12110105�i
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: MAIN STREET CUPERTINO
CONTRACTOR: MAIN STREET
PERMIT NO: 12110105
CUPERTINO AGGREGATOR LL
OWNER'S NAME: MAIN STREET CUPERTINO AGGREGATOR LL
203 REDWOOD SHORES PKWY
DATE ISSUED: 12/23/2014
OWNER'S PHONE: 6503441500
REDWOOD CITY, CA 94065
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
MAIN STREET- SITE IMPROVEMENTS PLAN FOR MAIN
License Class Lic. #
STREET CUPERTINO
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
Sq. Ft Floor Area:
Valuation: SO
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 31620078.00
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 EW IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 8 AYS O ERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAY ROM ST CALLED INSPE TION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Issued b Y Date:
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
RE -ROOFS:
Signature Date
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
fir 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
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sectio 25505,25T3, 3, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date:
permit is issued.
1 I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature J a4M Date 1
_ gL
4
I ____j
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION r11
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 1�
(408) 777-3228 • FAX (408) 777-3333 • buildinclacupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / Tl ❑ REVISION / DEFERRED ORIGINAL PERMIT
PROJECT ADDRESS
APN 9
OWNER NAME Uv F-6-,-bc5 CLC_ PHO?jS—b q`� )S()Ci
�-,,
E-MAIL
STREET ADDRESS Aa
Zo 2edwooJ Shores w�
CITY, ST ,ZI VVD� � 1 CA CI_100 _ FAX �� O
V
CONTACT NAME
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PHONE
- �I D� O U
IL
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e rl h c� z r r7 ea'S
La50 CDS-
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STREET D� 'A , L ��
J 1'v II I2.�1 S LII4e 2W
CITY, STATE, ZIP
",Ara A VleN Cit qN01
FAX
Sa- glob 04-,G-7
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER LICENSE TYPE
BUS. LIC 4
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
EXISTING USE
PROPOSED USE CONSTR. TYPE
# STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
❑ ATTACH
I
# DWELLING UNITS:
IS A SECON-D UNIT ❑ YES
SECOND STORY El YES
BEING ADDED? NO
ADDITION? ❑NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
;RECEIVED BY
TOTAL VALUATION:
PLANNING APPL F ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the 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/ARent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
PI 4N"cxEc�T�PE":;
,ROUT ncsLiP. �: °"'•
New SFD or Multifamily dwellings: Apply for demolition permit for
j`Y❑
existing building(s). Demolition permit is required prior to issuance of building
oNx TTS=coui,TEx "
uIl nlr,GPiv� RENIEw
permit for new building.
❑ E,CPRESSPL.
NG PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
G�'0 S
_
form if any Hazardous Materials are being used as part of this project.
❑
WEPT
LARGE
FIRE
Copy of Planning Approval Letter or Meeting with Planning prior to
_
submittal of Building Permit application.
`
1\LAJ012
ANITARY SE1�'ER DISTRICT
rOEP-N71'
ROti)•IENTALHEALTH
B1dgApp_2011.doc revised 06/21/11
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISIO
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(cbcupertino.org
n NEW CONSTRUCTION F-1 ADDITION M ALTERATION / TI R❑ REVISION /DEFERRED ORIGINAL PERMIT # 12110105
PROJECT ADDRESS Main Street Cupertino
APN # ? /(0 _ � - U
to
OWNERNAME Sand Hill Construction Management LLC
PHONE (650) 344-150.0)
E-MAIL
STREETADDRESS 2882 Sand Hill Road, Suite 241
CITY, STATE, ZIP Menlo Park, CA, 94025
FAX
CONTACT NAME Nandy Kumar
PHONE (408) 593-6605
E-MAIL NKUMAR@SHCMLLC.COM
STREET ADDRESS 2882 Sand Hill Road, Suite 241
CITY,STATE, ZIP Menlo Park, CA, 94025
FAX
IZI OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME Tomara Cleveland
LICENSE NUMBER 399163
7NSF TYPE B
BUS. LIC #
COMPANY NAME Devcon Construction Inc.
E-MAIL TCLEVELAND@DEVCON-CONST.COM
FAX (408) 262-2342
STREET ADDRESS 690 Gibraltar Drive
CITY,STATE,ZIP Milpitas, CA, 95035
PHONE (408) 964-5565
ARCHITECT/ENGINEERNAME Kevin Jones
LICENSE NUMBER
BUS. LIC#
COMPANY NAME Kenneth Rodriguez and Partners, Inc.
E-MAIL KEVINJ@KRPARCHITECTS.COM
FAX (650) 960-0707
STREET ADDRESS 445 North Whisman Road, Suite 200
CITY, STATE, ZIP Mountain View, CA, 94043
PHONE (650) 965-0700
DESCRIPTION OF WORK RFI's for Site Work for Main Street Cupertino to review for S,Je Final.
RF (5 j-6-76
EXISTING USE
PROPOSED USE
CONSTR. TYPE
#STORIES
USE TYPE
OCC.
SQ.FT.
VALUATION (S)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
❑ ATTACH
#DWELLING UNITS: ISSECOND UNIT []YES SECOND STORY ❑YES
BEING ADDED? []NO ADDITION? []NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN YES ION:
PLANNING APPL # []NO PLANNING APPROVAL LETTER EICHLER HOME?
By my signature below, I certify to each of the following: I am the property owner or authorized agent ct on the owner's behalf. I have read this
application and the information 1 have provided is correct. 1 have read the Description of Work a eri I agree to comply with all applicable local
ordinances and state laws relating to building co a ctlo . 1 authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
;z - ov
Signature of Applicant/Agent: - �"--� Date: `—/q —1J
SUPPLEMENTAL INFORMATION 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
❑ STANDARD
❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
❑ FIRE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_201 Ldoc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13)
ADDRESS: MAIN STREET SITE WORK
DATE: 09/14/2015
REVIEWED BY: MELISSA
14eeh. Permit Fee:
APN: 316 20 078
BP#: 12110105
*VALUATION: Iso
°PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building
USE: 1
7
PENTAMATION
PERMIT TYPE:
WORK
REV # 1 - RFI'S 1 - 676 FOR MAIN STREET SITE WORK
SCOPE
NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13)
<11ech. Plan Check
Alwnb. Nan Check
Plan Check
14eeh. Permit Fee:
Plaimb. Permit Fee
Elec. Permit Fee:
),lzerfldeeh..Insp,
Oiher Eke, Insp.
Suppl. PC Fee: (F) Reg. () OT
0.0
NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District. etc.). These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: (F) Reg. () OT
0.0
1 hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Feer Reg. Q OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
E)
Work Without Permit? 0 Yes (F) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
O
i
"ilvel Docurnenlalio;,, I : -,.S_
Strong Motion Fee:
$0.00
F 1 #
$859.00
Revisions
1PEVCOMTI Tenant Improvement
Bldg Stds Commission Fee:
$0.00
SUBTOTALS:
$0.00
$859.00
TOTAL FEE:
1 $859.00
Revised: 07/02/2015
CUPERTINO
TEMPORARY CERTIFICATE OF OCCUPANCY FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
ALBERT SALVADOR, P.E., C.B.O., BUILDING OFFICIAL O Vkloo1
10
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 tf '
(408) 777-3228 • FAX (408) 777-3333 • build inq(o?cupertino.orq
APN 3 1.6Z
AMOUNT
(1% VALUATION/) BLDBONDS]
$ l o v ]
DATE: 10/22/15
eIIbN:12-11010-5 �
SITE Stevens Creek & Finch Cupertino, CA 95014
5K min -10K max) Q v
ADDRESS:
TCO EXPIRATION (( �� f j
l (
Signature: ..,,.:::.....L
OWNER'SNAME: Sand Hill Properties
TOTAL FEE: $ �G / 0;—'- OCC]
I0 LA�
PHONE#: 650-344-150
❑ APPROVED
Main Street Aggregator, LLC
FAX#: 650-344-0652
Date:......................
MAILING ADDRESS (d different from site address):
220 Sand Hill Road, #241
Menlo Park, CA 94025
CONTRACTOR: Devcon Construction
PHONE#: -
FAX#: 408-262-2342
-
CONTACT: Tomara Cleveland
PHONE#: 408-964-5565
FAX #:
TEMPORARY CERTIFICATE OF OCCUPANCY INFORMATION
BOND TYPE: ❑SURETY BOND
AMOUNT
(1% VALUATION/) BLDBONDS]
$ l o v ]
CODE
❑CHECK ❑ CASH BOND
OF BOND:
5K min -10K max) Q v
EDITION:
TCO EXPIRATION (( �� f j
l (
Signature: ..,,.:::.....L
FEE: $286.00/m0
TOTAL FEE: $ �G / 0;—'- OCC]
I0 LA�
DATE (6 MONTHS MAX):
❑ APPROVED
❑ APPROVED WITH CONDITIONS`
Signature:.........................................................
USE
TYPE OF
CONSTR
FLOOR
AREA
OCC
LOAD
LEVEL
COMMENT
_75`51icWorks
❑ APPROVED
rg
Signature: ..,,.:::.....L
............................ Date: .L�...y.�...�.5
1
!her: %J
❑ APPROVED
❑ APPROVED WITH CONDITIONS`
Signature:.........................................................
Date:......................
OTHER DEPARTMENT / AGENCY APPROVALS:
Planning
Signature:... ...
Date:.�U �� ❑ APPROVED
APPROVED WITH CONDITIONS'
7—ire Edge,)
Signature: ..............
e... Date:........ l .. �' V 01 Z'XIISEI
APPROVED WITH CONDITIONS*
_75`51icWorks
❑ APPROVED
APPROVED WITH CONDITIONS`
Signature: ..,,.:::.....L
............................ Date: .L�...y.�...�.5
1
!her: %J
❑ APPROVED
❑ APPROVED WITH CONDITIONS`
Signature:.........................................................
Date:......................
*CONDITIONS OF COMPLETION - Attach a letter signed by the contractor and owner of the property
stating the list of items required to be completed for each individual Department before final occupancy
can be granted. Include approximate completion dates for each item.
The undersigned covenant and agree as a condition to the approval of the above request for temporary occupancy to have the building or
buildings complete and in compliance with all building codes, ordinances and regulations and ready for inspection prior to the expiration
date specified. If this Temporary Certificate of Occupancy expires, the total amount of the bond may be forfeited and the non-compliance
may result in an-erifoo7cement . tion
Owner ��Contracto I . I15
Si nature /..............:............ Date: F.�%.......... Si nature: .. .�u� �...... Date: .......
U
This temporary certific ensures t a r rotection and life safety systems have been completed, inspected, successfully tested and
approved for the spe is ea of e u' din specified above to provide a reasonable degree of safety to the occupants from fire and
similar emergencies
Buildinq Official: .........,..,.... ................. ............Print:.........i. .........-'vf,%�-C....................... Date:.�..z- .....
DEPARTMENT AC140N: After detertfiinViiort copies to: 1) applicant, 2) permit file
TempOceFa•m_2013.doc remised 717114
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(d)cupertino.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 ADDt2E S ��0 I �� APN Z
(
BP# /�
N`� ME � � -IOWNERAD RE $ `� ��. '/• �/',��
DESCRIPTION OF WORK:
YWC.I'y
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.)
?L1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
TL2. I understand building permits are not required to be signed by property owners unless they are responsible for
onstruction and are not hiring a licensed Contractor to assume this responsibility.
-DL3. 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.
_�L4. 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
t tal 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.
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.
X7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
-9 18. 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.
OwnerBuilderForm 2010.doc revised 04/14/10
T9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov for more information about licensed
contractors.
V10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
10-11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner -Builders as well as employers.
-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:
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 s49.1ture.
Property Owner's Signature: Date: LQU
------------------- -------------------------------------------------------------------------------------------------------------------------
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner -Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s) to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an
Owner -Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note: A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owners
signature.
Property Owner's Signature:
Date:
CNNnerBuilderForm 2010.doc revised 04114/10