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13040175�l _r CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 873 ROSE BLOSSOM DR CONTRACTOR: DORIN RICHARD I AND PERMIT NO: 13040175 MAXINE H OWNER'S NAME: DORIN RICHARD I AND MAXINE H 2526 ELFEGO NW DATE ISSUED: 10/15/2013 OWNER'S PHONE: 5056814380 ALBEQUREQUE, NM 87107 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL CONSTRUCT ONE STORY ADDITION (553 SQ FT); License Class Lie. # _ COVERED PORCH (186 SQ FT); INTERIOR REMODEL (SFD AND Contractor Date GARAGE)(1794 SQ FT); REMOVE AND REPLACE ROOF I hereby affirm that I am licensed under the provisions of Chapter 9 REV # 1- REVISE INTERIOR LAYOUT, NO STRUCTURAL CHANGES - (commencing with Section 7000) of Division 3 of the Business & Professions 7/21/14 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: $300000 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 35903049.00 Occupancy Type: Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180=D,0FJ%12MT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter 180 DT ED INSPECTION. upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the ate: 24 -2 granting of this permit. Additionally, the applicant understands and will com granting y: - with all non -point source regulations per the Cupertino Municipal Code, S ton 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: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I, as owner of the property, or my employees with wages as their sole compensation. will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505 33, 25534. 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 Owner or authorized agent: - Date: 7l zzl permit is issued. ` I I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all n so)� re ations r the Cupertino Municipal Code, Section Licensed Professional 9.18. ; Signature Date Z7 �71y CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building (a)cugertino.org I� J� l� 1 ---TAI DCDATTT 41 U NEW CONSTRUCTION L_l AUUI I IU1N IJ AL I DKH I I'Ji / 11 Ll - PROJECT ADDRESS/�+J3 %% S'7(�. / �• $ SO /C_ OWNER NAME lel11,1, �(/ r i✓�� / A_PHONEr- �/'Y2STREET ADDRESS �-11 CITY, STATE, Zu -G�'/is�• FAX CONTACT NAME / � �ur5 1 PHONE p ' r� p� �2z� O LO[J E MAIL��r r lr iry P,t•r t . C STREET DRESSU O %itQilL�/ CITY„�T/1TF�, ZIP �� ^ ` �T�/ ry �1S���x// e1A d FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR 11 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 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK A -,ed- - , EXISTING USE PROPOSED USE CONSTR E # S ORIEs USE TYPE OCC. Ql- VALUATION (S) EXISTG//�,. � NEW FLOOR DEMO TOTAL AREA - d AREA AREA NET AREA 100 / BATHROOM KITCHEN OTHER REMODEL AREA - REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ ATTACH .�A (f (% I ., /l 210 # DWELLING UNITS: IS ASECOND UNIT ❑ YES SECOND NO ADDITION? STORY OYES ( ' h W BEING ADDED? ❑ PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS APPROVAL LETTER EICHLER THE BLDG AN ❑ YES HOME? ❑ NOyam;': RECEIVE iC'w"" TOTAL VALUATION: 3 PLANNING APPL # ❑ NO PLANNING By my signature below, I certify to each of the follo g: I am the property owner or authorized agent to act on the property owner's behalf. I have read this it is I agree to comply with all applicable local application and the information I have provided is rrect. I have read the Description of Work and verify accurate. I authorize representatives of Cupertino to enter the above -id tified ro for inspection purposes. ordinances and state laws relating to building co ction. Signature of Applicant/Agent: Date: SUPPLEMENTALIN RMATION REQUIRED PLAN CHECK TYPE: ROUTING SLIP ❑ OVER-THE-COLNTLR ❑ BUILDING PLAN REVIEW New SFD or Multifamily dwe gs: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. El EXPRESS El PLANNING PLAN RF,�7EW 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 ❑ MAJOR ❑ SANITARY SEVI'ER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06/21/11 46�y Ir 4L OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinaCa)cupertino.ora CUPERTINO 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: P# SITE ADDRESS 873 Rose Blossom Dr. Cupertino, CA 95014 APN g _ v '3 0 Y 34 o OWNER NAMERichard &Maxine Dorin WNER OADDRESS 2526 Elfego Rd. NW Albuquerque, NM 87107 OF WORK: Remodel and reconstruction of residence 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.) . 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 insurance coverage for injuries to workers on my property. KD. I understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. . I 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. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. n"rstand_"mploy_orothermrisenaage an-pPrcons. other than California licensed Contractors, the of alue 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. Lb. 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. QI understand under California Contractors' State License Law, an Owner -Builder who builds single-family ntial 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 erformed under contract with a licensed general building Contractor. e5fis 8. 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. OwnerBuilderForm_2010.doc revised 04/14/10 s% 9b. I understand I may obtain more information regarding my obligations as an "employer" from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed contractors. 0 0.1 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. 95 1. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. �12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the in{{-o��rmation 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 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 owners si nature. Property Owner's Signature: ow-- Date: July 21st, 2014 (NOTE: The following Authorization Form is required to be c_o_m,_ p__1­e_t_e_ d 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): Remodel and reconstruction of residence per approved plans. Project Location or Address: 873 Rose Blossom Dr. Cupertino, CA 95014 Name of Authorized Agent: Marvin Davis Construction, Inc. Tel No 408-593-4634 Address of Authorized Agent: 1450 Koll Circle, Suite 104, San Jose, CA 95112 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. A /f /J Property Owner's Signature: L, (/ka,-� t `AL-- Date: July 21st, 2014 avnerBuilderForm 2010.doc revised 04/14/10 CUPERTINO r-1 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(51cupertino.org 1 I • F-1 -ITCTnXT /TlU=VDr7n V k J nVU-TNT A T PFP XATT R I:J i 3 o PROJECT ADDRESS �1 � 9 CC— /� [ 0 CIS,1^ _ � ` 17�I _ APN # OWNER NAME ^ PHONE��� / Q E n �`. CA A L (/ ( 1 K X W4 STREET ADDRESS D CITY, ATE, Z t r ^� _ / ! F• X CONTACT NAME T �� PH[#Ry, 3gO E "� 7/� PJI /' �7Gt •' �9'� STREET ADDRESS } �) / (� (` w l (/ T❑� TATE, ZIP r w /� /y X ' O FAX UUARCHITECT Ott`i�NER-BUILDER OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTORAGENT•t� ❑ ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARC/ENGINEER NAME • /� _ xd LICENSE NUMBER c BUS. LIC # COMP;M E-MAIL3 aoll- FAX ST T ADDRESS �' 27 v DESCRIPTION OF WORK 1 co" /�/ r; a ou-r . ee/a 0 EXISTING USE PROPOSED USE CONSTIL TYPE 11 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 DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑TES BEING ADDED? []NO ADDITION? []NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES RECEI -:: TOTAL VALUATION: PLANNING ADPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOAIE? ❑ NO _ a � e folio 'ng: I roperty owner or authorized agent to act o the rty owner's behalf. I have read this By my signature below, I certify to ea/pd application and the information I haveed is ect I a e r e Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to bcon ction. thor ze pres�ntatives of Cupertino to enter the above- identified prop for inspection purposes. " Signature ofApplicanUAgent: Date: (� SUPPLEMENTA INFORMATION Q RED PLANCIIECKTITE „f ROUT`ING New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. I'ki S f 1pCI OVER THIICOL'I+TTER ����,� �"� ❑ ExrRss +t, �`���IJILDINGR ��_ V ER'a' `p> Gr �REw, . Commercial Bldgs: Provide a completed Hazardous Materials Disclosure C12 ARD z `""� ru>ai t o form if Hazardous Materials are being used as of this any part project. Copy of Planning Approval Letter or Meeting with Planning prior to T - _ submittal of Building Permit application.a LLI a r sENViItO]!7MENTAG'AEALTH-'+,...,. °' BldgApp_2011.doc revised 06/21/11 POW -_70, -, CITY OF CUPERTINO t OW-_ I FEE ESTIMATOR - BUILDING DIVISION r ADDRESS: 973 ROSE BLOSSOM DR DATE: 02/11/2014 REVIEWED BY: MELISSA i APN: 359 03 049 BP#: 13040175 'VALUATION: $0 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair_ PRIMARY SFD or Duplex p PME Plan Check: PENTAMATION 1 GENRES PERMIT TYPE: i USE: Permit Fee: $0.00 WORK REV # 1 - REVISE INTERIOR LAYOUT NO STRUCTURAL CHANGES SCOPE $0.00 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, SanitarySewer District, School TL < L ..,,a » OGS...al:...:.....,, Jnfnr satinn ouaitahia and ore anly an estimate. Contact the Dent for addn7 info. FEE ITEMS (Fee Resolution 11-053 Elf. 7.%1!13) r..,��. QTY/FEE Ina/, Li I Elec. Insp. Fee: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, SanitarySewer District, School TL < L ..,,a » OGS...al:...:.....,, Jnfnr satinn ouaitahia and ore anly an estimate. Contact the Dent for addn7 info. FEE ITEMS (Fee Resolution 11-053 Elf. 7.%1!13) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? Q Yes O No $0.00 F -7 - hours Plan Check, Hourly $139.00 ISTPLNCK A Suppl. PC Fee: C) Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee -.0 Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 T_T_ O Work Without Permit? Yes O No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential Building or Structure Q 7'rurt l Fa CS. Strong Motion Fee: $0.00 Select an Administrative Item BldgStds Commission Fee: $0.00 SUBTOTALS: $0.00 $139.00 TOTAL FEE: $139.00 Revised: 01/15/2014 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 873 ROSE BLOSSOM DR CONTRACTOR: DORIN RICHARD I AND PERMIT NO: 13040175 MAXINE H OWNER'S NAME: DORIN RICHARD I AND MAXINE H 2526 ELFEGO NW DATE ISSUED: 10/15/2013 OWNER'S PHONE: 5056814380 ALBEQUREQUE, NM 87107 PHONE NO: JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL ❑ LICENSED CONTRACTOR'S DECLARATION INTERIOR REMODEL OF RESIDENCE AND GARAGE (1764 License Class Lic. # SQ Date FT); REMOVE AND REPLACE ROOF STRUCTURE (1764 SQ Contractor 9 FI'); CONSTRUCT 410 SQ FT ADDITION WITH A 120 SQ Ft I hereby affirm that I am licensed under the provisions of Chapter (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 valuation: $300000 performance of the work for which this permit is issued.. Sq. Ft Floor Area: I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 35903049.00 Occupancy Type: Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITBIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter 180 DAYS CALLED INSPECTION. upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the Is Date: granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. RE -ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. IK 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' 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 defined by the Bay Area Air Quality Management District I Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sec ' s 2 5, ,and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent ' Date: permit is issued. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I I I hereby affirm that there is a construction lending agency for the performance of become subject to the Worker's Compensation provisions of the Labor Code, must work's for which this permit is issued (Sec. 3097, Civ C.) forthwith comply with such provisions or this permit shall be deemed revoked. 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 anplicant understands and will comply with all non-poin urce lati p e6upertino Municipal Code, Section Licensed Professional 9.18. Date Signature C*1UrjA_iU=0 CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Tune Avenue Cupertino, CA 95014-3255 Telephone: 405-777-32211 Fax: 408-777-3333 *Our municipal code requires all businesses working in the cite to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR ANT) ALL SU1)CON TRACTORS 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 tf Cabinets & Millwork Cement Finishing Electrical' - Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Grazing Heating Insulation Landscaping j Lathing Masonty Painting / Wallpaper Paving Plastering ,Plumbing Roofing t +t`J } c t!�,I 't4vtcl-'e.1 Septic Tank v Street. Metal Sheet Rock ........ _. _ Tile .._....—...... _..__.._............ . ....... _........... __. _..._...... _...... _..... tractor Signature Date 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(alcupertino.ora 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 r)lCSSU�ns�i'� PEN� 5 _vI BP# f b v' 3 OWi 1(d 10W R` DESC IPTION OF,V K: on 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 - B der"er" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for h onstruction and are not hiring a licensed Contractor to assume this responsibility. . I 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. Q4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. P-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 co sidered an "employer" under state and federal law. C6. I understand if I am considered an "employer" under state and federal law, I must register with the state and al 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. 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. 'PI8. 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. Owner Builder FOrrr1 2010. doe revised 04/14110 /09. 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 con ractors. & 10.1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the parry legally and financially responsible for proposed construction activity at the site address listed above. IV, 1. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by II pplicable laws and requirements that govern Owner -Builders as well as employers. . I agree to notify the issuer of this form immediately of an additions, deletions, or changes to an of the Y 9 Y 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 for issuing the 2ermit. Note: A copy of the property owner's driver's license, form notarization, or other verification accept a to cit e required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: G" --------------------------------------------------------------------------------------------------------------------------------------------- (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: Ox,neiBuilderFonn 2010.doc revised 04/14110 a -N ]EE FOR RECORDING PURSUANT TO GOVERNMENT CODE SECTION 27383 zj745904 Regina Abcomendras Santa Clara County Clerk -Recorder 09/06/2017 01x52 PM New Mexico Notaria'l Certificates r. CALIFORNIA ALL- PURPOSE CERTIFICATE OF ACKNOWLEDGMENT1 A notary public or other officer completing this certificate verifies onlythe identity of the individual who signed the document to which this certificate is: attached, and not the truthfulness, accuracy, or validity of that document. State of California County of On a. t before me, (Here insert name anq title of the officer) personally appeared: �­ who proved to me, on the basis of satisfactory eviAnce'to- be the person(s) whose name(s) isfare subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies),:and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s)- acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. AIJUITIONAL OPTIONAL INFORMAT101 DESCRIPTION OF THE ATTACHED DE4T! ,OCUM MCA 1' 44-1 (Title or descrl$tion bf attached document) h 14 �3 GI! —0«s I (Title or description of attached document continued) Number of Pages Document Date INSTRUCTIONS Ut-NI) CA_DT UrPTNT OIVG THIS FORINT This form complies with current California statutes regarding hotarwording and, if needed, should be completed and attached to the'document. , Acknowledgments from other states may be completed for docu,nients.lbeinz sent to that state so long as the wording does not require the California notary to violate -California notary law. ® State and County information must be the State and County where the document signer(s) personally appeared before the notary public for acknowledgment. ® Date of notarization must be the date that the signer(s) personally appeared which must also be the same date the acknowledgment is completed. ® The notary public must print his or her name as it appears within his or her commission followed by a comma and then your title (notary public). ® Print the name(s) of document signer(s) who personally appear at the time of notarization CAPACITY CLAIMED BY THE SIGNER e Indicate the correct singular or plural forms by crossing off incorrect forms (i.e. * Individual (S) he/sheMiey—, is /,ffe ) or circling the correct forms. Failure to correctly indicate this El Corporate Officer information may lead to rejection of document recording. e The notary seal impression must be clear and photographically reproducible. hupression must not cover text or lines. If seal finpressiou, smudges, re -seal if a (Title) sufficient area permits, otherwise complete a different acknowledgment form. El Partner(s) Signature of the notary public must match the signature on file 'with the office of 0 ttorne Attorney -in -Fact y the county clerk. Additional information is not required but could help to ensure this F1 Trustee(s) acknowledgment is not misused or attached to a different document. Other Indicate title or type of attached document, number of pages and date. Indicate the capacity claimed by the signer. If the claimed capacity is a J:00-873-9865 corporate officer, indicate the title (i.e. CEO, CFO, Secretary). Cly 2015 V�arsion www.NotaryCls3csxw,� Securely attach this document to the signed document with a staple.