Mise Bldg/Structure Suppl. PC Fee: (S) Reg. 0 0T— 0.0 hrs $0.00 or Element of a Building F PNIE Plan Check: $0.00 Permit Fee: $2,919.78 Suppl. Insp. Feei@ Reg. 0 OTEE]-1ir-S $0.00 PNIE Unit Fee: $0.00 PME Permit Fee: $0.00 _1-91.x: IBCONSTAXR #new units $583.80 0 Work Without Pennit? 0 Yes (j) No $0.00 PLL0A1GkVCTR $439.53 Select a Non-Residential Building or Structure 0 A IBSEISMCR $28.00 Select an Administrative Item S[ol, Con-,­n.jss:'on IBCBSC $12.00 SUBTOTALS: 1 $6,854.221 $0.00 TOTAL FEE: -$6,854.221 Revised: 1/19/2012 Building Department City Of Cupertino 10300 Tone Avenue Cupertino, CA 95014-3255 C O P E RT I N O Telephone: 408-777-3228 Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: Ste/ ERMIT# / OWNER'S NAME: _ 51-V bM PHONE# G�'_ ((i-'55-1 2 GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: 08 f4LX- z,Ik- 4-1� Pt:-f) �V a C."� WTY/ZlPCODE: Ou 0 *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: Signature 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 Si16re Date .6 OWNER-BUILDER NOTICE COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPER'rlNo (408)777-3228- FAX(408)777-3333- bui1d6Q acuoertino.oro Effective January, 1, 2009, Assembly Bill 2335 amends California Health and Safety Code, Section 19825, regarding disclosures and verifications required for all applicants seeking Owner- Builder construction permits. These new application requirements provide an enhanced level of consumer awareness and protection for property owners accepting the risks associated with Owner-Builder construction permits. "The Legislature hereby finds and declares that there is an urgent and statewide public interest in assuring that building contractors comply with the Contractors License Law...and provisions of law relating to Workers' Compensation Insurance for building construction,that property owners are informed about, and protected from, fraudulent representations, liability for worker's injuries, liability for material and labor costs unpaid by contractors, licensing requirements, and employer's tax liabilities when improving their property as owner-builders" Important information you need to know BEFORE I pulling your permit! The term "Owner-Builder" can mean three different things: "Owner as Worker","Owner as Contractor" or "Owner as Employer" Understand each has Benefits or Risk, and it is possible to combine them! Hiring a California Licensed Contractor means you do not personally perform any of the construction work, the permit is not taken out in your name, you are not personally responsible for the construction and you are not an Owner-Builder. Instead,you become a"Customer' and California law provides you the benefit of protection from poor workmanship, failure to finish the job and financial risk due to worker injury. Benefit/Risk: Highest Benefits and the Least amount of Rist: Owner-as-Worker is a type of Owner-Builder where you personally performs the construction work, the permit is taken out in your name and you are personally responsible for the construction management, knowledge, workmanship, and completion of the job. You benefit by not paying others to perform this work for you and your risk depends on your own ability to complete the job successfully. Benefit/Risk: Passible Benefit with Lois Financial Risk Owner-as-Contractor is a type of Owner-Builder where you personally act as your own General Contractor, the permit is taken out in your name and you hire California licensed sub-contractors to perform portions of the construction work. WARNING: The benefit of protection provided by law when you hire only California licensed sub-contractors can tum to serious financial risk if you hire unlfeensed contractors to perform any of the work. Benefit/Risk: P_:.ssihle Benefr and Significant Financial Risk Owner-as-Employer is a type of Owner-Builder where you pay any individual to perform any construction work valued at more than $500.00, the permit is taken out in your name and you are personally responsible for their employment requirements, supervision,performance,safety and welfare while on your property. WARNING: Cost savings benefit can turn to serious financial risk if you fail to deduct payroll taxes or provide Workers c0777pensation insurance for each worker. Benefit/Risk: Possitre E3encf-f with Significant Financial Risk Over 20,000 consumer complaints are filed each year. Many complaints relate to owner/builder projects and include workmanship and workers' compensation issues Homeowners suffer financial harm due to defective workmanship and injured employees. aiwerBuilder 2010.doc revised 06/08/10 Following are alarming examples of what has occurred with Owner-Builder permits: Example 1: Homeowner received insurance money to rebuild burned-down home. ■ Owner/Builder permit pulled to rebuild structure. ■ Unlicensed contractor built substandard structure— must be torn down and replaced. ■ Estimated financial injury is $225,000. ■ Additional financial injury - IRS threatened to tax insurance payout if house not completed by the end of the year. Example 2: Brother-in-law had active license but filed an exemption from Workers Comp. ■ Owner-Builder hires brother-in-law to install a new roof. ■ Employee falls and sustains multiple spinal and extremity fractures as well as a head injury and remains in a coma to this day. ■ The Owner-Builder, who has sold the home, is now a defendant in a lawsuit for reimbursement for benefits paid to the injured worker. Example 3: Employee of contractor without Workers Comp is hired by Owner-Builder to install septic system and suffers injury that results in permanent disability. ■ The Owner-Builder did not have a homeowner's insurance policy on the house against which to submit a claim. ■ The Owner-Builder is now a defendant in a lawsuit for reimbursement for benefits paid to the injured worker. Did you know— unlicensed persons frequently have the property owner obtain an "Owner- Builder" building permit which erroneously implies that the property owner is providing his or her own labor and material personally? Did you know—your homeowner's insurance may not provide coverage for injuries sustained on your property by an unlicensed contractor and his/her employees? Did you know— if you are considered an "employer" under state and federal law, you must register with the state and federal government, withhold payroll taxes, provide workers compensation and disability insurance and contribute to unemployment compensation for each "employee"? Did you know—that if you fail to abide by these laws you may be subjected to serious financial risk? OWNERS BEWARE AND CONSIDER THE RISK BEFORE ACCEPTING FULL RESPONSIBILITY FOR YOUR CONSTRUCTION PERMIT OwnerBuilder 2010.doe revised 04/12/10 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE- CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333- buildinQ5,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: SITE ADDRESS 'C� T/ � AP N BP# OWNER NAME OWNER ADDRESS DESCRIPTION OF WORK: Vs �c U6 We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you,the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) 1. 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 Qiinnsuurance coverage for injuries to workers on my property. k% ' 2. 1 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. 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. "IV.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. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the otal 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 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. 7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. Z8. I 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. OwnerBuilderFonn 2010.doc remised 04114110 ''Pk- 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 Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed contractors. A10. 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. , 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. X�<2. 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 affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued, this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's sl ure. 7 Property Owner's Signature: Date: '13 -- ------------------------------------------------------------------------ ------------------------------------------------------------------ (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: Tel No Address of Authorized Agent: 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: OliVerBuilderForn? 2010.doe revised 04/14/10