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10070190I CITY OF CUPERTINO BUILDING PERMIT I IBUILDING ADDRESS: 10625 JOHNSON AVE I CONTRACTOR: SKYLER CHANG & HUI I PERMIT NO: 10070190 OWNER'S NAME: SKYLER CHANG & HUI HUANG 10625 JOHNSON AVE I DATE ISSUED: 12/08/2010 I OWNER'S PHONE: 4087779333 1 CUPERTINO, CA 95014 1 PHONE NO: I ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor Date 1 hereby affirm that 1 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. 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. BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r' MECH __ RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: NEW SFDWL-2 STORY IST FLR(1505SQ)-2ND FLR(884.ISQ) GARAGE(461SQ);LANDSCAPE AREA(1975SQ) SANITARY IS SUNNYVALE'S JURISDICTION. Sq. Ft Floor Area: I Valuation: $300000 APN Number: 37527014.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Signature Date I Issued by: OWNER -BUILDER DECLARATION I hereby affirm first 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 Califomia. If, after making this certificate of exemption, become subject to the Worker's Compensation provisions of the Labor Code, 1 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. Additionally, the applicantunderstands and will comply with all non -point sou �g regulations per the Cupertino Municipal Code, Section 9.18. III _ /- 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 Applicant: 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. 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 1 use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner o �tagent : p Date: CONSTRUCTION LENDING AGENCY 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 understand my plans shall be used as public records. Licensed Professiona CITY OF CUPERTINO BUILDING PER1VLI.XTE 2:� BUILDING ADDRESS: 10625 JOHNSON AVE CONTRACTOR: SKYLER CHANG & HUI PERMIT NO: 10070190 HUANG OWNER'S NAME: SKYLER CHANG & HUI HUANG 10625 JOHNSON AVE DATE ISSUED: 12/08/2010 OWNER'S PHONE: 4087779333 CUPERTINO, CA 95014 PHONE NO: LICENSED CONTRACTOR'S DECLARATION License Class y Lic.# X Contractor bgt /' f-%^Aoyi Date 1 hereby affirm that 1 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. 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 whjphihis permit is issued. AM10 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. Signature Date (,/I/ I ❑ OWNER -BUILDER DECLARATION 1 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) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). 1 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. 1 have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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, 1 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. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r MECH I— RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: NEW SFDWL-2 STORY IST FLR(1505SQ)-2ND FLR(884.ISQ) GARAGE(461S%LANDSCAPE AREA(1975SQ) SANITARY IS SUNNYVALE'S JURISDICTION. _ fir dy n chi tk4ro,-6HZ 'Criss- 644 4 (sem' J. - Sq. Ft Floor Area: I Valuation: $300000 APN Number: 37527014.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Date:_��4 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 1 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 1 store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Ownelo ulhor' ant: �f Date:/ / // CONSTRUCTION LENDING AGENCY 1 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 I understand my plans shall be used as public records. Signature Date I Licensed Professional I CITY OF CUPERTINO BUILDING PERMIT I IBUILDING ADDRESS: 10625 JOHNSON AVE I CONTRACTOR: SKYLM CHANG & HUI HUANG I PERMIT NO: 10070190 I OWNER'S NAME: SKYLER CHANG & HUI HUANG NER'S PHONE: 4087779333 ❑ LICENSED CONTRACTOR'S DECLARATION License Class Lie. # Contractor Date 1 hereby affirm that 1 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. 1 hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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. 10625 JOHNSON AVE ! I DATE ISSUED: 12/08/2010 CUPERTINO, CA 95014 PHONE NO: BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r MECH RESIDENTIAL COMMERCIAL JOB DESCRIPTION: MEW SFDWL-2 STORY 1ST FLR(1505SQ)-2ND FLR(884.ISQ) GARAGE(461SQ);LANDSCPE AREA(1975SQ) SANITARY IS SUNNYVALE'S JURISDIC ION. Sq. Ft Floor Area: Valuation: $300000 APN Number: 37527014.00 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Signature Date I Issued by: OWNER -BUILDER DECLARATION V'bereby 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 (Sec. 7044, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). ):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. 1 have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 1 certify that in the performance of the work for which this permit is issued, l shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I 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 1 certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the ing of this permit. Additionally, the applicant understands and will comply all non -point souregulations per the Cupertino Municipal Code, Section 9.18. T_ / 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, 1 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 1 use !equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with! the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner o a t agent: 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 1 understand my plans shalfbe used as public records. Licensed Professional CITY OF CUPERTINO BUILDING PE 424& t I BUILDING ADDRESS: 10625 JOHNSON AVE vvIN-R'S NAME: SKYLER CHANG & HUI HUANG CONTRACTOR: SKYLER CHANG & HUII PERMIT NO: 10070190 HUANG 10625 JOHNSON AVE I DATE ISSUED: 12/08/2010 OWNER'S PHONE: 4087779333 I CUPERTINO, CA 95014 1 PHONE NO: I KLICENSED CONTRACTOR'S DECLARATION License Class Lic. # 931 62:31/ Contractor n/► P k/t.IM 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. 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 wh' h his 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. �ignati are Date ❑ OWNER -BUILDER DECLARATION I hereby affirm that I 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 (Sec.7044, Business & Professions Code) 1, 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 I have read this application and state that the above information is cr+**ect. I agree to comply with all city and county ordinances and state laws relating nue, ipon trding construction, and hereby authorize representatives of this city to enter die 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. BUILDING PERMIT INFO: BLDG r— ELECT r— PLUMB r MECH I— RESIDENTIAL F— COMMERCIAL F_ JOB DESCRIPTION: NEW SFDWL-2 STORY 1ST FLR(1505SQ)-2ND FLR(884.ISQ) GARAGE(461 SQ);LANDSCAPE AREA(1975SQ) SANITARY IS SUNNYVALE'S JURISDICTION. (b(� o pT Sq. Ft Floor Area: I Valuation: $300000 APN Number: 37527014.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued Date: � Z—&r, b . 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. I 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 use equipment or devices which emit hazardous air contadnnants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owneo uthor'OML ` 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 Date I Licensed Professional CUPERTINO GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinq(aDcupertino.org ❑ PLUMBING ❑ MECHANICAL ELECTRICAL ❑ MISCELLANEOUS MEP PROJECT ADDRESS `O (.O- , J APN # s5 OWNERNAME� PHONE E-MAIL STREET ADDRESS _ CONTACT N ` C TE, ZIP FAX PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR 0 CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMB LICENSE TYPE BUS. LIC b COMPANY NAME i o E-MAIL r L FAX STREET ADDRES � two 2?� STATE7>� . �al� .n PHONE _ - G. ARCHmcCr/ENwEER NAME ` ,�•► LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE 'SE OF SFD or Duplex ❑ Multi -Family STRUCTURE: ❑ Commercial PROJECT IN WILDLAND URBAN INTERFACE AREA Cl Yes ❑ No PROJECTIN FLOOD ZONE ❑ Yes ❑ No DESCRIPTION OF WORK c kn aa TOTAL VALUATION: r�./�O REQEgB 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 T h2ve read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relati g to building construction. I thorize representativ o to enter the above-identifiedpro erty for inspection purposes. Signature of Applicant/Agent:(OD Date: 1 t SUP MENTAL INF TION ROQUUMES 4 ism � ...:�-��„� MEPMiscRpp_2011.doc revised 03/16/11 CITY OF CUPERTINO rw-_-"7 FEE ESTIMATOR - BUILDING DIVISION APPLIANCE / EQUIP TYPE ADDRESS: 10635 johnson ave. DATE: 05/04/2011 REVIEWED BY: bobs. UNITS APN: I BP#: 'VALUATION: $900 Y'PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex USE: # PENTAMATION 1 REAP8 I PERMIT TYPE: WORK add new 40 amp circuit for charging dock station at garage local SCOPE APPLIANCE / EQUIP TYPE FEE ID QTY/FEE QTY UNITS BP FEES Other Power Devices 1BREMPOWER 1 # $158 PME Unit Fee: $158.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes E) No $0.00 TOTALS: Travel Documentation Fee: I TRA VDOC $158.00 Strong Motion Fee: IBSEISA11CR h—d — ihn n,alrms"nri7 ;"fnrmidnPv asyjWahlo and tyro nm1ty an octimato Cnntad-t tho Dont fnr addnl info. FEE ITEMS (Fee Reso tion 09-051 L—ff. 0 FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $158.00 PME Permit Fee: $42.00 Work Without Permit? 0 Yes E) No $0.00 Travel Documentation Fee: I TRA VDOC $42.00 Strong Motion Fee: IBSEISA11CR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $243.50 $0.001 TOTAL FEE: $243.50 Revised: 04/29/2011 e C:v, CL vk r'1 9, !� O C /06 . ef0� A/ O they Qha ��FAq h tamp ��th rastr�AGzb/ 9T 9�M 0"a0 0/0,110 01, 6y YAr°G/ ° this gyp1110 S% /IS, pF U 9 F �� p O /!s °f 1106 a�jq 7j t , °r (�/ �e Q' 9 s h9 t° 'fit ly ayC a�a po°ii; B4ii a e atth �ty0/' l°�aati0, a,�9 ats aay a °rS k°/Zti �4 OT . a J013 Cor)x/' THIS PLAN SHALL THE JOB REMAIN O � cl- AT ALL TIMES DURI CONSTRUCTION TD 'En C o- _ �\ e c. -� i cz \ Co r -\--<-r C" C- ,n o 'zy-) C_ CCD C c1c� 4© AY n C i Y-'c.�i A -o Gr cx-c o-t)e c (E:)� 2�- ,� p t 0 C C Intelligent EV solutions bink Federal Communications Commission (FCC) Statement NOTE: This equipment has been tested and found to comply with the limits for a Class B digital device, pursuant to Part 15 of the FCC Rules. These limits are designed to provide reasonable protection against harmful interference in a residential installation. This equipment generates, uses and can radiate radio frequency energy, and if not installed and used in accordance with these instructions, may cause harmful interference to radio communications. If this equipment does cause harmful interference to radio or television reception, which can be determined by turning the equipment off and on, the user is encouraged to try to correct the interference by one or more of the following measures: • Reorient or relocate the antenna. • Increase the separation between the equipment and the receiver. • Connect the equipment to an outlet on a circuit different from that to which the receiver is connected. • Consult the dealer or an experienced radio/TV technician for help. This device complies with Part 15 of the FCC Rules. Operation is subject to the following conditions: 1. This device may not cause harmful interference, and 2. This device must accept any interference received, including interference that may cause undesired operation. IM0001 t2 R WMv1.1 5 Intelligent EV solutions Guidelines and specifications bink This Installation Manual describes how to properly install Blink Model WE-30C/K and WE-48C/K Electric Vehicle Supply Equipment (EVSE), referred to as the "charger" throughout this document. Applicable codes and standards The installer or contractor is responsible for obtaining and becoming familiar with the following publications. Installer or contractor work and materials shall comply with the local municipality's currently adopted versions of: • National Electric Code • Municipal, county and state building codes and standards • Occupational Safety and Health Administration (OSHA) • Uniform Building Code • Other relevant codes and standards that apply to the installation of structural components and electrical equipment Installer/contractor notes The installer or contractor selected to install the blink Model WE-30C/K and WE-48C/K chargers, including electrical connections, shall conform to the following general notes: • Installation shall be performed as described in the electrical plans and approved drawings. • All work shall comply with the latest adopted edition of the National Electric Code and Building Code. • Labor and materials not specifically described, which are incidental to installations and without which a satisfactory job cannot reasonably be completed, are a part of this installation work. • All materials used in the installation shall be new and UL listed and labeled where required. • The installation of AC power circuits and circuit disconnects are not included in this work. Such work must be performed by a certified electrical contractor. • It shall be the installer's or contractor's responsibility to carefully read this entire guide and associated drawings and sketches to determine his/her responsibilities. Failure to do so shall not release the installer or contractor from doing the work in complete accordance with this document. IM0001 L2 R WMv 1.1 6 Intelligent EV solutions bink • During performance of the work and after all requirements of this installation manual and associated details are fully completed, ECOtality NA and/or the customer shall have the option to inspect the work. • The installer or contractor shall not modify or otherwise alter charging equipment other than specifically authorized by these installation instructions. Unauthorized modification to the charging equipment will void the manufacturer's warranty. Customer responsibility The customer is responsible for contracting with a certified electrical contractor to perform all electrical work, including connections at the charger, supply circuit and main service panel. Tools required for installation Meters • Current Clamp Meter (with 600 A MAX AC/DC) (Recommend: Fluke° 336) • Digital Multimeter (1000V MAX DC/AC) (Recommend: Fluke° 87V) Hand tools • Drill bit, 3/16 inch • Hammer • Pencil/marker • Slotted and TORX°-head screwdrivers • Wrench, 10 mm • Torque wrench (reference) Installer -supplied items • Service wiring to charger • Conduit and fittings (1 -inch trade size), except for cord -connected units Charger features and specifications Features • Charge circuit interruption device (CCID20) • Ground monitoring circuit • Nuisance -tripping avoidance and auto re -closure • Cold load pickup (randomized auto -restart following power outage) • Certified energy and demand metering IM0001 L2 R WMv1.1 7 Intelligent EV solutions • Wireless IEEE 802.119 • LAN capable • Web -based bi-directional data flow bink • Cord management system • Power cord for connection to NEMA 6-50R receptacle (WE -30K and WE -48K only) Specifications Model WE-30C/K WE-48C/K Input Voltage 208-240 VAC +/-10% (120 VAC to GND) Input Phase Single (3 -wire) Frequency 60 Hz Input Current 30 Amps (maximum); configurable to 12A, 16A, or 24A 48 Amps (maximum); configurable to 12A, 16A, 24A, or 30A Breaker Size 40 Amps; Available settings: 15A, 20A, 30A, or 40A 48 Amps; Available settings: 15A, 20A, 30A, 40A, or 60A Output Voltage 208-240 VAC +/-10% Output Phase Single Pilot SAE J 1772TM compliant Connector/Cable SAE J 1 772T compliant; UL -rated at 30A maximum Cord Length (output) 18 feet (approximate) Cord Length (input) 1 foot (WE -30K and WE -48K only) Exterior Dimensions Charger assembly: 18" wide x 22" high x 5-9/16" deep Cord reel: 18" diameter Temperature Rating -22 °F (-30 °C) to +122 °F (+50 °C) Enclosure NEMA type 3R sun- and heat -resistant Mounting Wall mount IM0001 L2 R WMv 1.1 8 Intelligent EV solutions Charger layout bink The charger assembly should be mounted on the wall in close proximity to the vehicle stall and at a location where the 18 -foot charger cord can be easily connected to the vehicle charging port without the cord stretching taut or presenting a trip hazard. The charger assembly must be mounted at a height (minimum 18 inches [460 mm] above floor) where the panel display can be easily seen and monitored by the operator. A height of 60 inches (152 cm) to the center of the display is suggested. The cord reel can be mounted below or in another location near the charger assembly that best accommodates the user's preferences and comfort. The charger assembly and cord reel may be installed on adjacent walls (corner mounted). For cord -connected chargers (models WE -30K and WE -48K), there must be sufficient space allowed between the charger assembly and mounting of the cord reel for installation of the 6-50R receptacle. A WARNING: RISK OF FIRE This equipment has arcing or sparking parts that must not be exposed to flammable vapors. This equipment must be located at least 18 inches (460 mm) above the floor. Figure 1 — Charger Instaiiations, iypicai IM0001 _L2_R_WMvl .1 9 Intelligent EV solutions Installation bink WARNING: RISK OF FIRE To reduce the risk of fire, install charger on a wall constructed of a material resistant to combustion such as plasterboard (drywall) over studs, 16 inches on center. The charger kit supports installation of the charger assembly over a wood -framed wall (studs on 16 -inch centers) with or without plasterboard (drywall) covering. If the assembly is to be installed on a brick or concrete wall, anchors (not supplied) of an appropriate size suitable for the 1 /fl- inch lag screws and wall material must be used. WARNING: Suitable wall anchors (not supplied) for brick or concrete walls must withstand a pull-out force of 80 Ib (36 kg) per anchor, without damaging the wall mounting. Shipping box contents 1. Cord reel A. Charger housing assembly (with 18 -foot 2. Cord reel cover charger cord) 3. Cord reel cleat 5. Hardware packet Figure 2 — Shipping Box Contents IM0001 L2 R WMv 1.1 10 Intelligent EV solutions Charger housing assembly and cord reel bink Figure 4 — Charger Housing Assembly and Cord Reel Item # Part Number Description 10ty 1 11-357-0277 Torx-head screw (T30) 2 2 20-030-0001 Bezel 1 3 11-356-0273 M6 x 20 hex -head bolt 8 4 20-180-0001 Charger housing cover 1 5 11-031-0564 1/4 -inch lag screw 8 6 11-452-0163 1/4 -inch washer 8 7 20-180-0001 Charger unit and base 1 IM0001 L2 R WMv 1.1 12 Intelligent EV solutions I I IE ---WALL STUDS I 1 Figure 5 — Charger Assembly Installation bink 6. Using the housing assembly as a template, mark the centers of the four mounting holes and remove the housing assembly from the wall. IM0001 L2 R WMv 1.1 14 a a MARK HOLES (4 LOCATIONS) 22" a a 64" TO FLOOR RECOMMENDED I I NEMA 6-50R I 1 I MOUNTED IN A I 0 5S DEEP BOX I _ _ o (METAL ONLY), CENTERED ON I I STUD I Figure 5 — Charger Assembly Installation bink 6. Using the housing assembly as a template, mark the centers of the four mounting holes and remove the housing assembly from the wall. IM0001 L2 R WMv 1.1 14 = - CITY OF o 1! o CITY OF CUPERTINO NEW SINGLE/MULTI FAMILY DWELLING CUPERTINO PERMIT APPLICATION FORM APN# 1-) _0/ � Date: Are you adding a 2" unit? Yes ❑ No If yes, You also need to fill out the permit application for a 2nd unit. Building Address: )l Mailing Address (if different from building address): Owner's Name- Phone#: �WL9-K n/e-- 9�- `ll Do you have the pl nning Residential Design Review/Minor Residential Permit approval? Yes o❑ If yes, please provide a copy of your planning approval letter. Planners Name.-1`c-c_ . If no, see Planning before submitting plans to the Building Department. Have you applied for the demolition permit? Yes ❑ No Applicant Signatur a of Demo If no,pick up application and procedures. Requirements): Contractor: Phone#: Fax#: Cupertino Business License#: State Contractor License #: Contact: S' o - _ 3 90 Phone #: 1 / Fax#: o _ Landscape Or finance Compliance: Landscape area in sq.ft. (includes all irrigated areas): `7 Q- If 2,500 sq. ft. or less, compliance with the Landscape Water-Efficiency Checklist is required. If more than 2,500 sq.ft.,a complete Landscape Project Submittal is required. Compliance Method: ❑ Plant T ❑ Water Budget Single-Story ❑ Two-Story Three-Story ❑ Basement Hillside ❑ Multi-family ❑ Apartment ❑ Condo ❑ Townhouse ❑ Sq.Ft. Living Area-Including Basement & Attached Garage: Sq. Ft. Garage (Detached Only): Living area: �f�� j �,(��f: l S'c Basement: J Attached Garage: G� Total Sq. Ft: Job Description: Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ IUIIUV-A ❑ II/III B, IV-HT, V-B Valuation: Project Size: Standard V/ Large E] Major❑ Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set& the sheet index. Green Building Points Achieved: For help, contact Build it Green at m m-w.builditareen.ora Revised 05/18/10 CITY OF syr. Is CITY OF CUPERTINO NEW SINGLE/MULTI FAMILY DWELLING CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group Permit Type 1RIINSP Apt Bldg inspection fee B 1R1APT lR1PLNCK Apt Bldg plan check fee B 1RIREINSP Apt Bldg repeat unit B 1RIAPTR Inspection fee l R 1 REPLNCK Apt Bldg repeat unit plan B check fee lR3INSP Dwellings Inspection B 1R3SFDW lR3PLNCK Dwellings Plan Check B 1R3REPINSP Dwellings Repeat B 1R3SFDR Ins ection lR3REPPLNC Dwellings Repeat Plan B Check 1R3HINSP Dwellings Hillside B 1R3HILL Ins ection lR3HPLNCK Dwellings Hillside Plan B Check lR3HREINSP Dwellings Hillside B Repeat Ins ection lR3HREPLNC Dwelling Hillside Repeat B Plan Check lR3ALTINSP Dwellings Alternate B 1R3SFDALT Materials 1R3ALTPLNCK Dwellings Alternate B Materials 1GARDTW<=lK Detached Garage Wood B 1 GARDTM<=l K Detached Garage B Masonry 1BCONSTAXR ConstaxResi/Mobile B 113MITIGATR Residential Housing PL Mitigation Fee-chrg only if lot is vacant or it is a subdivision-see planning 2 of 3 CITY OF CITY OF CUPERTINO NEW SINGLE/MULTI FAMILY DWELLING CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group Permit Type "1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1BSEISMICR Seismic Residential B 1PLLONGRNGR Long Range PL Planning/Residential 1BPWSVCS Main Water Service P 1BSWIM Swimming Pool B 1PCESS For Ea.Cesspool P 1PATMOBF For Atmospheric Type P Vacuum Breaker- backflow not included in item 1 (1-5) (5+) 1PPRSEWG Ea. Private Sewage P Disposal System 1PRSEWER For ea building sewer, P sanitary sewer, & ea trailer ark sewer 1BPSPRINK For ea. Lawn Sprinkler Sys P on any one mtr, incl. backflow protect device IEPERMITFEE Electrical Permit Fee E 1MPERMITFEE Mechanical Permit Fee M 1PPERMITFEE Plumbing Permit Fee P 1BUSLIC Business License B 3of3 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: DATE: REVIEWED BY: APN: BP#: "VALUATION: $300,000 RPERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY APPLICATIONor Duplex APPLICATION 1R3SFDW USE: TYPE: xW as 00 3 � OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. s .ft. R-3(Custom) II-B,III-B,IV,V-B 2,850 $2,695.96 1R3PLNCK $2,623.64 1R3INSP TOTALS: 2,850 $2,695.96 $2,623.64 F771 NOTE: Thesefees are based on the preliminary into rmation available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS (lee Resolution 09-051 1,,'/f7,,J,,`09 FEE QTY/FEE MISC ITEMS Plan Check Fee: $2,695.96 Select a Misc Bldg/Structure Suppl.PC Fee: (F) Reg. 0 OT0.0 hrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: $2,623.64 Suppl. Insp.Feer Reg. 0 OT0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Constr.Tax: IBCONSTAXR 1 bI#d2s $558.42 Acoustical Fee: 0 Yes Q No $0.00 Q Work Without Permit? () Yes (F) No $0.00 0 Planning Fee: PLLONGRNGR $370.50 Select a Non-Residential Building or Structure Strom r Motion Fee: IBSEISMICR $30.00 Select an Administrative Item Bld(, Stds Commission Fee: 1BCBSC $12.00 SUBTOTALS: $6,290.52 $0.00 TOTAL FEE: $6,290.52 Revised: 7/27/2010 Building Department City Of Cupertino LM 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/SUBCONTRACTOR LIST JOB ADDRESS: ✓1fOei PERMIT# / 00­70 / (? 0 OWNER'S NAME: PHONE# GENERAL CONTRACTOR: BUSINESS LICENSE # ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY 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 Ow ontractor Signature Date UTILITY RELEASE REQUEST FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL CUPERTINO 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228•FAX(408)777-3333•buildinoCa.cupertino.org PURPOSE For residential single family or duplex construction, there are cases where gas and electric utilities are requested to be released prior to the issuance of the certificate of occupancy. Upon approval from the building inspector,the City of Cupertino is allowing both utilities to be released prior to the final sign-off of the building. INSTRUCTIONS 1. Download this form at: http://www.cupertino.org/index.aspx?page=297. 2. Complete the form and obtain signatures from both the owner of the property and the primary contractor. 3. Fax, E-Mail, Mail or hand deliver the original signed form to: City of Cupertino Building Division Attn: Utility Release Request Form 408-777-3228 office 10300 Torre Ave. 408-777-3333 fax Cupertino,CA 95014 building-(cr�,cupertino.org 4. Schedule a Gas Meter Release inspection(#403) and/or Electric Meter Release inspection (#404). Please note, a Gas Test inspection (#506) is required prior to or at the same time of the Gas Meter Release inspection. BUILDING INFORMATION (Please complete the following information): APN BLDG PERMIT#: DATE: , SITE _ 1 ADDRESS: h" 6, J l%� ) L6 OWNER'S NAME: PHONE#- jt { -i � � : F MAILING ADDRESS(if differ#t from site address): (J CONTRACTOR: PHONE -7 i V) l 1 i�1�1`1 FAX#: — _ <1 CONTACT: PHONE* FAX#: request the City to release my utilities prior to obtaining a final inspection approval for the building. I fully understand the occupants of the building cannot move into the residence until they receive all of the required final sign-offs and the City has issued a certificate of occupancy for the b 'Idin . Owner:. ......: ...�...... ..-., ::........ .... .... .........................Print:.... Date:..../. . ..1. ..�.�.... Contractor:.....,. :::-.... .:'...........Print:... .......Date:J.. ,. .�.. .. .��.... UtilityReleaseForm_2011.doc revised 08/09/11 OWNER-BUILDER NOTICE COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333• buildirioacupertino.org 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 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 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: 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 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 unlicensed contractors to perform any of the work. Benefit/Risk: 2 c:-:`ii 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: ? 3 :i` 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. OwnerBuilder 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' understate 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 OwneBuilder 2010.doc 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-bulldinQ(a)cuoertino.org Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS APN BP# o ' -2 ' 31 1 J -� OW NA,E OWNER AD RESS 1_1 :> >`CJr162 Er 2 DESCRIP ION OF WORK: 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.) 96,1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Builder' building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. �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. ��. 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. L L-4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. �5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" understate and federal law. ,-'�6. 1 understand if I am considered an "employer' under state and federal law, I must register with the state and federal government,withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. � , I understand under California Contractors'State License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale,unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. ` $ 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. OwneJBuilderForm 2010.doc revised 04114110 L 9. 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.csib.ca.gov for more information about licensed contractors. �10. I 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. I 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. 02. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors'State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner-Builder and wish to hire Contractors,you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers'compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS:Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued,this form must be completed and signed by the property owner and returned to the agency responsible 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 signature. Property Owner's Signature: Date: --------------------------------------------------------------------------------------------------------------------------------------------- (NOTE: The following Authorization Form is required to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner-Builder). 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: 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: -, — y OwnerBuilderForm 2010.doc revised 04114110