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B-2017-0675CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: CONTRACTOR: PERMIT NO: B-2017-0675 21230 HOMESTEAD RD CUPERTINO, CA 95014 (326 05 085) OWNER/BUILDER OWNER'S NAME: VILLAGE GREEN ASSOCIATES OWNER'S PHONE: 650-961-8330 LICENSED CONTRACTOR'S DECLARATION License Class Lic. # Contractor OWNER/BUILDER 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: 1. 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. z. 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. 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 5/1/2017 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. 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) z' 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: 1. 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 `erforrnance of the work for which this permit is issued. �z:_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. 3. 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 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. anature Z00 Date 5/112017 DATE ISSUED: 05/01/2017 PHONE NO: BUILDING PERMIT INFO: X BLDG —ELECT —PLUMB _ MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: VILLAGE GREEN - REPLACE CEILING MOUNTED SIGN Sq. Ft Floor Area: I Valuation: $5000.00 "N Number: Occupancy Type: 326 05 085 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. by: Abby Ayende 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: 5/1/2017 ALL ROOF COVERINGS TO BE CLASS "A" OR 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 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, e 25505, 25533, and 25534. Owner or authorized agent: Date: 5/1/2017 NSTROC7TION LE EN Y I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHiTFCT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional 5_WO__06TIS Wt 1I MANIUNITY DEVELOPMENT DEPARTIMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 CUPERTINO 1 F] NEW CONSTRUCTION F] ADDmoN 17`I -'ALTERATION Ti M REvisioN / DEFERRED ORIGINAL PERMIT PRO-cTA`DREss 21230 W. Homestead rd I APN 9 32fp- � SJR- cG Cs — OWNER NAME village green associates LP PHONE 7P-MA ave ry Pacbell.com STREET ADDRESS 130 E. Dana st. CITY, STATE, ZIP mountain view, CA 94041 FAX 650-961-8331 CONTACT NAME Rob-Moyer_r, PHONE 408-593-8115 E-MAIL rmoyer@thormaimech.cor i STREET ADDRESS 425 Aldo ave C', '�QL'Qlara. CA 95054 FAX 408-988-8744 1 11 OWNER ER OWNER BUILDER ❑ OWNER AGENT ❑ CONTRACTOR 0 CONTRACTOR AGENT 11 ARCHITECT ❑ ENGINEER_ 0 DEVELOPER El TENANT CONTRACTORNAME LICENSE NUMBER LICENSE TYPE BUS. LTC 4 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCMTECT/ENGINEERNAME LICENSE NUMBER BUS, LIC A COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK replace signs for property EXISTINGUSE PROPOSED USE CONSTR TYPE 11STORIES USE TYPE OCC. SQFT. VALUATION E)USTG NEWFLOOR DEMO TOTAL $5,000-00 AREA AREA AREA NETAREA BATHROOM REMODEL AREA KITCHEN REMODEL AREA OTHER REMODEL AREA PORCH ToTALDECK/PORCH . AREA GARAGE AREA: DETACH 0 ATTACH —i—DWELLINGuNus, IS A SECOND UNIT []YES SECONDSTORY DYES BEINGADDED? ONO ADDITION? ONO PRE -APPLICATION r1YES IF YES, PROVIDE COPY OF ILSTHE BLDG AN 0 YES I RECEIVED BY: TQTAL VALUATION: PLANNING APPL A ONO PLANNING APPROVAL LETTER EICHLERHOMEZ ONO (X I Al A ,13y my signature below, I certify to each of the following: Ian, the property owner -authorized agent to act A the property owner's behalf lhave read this and the information I have provided is'correct. I have read the Description of Work and verify it is accurale,- I agreetO comply with all applicable local application ordinances and state laws relating to construction. I authorize representatives of Cupertino to enter the above-ide tiff d property for inspection purposes. Signature ofApplicant/Agent: Date: SUPPLEMEKTAL INFORMATION F-UQUIRED PLAN CHECK TYPE ROUTING SLIP El OVER THE -COUNTER El 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 El EXPRESS El PLANNING PLAN REVIEW permit for new building. Commercial Bldgs: Provide a completed Hazardous Materials Disclosure El STANDARD El PUBLIC WORKS ib­rm it any Hazardous Materials are being used as part of this project. El LARGE 0 FIORE DEPT Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT — submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BidgApp__:201 1. doc revised 06121111 n We' OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 UPERTtNta (408) 777-3228 • FAX (408) 777-3333 • buildina cDcupertino.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 n O t _ l � qpN BP# ��°t,�j�•��� QWNF-R NAME ADDRESS G a OWNER X 13 o . n•,_ G AW DESCRIPTION OF WORK: G4 1r o gr We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- uiider" 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. I understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. T 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. pv< I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. 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" 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 ,mme to serious financial risk. 7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. hl- Y 8. 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. OtivneBuilde7Fornt 2010.doc revised 04/14/10 .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. 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. klAl. I agree that, as the party legally and financially responsible for this proposed construction activity, 1 will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. y'1"Z. I 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 Des/cription of Work)):"' l�lgjta G OG. % ♦� A 5 Project Location or Address: *7/Z3 I/li �Gr►G jC Name of Authorized Agent: �y� Mafe Ifo Tel NoIF Address of Authorized Agent: 06 OG i �<hEX G/vim Com„ I declare under penalty of perjury th ! - the property owner for the address listed above and I personally filled out the above information and certify its a ura .:!Vote: A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city y e required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: A 7 Oi+meiBzrildeiFornnz 2010.doc remised 04114110 P�