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13050024
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7541 HEATHERWOOD DR CONTRACTOR: MANLEI CHIAO PERMIT NO: 13050024 OWNER'S NAME: MANLEI CHIAO 7541 HEATHERWOOD DR DATE ISSUED: 06/04/2013 OWNER'S PHONE: 4087357352 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL CONSTRUCT 185 SQFT ADDITION, 184 SQFT INTERIOR License Class Lic. # REMODEL, REROOF EXISTING WITH COMPOSITION(2118 Contractor Date SQFT) I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: 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 of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $25000 performance I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 35926055.00 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 WIT O DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter 180 DA F M LAST CALLED INSPE 'Y'ION. upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, City in consequence of the 2 l costs, and expenses which may accrue against said Issued by: 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: Signatur 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. 12( 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. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and performance I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505, 25533, and 25534. 3 r Section 3700 of the Labor Code, for theerformance of the work for which this p �— -- 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 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.) Lenders Name APPLICANT CERTIFICATION Lender's Address – I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional t -t W ` DateS Sign Signature CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7541 HEATHERWOOD DR CONTRACTOR: MANLEI CHIAO PERMIT NO: 13050024 OWNER'S NAME: MANLEI CHIAO 7541 HEATHERWOOD DR DATE ISSUED: 06/04/2013 OWNER'S PHONE: 4087357352 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class Lic. # CONSTRUCT 185 SQFT ADDITION, 184 SQFT INTERIOR REMODEL, REROOF EXISTING WITH COMPOSITION(2118 Contractor Date _ SQFT) I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions REVISION #1- MODIFY STRUCTURAL FOUNDATION- ISSD Code and that my license is in full force and effect. OTC 7/18/2013 I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the Sq. Ft Floor Area: Valuation: $25000 performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this APN Number: 35926055.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION�p00001— I certify that I have read this application and state that the above infoinat� i n is PERMIT E IRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and stale laws relating WITHIN DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purpokes. (We) agree to save 180 DA M LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the 7. granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code, Section 9.18. RE-ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. OWNER-BUILDER DECLARATION Signature of Applicant: Date: 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 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this the Health & Safety Code, Sections 25505, 25533, and 25534. L' lid. y -rte^l Owner or authorized agent: Date: permit is issued. — I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION costs, and expenses whichmay accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. p Signature �� Date CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildina,(a.cupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI Of REVISION /DEFERRED 13 os()azq ORIGINAL PERMIT #_ _ PROTECT ADDRESS f + � e 1 �G� 4 -p j- ` y l�\ APN # OWNER NAME \� PHONE / J 1_�) � 3 �j/ E-MAIL L� 71 STREET ADDRESS�� / CITY, STATE, ZIP � " �� - In FAX �� I CONTACT NAME Rn Iij (_f -t• `"� -a,'vc �/YL PHONE E-MAIL STREET ADDRESS -7 CITY, STATE, ZIP FAX 11:04'NER ❑ OWNER BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK Pao 6 t cel EXISTING USE PROPOSED USE CONST R- TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION ($) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECKAREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ ATTACH # DWELLINGUNrrS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEQdG ADDED? ❑NO ADDITION? ❑NO PRE -APPLICATION ❑ TES IFYES, PROVIDE COPY OF IS THE BLDG AN ❑ YES ` RW�p-TOTAL V ALUATION. -PLANNINGAPPL # ❑ NO PLANU'II4G APPROVAL LETTER EICHLER HOME? ❑ NO _ By my signature below, I certify to each of the following: I am the property owner or authori ent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building nstruction I authorize representatives of Cupe o to enter the above) -identified property for inspection purposes. , Signature of Applicant/Agent:]/ ' Date: ` SUPPLEMENTAL IINTFORM.ATION REQUIRED aNCI eKTYPE av iioi c-sNow&" ,r> k. New SFD or Multifamily dwellings: Apply for demolition permit for p F } Da N existing building(s). Demolition permit is required prior to issuance of buildirig' permit for new building. P g• OVER THECOLT�TER ggg-n—gif E � ❑xPIiESS BUII DIAG PLA . VIEWi - P�L"N=IN PI Fig Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STAiYD ❑ Pt7BLIcwoRKS _ form if Hazardous Materials being this E any are used as part of project. ZARGE u kr c FIRE DEBT + n 4e _ Copy of Planning Approval Letter or Meeting with Planning prior tof SANITARY SERER-DISTRICF submittal of Building Permit application. ©rQR, rf f Bldglpp_2011.doc revised 06/21/11 CUPERTINO ❑ NEW CONSTRUCTION CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISIO 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildingCa�cupertino.org ADDITION ❑ ALTERATION / TI ❑ REVISION/ DEFERRED GINAL PERMIT # PROJECT ADDRESS t4,1 APN # �� 5 c _ 7_6C, - O OWNER NAME V • (/I�v`�(l-p PHONE 4 u � (i�-/ �� E-MAIL STREET ADDRESS CITY, STATE, ZIP +/1 FAX CONTACT NAME J L� PHONE E-MAIL I V ( / l STREET ADDRESS CITY, STATE, ZIP FAX OWNER ❑ OWNER -BUILDER 11 OWNER AGENT 13 CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT 11 ENGINEER ❑ DEVELOPER 11 TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITEC NGIN E LICENSE NUMBER BUS. LIC # COMPANY NAME -, E-MAIL J`e i1ieCJ'i� L oGc>� 129 �� �. STREET ADDRESS 01� CITY, STATE, ZIP / T KrS ONJ p S �9- p � DESCRIPTION OF WORK _, Cea9t!_� EXIS G USE L i PROPO USE CONSTR. t/, i TYPE y/0 i' #STORIES USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG AREA /_/ NEW FLOOR AREA / DEMO AREA TOTAL NET AREA BATHROOM REMODEL AREA KITCHEN REMODEL AREA OTHER REMODEL AREA ! J PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: DETACH ❑ ATTACH # DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES BEING ADDED? ❑ NO ADDITION? ❑ NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YESRECEIVE BY: TOTAL VALUATION: PLANNING ADPL # 0 NO PLANNING APPROVAL LETTER EICHLER HOME. ❑ NO V 6� 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. 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 construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: 9 SUPPLEMENTAL INFORMATI10N REQUIRED PLAN CHECK TYPE ROUTING SLIP ❑ OVER-THE-COUNTER BUILDING 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. EXPRESS PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure �❑l i/y STANDARD El PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. /❑ LARGE ❑ FIRE DEPT _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_2011.doc revised 06/21/11 CITY OF CUPERTINO UIV-V V Q-rIM A TnR _ RI TIi .11ING niVISION OCCUPANCY TYPE:F11-B,111-BjV,V-B 7541 Heatherwood Dr. DATE: 05/03/2013 REVIEWED BY: Sean IlaADDRESS: APN: BP#:/ ,� v,� C�� 'VALUATION: 1$25,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY USE: SFD or Duplex 2nd Unit? Yes NoJPE�NTAMTAA�TIN OTC? © Yes ONo 1R3SFDADD WORK Construct 185 sq ft addition; 184 sq ft interior remodel; reroof existing with com osition 2118 sq ft). SCOPE 2,118 s.f. $330.00 OCCUPANCY TYPE:F11-B,111-BjV,V-B OF STR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) F.lec. Permit l a c 185 $1,014.00 IADDPLCK $983.00 1ADDINSP /.1 _ Insp. I cv: $0.00 2,118 s.f. $330.00 F ' S 't S er District School Permit Fee: $983.00 Suppl. Insp. Fee -.0 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 185 $1,014.00 1 $983.001 1 MECH, HOURLY 0 Yes 0 No NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public W PLUMB, HOURLY 0 Y 1. es (F) No ELEC, HOURLY 0 Yes Q No •-- ---------- MISC ITEMS Plumb. Plan Check ;cc. Plan Check ��Iech. Pcf waFee: Phtmh. V F.lec. Permit l a c Other Alech. Insp. Ocher Plumb Insp. 01her Elec. Insp. Li /deet: Insp. Fee: $0.00 /.1 _ Insp. I cv: $0.00 2,118 s.f. $330.00 F ' S 't S er District School urns, tre, ant wy ew __[•_-._. s:.... ,. ,.: /..67., .... �/ n.n nn/v nn oar;mntn- Contact the Dew for addn'l info. District, etc.). These fees are Dasea on the reununui FEE ITEMS (Fee Resolution 11-053 Eff 7%1112) uo v.nsusys u.w.. FEE »•.» »•- QTY/FEE •-- ---------- MISC ITEMS Plan Check Fee: $1,014.00 184 s.f. $400.00 Remodel, Other 1REMRESOTx Suppl. PC Fee: Q Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 2,118 s.f. $330.00 Re -roof IREROOFRES Permit Fee: $983.00 Suppl. Insp. Fee -.0 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: Administrative Fee: 0 Work Without Permit? 0 Yes Q No $0.00 Advanced Planning Fee: IPLLONGR $24.05 Select a Non -Residential Building or Structure 0 0 I ravel Documentation Fees: Strong Motion Fee: IBSEISMICR $2.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $2,024.55 $730.00 TOTAL FEE: $2,754.55 Revised: 04i29i2Oi 3 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: 7541 Heatherwood Dr. PERMIT # 13050024 OWNER'S NAIV1( Maniei Chiao PHONE # 408439-3069 GENERAL CONTRACTOV wen -Ping l -i BUSINESS LICENSE # ADDRES` 1614 Ridgetree way CITY/LIPCODE:San Jose/M5131 *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. ('� lam not using any subcontractors: Signature Date Please check applicable subcontractors nd complete the following information: k / izl--_ -- - Owner / Contra or Signature )ate 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 k / izl--_ -- - Owner / Contra or Signature )ate .r r. 4` CUPERTINO OWNER -BUILDER NOTICE COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 • buildinana cupertino.org Effective January, 1, 2009, Assembly Bill 2335 amends California Health and Safety Code, Section 19 825,. 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 o«mer-builders" Important information you need to know BEFORE pulling your permit! The term "Owner -Builder" can mean three different things: "Owner as TForker", "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: Hiahest Benefits and the Least amount of Risk Owner-as-GT,orker 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: Possible Benefit 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 turn to serious financial risk if you hire unlicensed contractors to perform any of the work. Benefit/Risk: Possible Benefit and Significant Financial Rist: 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: Possible Benefit 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 homeowners 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 NmerBuilder 2010.doc revised 04/12/10 OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(alcuDertino.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 rLd l APN BP# OWNER NAME �/ (4 LZ OWNER ADDRESS �f�/i�� 'a-te4_7�' DESCRIPTION OF WORK: ylt Weare 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.) V1. 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. V2. 1 understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. 3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that.l 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. V/ 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. 5. I. understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer" under state and federal law. V 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. V 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 iVQ8.rmed under contract with a licensed general building Contractor. 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. 0-wnerBuilderFornt 2010.doc revised 04/14/10 V 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.cslb.ca.gov for more information about licensed contractors. i �✓ 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 a I applicable laws and requirements that govern Owner -Builders as well as employers. 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I, have provided on .this form. Licensed contractors are regulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If you obtain a permit as Owner -Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.). Lender Name: f^'� i 2�C C `" 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: 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: 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: OwnerBuilderForn1 2010.doc revised 04/19/1.0