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11090078CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19969 PEAR TREE CT O` 3'S NAME: GIESE RICHARD A AND GERALYN C OWNER'S PHONE: 4083166912 LICENSED CONTRACTOR'S DECLARATION License Class Lie.# 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. CONTRACTOR: GIESE RICHARD A AND PERMIT NO: 11090078 GERALYN C 19969 PEAR TREE CT DATE ISSUED: 10/11/2011 CUPERTINO, CA 95014-2318 PHONE NO: BUILDING PERMIT INFO: BLDG F ELECT F PLUMB MECH F_ RESIDENTIAL I— COMMERCIAL JOB DESCRIPTION: ADDITION TO SFDWL 312 SQ FT TO KITCHEN, SUNROOM REMODEL 266 SQ FT TO KITCHEN/ DINING ROOM 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. 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 Sq. Ft Floor Area: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county 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, costs, and expenses which may accrue against said City in consequence of the 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. Si re Date VOWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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. 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 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 become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that 1 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' 'ding construction, and hereby authorize representatives of this city to enter u e 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 granting of this permit. Additionalln the applicant understands and will comply with all non -poi ur ul S per the Cupertino Municipal Code, Section 9 18 APN Number: 31630086.00 Valuation: $50000 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAS ALLED INSPECTION. Issued by: Date: ld '1 �J1 RE -ROOFS: 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. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I us uipment or devices which emit hazardous air contaminants . efin by a Bay Area Air Quality Management District I will maintain co plian wit Cupertino Municipal Code, Chapter 9.12 and the H alth S fety C de, S o s 25505, 25533, and 25534. l O' err�th, d g tom✓ Date: CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Signature AZ1_ l.� Date ` ` Licensed Professional CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS. 19969 PEAR TREE CT CONTRACTOR: GIESE RICHARD A AND PERMIT NO: 11090078 GERALYN C OWNER'S NAME: GIESE RICHARD A AND GERALYN C 19969 PEAR TREE CT DATE ISSUED: 10111/2011 OWNER'S PHONE. 4083166912 CUPERTINO, CA 95014-2318 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG i ELECT r PLUMB r License Class Lie. # MECH RESIDENTIAL COMMERCIAL Contractor Date 1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ADDITION TO SFDWL 312 SQ FT TO KITCHEN, SUNROOM (commencing with Section 7006) of Division 3 of the Business & Professions REMODEL 266 5Q FT TO KITCHEN/ DINING 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: 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. 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 permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. 1 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, costs, and expenses which may accrue against said City in consequence of the 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. Signature Date OWNER -BUILDER DECLARATION ereby affirm that 1 am exempt from the Contractor's License Law for one of the following two reasons: 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 (See.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (See.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three dcclarafions: 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. 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 permit is issued. 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, alter making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county 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, costs, and expenses which may accrue against said City in consequence of the granting of this permit. AdditionalbM the applicant understands and will comply with all non -pow �Qur ul per the Cupertino Municipal Code, ection 9.18. / 1 �� 1 1 e Sq. Ft Floor Arca: I Valuation: $50000 APN Number: 31630086.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAS ALLED INSPECTION. Issued by: Date: RE -ROOFS: 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. Signature of Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(x) should I store or handle hazardous material. Additionally, should I us uipment or devices which emit hazardous air contaminants efin y e Bay Area Air Quality Management District I will maintain co pli nc wit t Cupertino Municipal Code, Chapter 9.I2 and the H alth S f. de, S iq "s25505,25533, and 25534. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION 1 understand my plans shall be used as public records. Licensed Professional CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - building acupeitino.org Oq DO -7 g' Izi.-jnZa [:]NEW CONSTRUCTION ® ADDITION ❑ ALTERATION / Tl ❑ REVISION /DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS 1 \-1,. 1 APN E-SVa G PHONP 1 / 7E -MAIL ^�j^^ j �n e /t _ U STREET ADDRESS 10M, qau CITY. STATE• ZIP(],y a FAX CONTACT NAME PHONE, SDW- 45%5_08 E-MAIL debvC,�e.61ueJ1V1v5c e,51 STRSFrADDRESS =,STATE,tM CAQ400Z FAX 12TR OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT ❑ CONACTOR 11CONTmcroP AGEENT B<1 1TECT 0 ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME r LICENSE NUMHIIt LICENSE TYPE BUS. CIC # COMPANY NAME E-MAIL FAX STREET ADDRESS I=, STATE, ZIP PHONE ARCHIiECT/FNGINEER N LICENSENUMBER BUS. LIC # cOMPANY NAME i . - 2V ., L..O �1 E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRJPTI N OF P.o �S s ►4, I v N IGH J" 4 P-201'( E=TIJGUSE PROPOSED USE CONSTRTYPE #STORIES USE TYPE OCC, SQ -FT. VALUATION (5) RErG A AREA `; ?7'Z) NEW FLOO2R AREA '/ `Z DEMO AREA TOTAL NET AREA f� fil -� �_ BATHROOM REMODELAREA KITCHEN REMODELAREA OTHER REMODELAREA PORCHAREA DECK AREA TOTAL DECKIPORCHAREA GARAGE AREA: LJ DETACH ❑ATTACH 4DWELLING Ut4TS: ISA SECOND UNIT ❑YES SECOA'DSTORY ❑YES 1 BEING ADDED? 5RI40 ADDITION? 5NO PRE -APPLICATION ❑YES IF YES, PROVIDE COPY OF IS THE BLDG AN ©YES RECEIVED BY: TOTAL VALUATION: PLANNINGAPPL# [:IND PLANNING APPROVAL LETTER EICHLERHOME? E@NO //I� ^11 I By my signature below, I certify to each of the folio g I am the property owner or authorized agent to act on the pretty owner's behalf. I have read thss application and the information I have provided is ct, 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 co ction. I a orim mentatives of Cupertino to enter the above -identified property for inspection pufposcs, Signature of Applicant/Agent Date: .6 20 SUPPLEMENTAL INFORMATION REQ D PLAN CHECK TYPE ROUTING SLIP ❑ ovER-THF-COUNTERBU'C uam GniGni PLAN REVIEw _ New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. L7 EXPRF.ss L PLAINING PLAN REVIEW _ Commercial BIdgs: Provide a completed Hazardous Materials Disclosure El STANDARD El KS PUBLic woR form if any Hazardous Materials are being used as part of this project. ❑ LARGB dIEPT _ Copy ofPlanning Approval Letter or Meeting with Planning prior to C1r� tWOR E.- J.11NARYSEWER DISTRICT submittal of Building Permit application. ❑ ENV1RONMENTA L HEALTH B1dgApp_2011.d6c revised 06121111 Vt. -0M CITY OF CUPERTINO I �f1 FEE ESTIMATOR -- BUILDING DIVISION imADDRESS: 19969 pear tree ct. DATE: 09/0812011 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$50,000 *PERMIT TYPE: Building Permit 312 PLAN CHECK TYPE: Addition $1,205.00 PRIMARY SFD or Du lex USE: P '4'eo. In%p. Fc- e: 2nd Unit? Yes • No OTC? 0 Yes (DNo PENTAMATION PERMIT TYPE: 1 R3SFDADD WORK 1st story kitchen and sunroom addition of 312 sf, remodel exisiting kitchen and dining area of 266 sf. SCOPE 1 hrs $0.00 OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA 01). PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) II-B,III-B,IV,V-B 312 $1,482.00 TADDPLCK $1,205.00 IADDINSP '4'eo. In%p. Fc- e: $0.00 Permit Fee: $1,205.00 Suppl. Insp, Feet Reg. 0 OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 312 $1,482.00 $1,205.00 MECH, HOURLY 0 Yes O No PLUMB, HOURLY 0 Yes Q No ELEC, HOURLY 0 Yes Q No ;tfe, h. Nan, Choc;; P!luuFr. Plan ("heck Fier. "tall Chw14 i,fe h. Perra,aVvic. Plumb. PernurFrce: De,:. Pern:irFee: (71Acr,!•fe, !r. Ir�sr,. c?.r;rc,• Pi:�,rr1, l,rrp, f)°;tt'r Ii1Es: krsn, le Ir_ I'n I). PeL': Mundy. 107sp, t'i'c': '4'eo. In%p. Fc- e: NOTE: This estimate does not include fees due to other Depts (i. e. Public ;forks, ,Sanitary ,Server District, ,School District, etc.). These fees are based on the nrelitninary information available and are only an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee Resohrtion 11-053 Eff 7/I/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: $1,482.00 266 S.f. $392.00 Remodel, Other IREMRESOTH Suppl. PC Fee: G) Reg. 0 OT 0.0 1 hrs $0.00 PME Plan Check; $0.00 Permit Fee: $1,205.00 Suppl. Insp, Feet Reg. 0 OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 (, oustructi(nr Irrx7_7 A(Inlinlslralive Fee: 0 G) Work Without Permit? 0 Yes (D No $0.00 Advanced Planning Fee: PLLONGRNGR $40.56 Select a Non -Residential Building or Structure G) 0 7-tfvel Durxmeniation F -'.e5•: Strom. Motion Fee: IBSEISMICR $5.00 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $2.00 SUBTOTALS: $2,734.56 $392.00 TOTAL FEE: 1 $3,126.56 Revised: 09102/2011 Building Depat-tment City OCCupertino 10300 Torre Avenue Cupertino, CA 05014-3255 Telephone: 408-777-3228 DUPE RTI N O Fax: 408-777-3333 CONTRACTOR 1 SUBCONTRACTOR LIST JOB ADDRESS: l q J{Q_jtATQrt C7t` -- PERMI"I# t t090026 OWNER'S NAME: i C5t= _ PHONE # _j---�gr �i��o_ 6q(,- GENERALCONTRACTOR- ADDRESS: I Rrp R:srtc .-e.,V BUSINESS LICENSE # C'1TY17fPCO17E: �V L *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) NVILL BE SC:III;DULED UNTIL TIE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE. OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. 1 am not using any subcontractors: --- -- --- Signature Date Please cheek applicable subcontractos-s and complete the following information: ✓ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Ccmcrnt 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 I Contractor Signature, Date >www.baggengineers.com B.VGG > info@baggengineers.com > phone: 650.852.9133 0-fax:650.852.9138 ®� ENG® > 847 West Maude Avenue, Sunnyvale, California 94085-2911 City of:, Cupertino, CA. Project Name: Giese Residence - Residential Addition Address: 19969 Pear Tree Court Date/Day: March 9, 2012 (Friday) Project Number: GIESE-12-01 Permit No: 11090078 Inspection Coverage ❑ Concrete ❑ Masonry ❑ Welding—Shop Foe- Continuous E]Pre-stressed Concrete ❑ High Strength Bolting ❑ Welding—field Periodic G Reinforcing Steel 0 Epoxy Bolts/Dowels ❑ Torque test Describe inspections made, include locations: I visited the subject Project and observed the placement and epoxy (Simpson Set XP with expiration 4/30/2013) of two (2) 5/8" dia. ail -thread (AT) bolts (with minimum 12" embedment) for two (2) HDU4's per the Project's CONSTRUCTION DOCUMENTS, detail #8 (Foundation Holdown Bolts) and Note 448 (Connections to Foundation - Tiedowns); both drilled holes for the aforementioned (2) AT bolts were debris evacuated prior to AT installation. Tests made: NA Items requiring corrections, corrections of previously listed items, and previously uncorrected items: NA Comments: To the best of my knowledge, work inspected was in accordance with the building department approved design drawing, specifications, and applicable workmanship provision of the California Building Code except as listed above. The Work Inspected • WAS ❑ WAS NOT In accordance with the approved documents (see above) Signature of Special Inspector Louis C. Smith Print Name ACI# 00093077 Certification No# (This report to remain at lobslte with the contractor for review by the Building Deportment's Inspector upon request.) CUPERTINO OWNER -BUILDER NOTICE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 • bulid 6g(c�cupert! no.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 pulling your permit! The term "Owner -Builder" can mean three different things: "Owner as Worker", "Owner as Con&actor" or "Owner as Employer" Understand each has Benefits or Risk, and it is possible to combine them! Hiring a California Licensed Contraetor 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. BenefitMsk: Highest Benefits and the Least amount of Risk Owner -as -Worker is a type of Owner -Builder where you personally perform 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: ilt. i, ,,rcfiz with Low 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 Iicensed sub -contractors to perform portions of the construction work. WARNING: The benefit of protection provided by Iaw when you hire only California licensed sub -contractors can tum to serious financial risk if you hire unlicensed contractors to perform any of the work. BenefiMsk: 1'1-,1Ihlk iiL:;c;i 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 compensation insurance for each worker. Benefit/Risk: -P-1. ;; 3s . _ ' : with Significant Financial Risk Over 20,000 consumer complaints are filed each year. Many complaints relate to ownerlbuilder projects and include workmanship and workers' compensation issues Homeowners suffer financial harm due to defective workmanship and injured employees. Ou,nerBuilder 2010.doe revised 06108110 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 OvnerBuilder 2010.doc revised 04112110 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinclacugertino_orq 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 WS S r-- ' ��� APN 13P#�Q OWNE`C AAMC OWNER ADSS-QGUIiQ DESCRIPTION OF WORK: �/� D D� e, 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 (DIRE TIONS: 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- Buiideri building permit that erroneously implies that the property owner is providing his or her own labor and material personally. 1, 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 the onstruction 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 p otect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her e instead of my own. 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. V-2 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the to al value of my construction is at least five hundred dollars ($500), including labor and materials, I may be 0�6. an "employer" under state and federal law. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and eral 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 _pMo serious financial risk. Vsidential I understand under California Contractors' State License Law, an Owner -Builder who builds single-family 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 pe ormed under contract with a licensed general building Contractor. V8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for nynancial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerBuilderFonn 2010.doc revised 04114110 9. I understand 1 may obtain more information regarding my obligations as an "employer" from the Internal evenue 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.csib.ca.gov for more information about licensed contractors. V am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I rty 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, 1 will abide lqy�a 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 mation 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 drivers 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: -- ------------------------------------------------------------------------------------------------------------------------- ------------------ (NOTE: The foNowing 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, 1 hereby authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: Tel No declare under penalty of perjury that I am the property owner for the address listed above and 1 personally filled out the above information and certify its accuracy. Note: Ac of the property owner's drivers license, form notarization, or other verification acceptable to th may req ' ed b resented when the permit is issued to verify he property owners signature, ll Property Owner's Signature: Date: �0 L' OwnerBuilderForm 2010.doc revised 04114110