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B-2016-2025CITY OF'CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2025 10211 COLBY AVE CUPERTINO, CA 95014-2419 (316 28 041) F LUNA CONSTRUCTION SALINAS, CA 93915 OWNER'S NAME: SAMEER JAIN AND DEEPIKA JAIN DATE ISSUED: 05/25/2016 OWNER'S PHONE: 925-354-8567 PHONE NO: (831) 595-6590 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lie. #5385-30 Contractor F LUNA CONSTRUCTION Date 08/31/2016 X BLDG _ELECT _PLUMB MECH X RESIDENTIAL COMMERCIAL 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. JOB DESCRIPTION: BATHROOM REMODEL 124 SQ FT - MASTER AND HALL; I hereby affirm under penalty of perjury one of the following two declarations: RELOCATE CRAWL SPACE ACCESS 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 l/ J (r performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this Sq. Ft Floor Area: Valuation: $10000.00 permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above Number: Occupancy Type: information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize 316 28 041 3 16 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 PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature r�� Date 6/6/2016 Issued by: Abby Avende n 0 $ 1 �MJVU Date: 05/25/2016 y OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is following two reasons: 2. I, as owner of the property, or my employees with wages as their sole installed without first obtaining an inspection, I agree to remove all new materials for compensation, will do the work, and the structure is not intended or offered for inspection. sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed Signature of Applicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 6/612016 I hereby affirm under penaltyof perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER t. 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. HAZARDOUS MATERIALS DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code, for the performance of the work for which this California Health & Safety Code, Sections 25505, 25533, and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the 3. I certify that in the performance of the work for which this permit is issued, I Health & Safety Code, Section 25532(a) should I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If, after making this certificate of will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensati6n provisions of the the Health & Safety Code, Sections 25505, 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. I Owner or authorized aged APPLICANT CERTIFICATION ; Date: 6/6/2016 1 certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction, and hereby authorize representatives of this city of work's for which this permit is issued (Sec. 3097, Civ C.) to enter upon the above mentioned property for inspection purposes. (We) agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which'may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code, Section 9.18. 1 understand my plans shall be used as public records. Licensed Signature Date 6/ti/2016 Professional 4 Monday, May 30, 2016 To, City of Cupertino Building Department Sub: Authorization to transfer, the permit no B-2016-2025 to F LUNA CONSTRUCTION,("Contractor") (CA License 538530 at PO BOX 5013, SALINAS, 4 CA 93915) Hi , I Sameer Jain and Deepika Jain owner of property 10211 Colby Avenue, Cupertino,CA- 95014 authorize F LUNA CONSTRUCTION,("Contractor") (CA License 538530) to transfer building permit B-2016-2025 from owner name to F LUNA CONSTRUCTION name. Please reach out to us in case you have additional questions. Thanks � e ✓ ameer Jain and Deepika Jain M40 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMITNO: B-2016-2025 10211 COLBYAVECUPERTINO, CA 95014-2419 (316 28 041) OWNER'S NAME: SAMEER & DEEPIKA JAIN OWNER'S PHONE LICENSED CONTRACTOR'S DECLARATION License Class Llc. # Contractor 'Date Ihereby 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: s. 1 have and will maintain a certificate of consent to solf-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. 2. 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 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 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: t. 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 (See.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (See.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarafIons; 1. 1 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 performanoe 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. a 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 wit ll non -point source regulations per the Cupertino Municipal Code, Sectio 8. Date DATE ISSUED: 0512512016 PHONE NO: BUILDING PERMIT INTO: X BLDG ELECT —PLUMB _ MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: BATHROOM REMODEL 124 SQ FT - MASTER AND HALL; RELOCATE CRAWL SPACE ACCESS Ft Floor Area: ('Valuation: $10000.00 IAPNNumber: (OccupancyType: 316 28 041 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. by: Abb;rLA, ende 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: TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 695 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain compliance vvith 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 ons 25505, 25533, and 25534. Owner or authorized agent: I'" ` 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 Address ARCHITECT'S DECLARATION understand my plans shall be used as public records. Licensed I I NFW V0NSTRTTCTNIM CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORR; AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinciftupertino.org tzotu _'Z0 2,5 I A•n-nTTT(TTT M AI TP.D ATTf1AT i TT M DVI ^"Tr_ .rn r nnn Ai'N# PROIECTADDRESS 14211 60L8y AVC.j Df6 �� V'7� OWNERNAME 5am eea Qa i o 7oUrL PHONE �✓)3S S5j MJ a r)tej, Qpc" u m ji nb , STREET ADDRESS d O 2) y ,01- y� Y /l y<. C.a G7 /V CITY, STATE, ZIP C a ff R T yVe j (A ?5a / FAX CONTACT NAME • r tQ o yyn �df PHONE FS (�%S� NOV(1 �f G E-MAIL rL i1�eJ1 J� f wil l eo Vt sTEBETADDR"s { Q 31 /'� , i tj�Jt Are. a CIT ,STATE,'( QS A �� Z 0 / +� AAO SQ ��1 g T SS' ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER.AGENT ❑ CONTRACTOR ❑CONTRACTORAG$NT ❑ ARCHITECT ❑ ENGINEER ❑ DEvELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS, LIC # COMPANYNAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PH101NB ARCHITECTIENGINEBRNAME LICENSE NUMBER BUS. iLIC # COMPANY NAME E-MAIL VAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK + /f Hallbatu e wodej EXISTING USE R�. PROPOSED USE " TR. TYPE # STORIES _e15 -! ` USE TYPE OCC. SQ.PT. VALUATION ($) EXISTO AREA - NEW FLOOR .AREA DEMTOTAL AREANETARBA BATHROOM REMODEL AREA d�. KITCHEN FIER REMODEL ARRAMODEL ARBA ;E01 L'ORCH AREA DECK AR$A TOTAL D$CKlPOGARAGE ARRA: ❑llETACH (]ATTACH kDWELLBVGUNITS: ISASECONDUNIT ECONDSTORY ❑YRSDDITION? ❑NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES'RECEVBD;.B.:Y,TAL VALUATION:. PLANNINGAPPLO ONO PLANNING APPROVAL LETTER EICHLERHOMEY ONO __ ,zs rx U 00 By any signature below, I certify to each of the following: I am the property owner or authorized agent to act on le property owner's behalf, I have this read application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. i( or, s rep sentatives of Cupertino to enter the above-ijdentifled property for inspection purposes. Signature of ApplicantlAgent hate: SUPPLEMENTAL INFORMATION. REQUIRED�.,Y_ a x,�CA OiICIC�_. ` r Px`y.' Jam_ New SFD or Multifamily dwellings: Apply for demolition permit for I";V' 1K!E E�� "QQUILD myVERII �C g _ existing. building(s). Demolition permit is required prior to issuance of bnildn �� , ��-R•= =�``= � �. ��.�?�Arri�►�:i�} permit for new building, g � w'� mg, � Commercial Bldgs: Provide a completed Hazardous Materials Disclosure10, °� � forth if any Hazardous Materials are being used as part of tivs project.= a�D'- s 8-... a=❑:FIRB=AEP",-:. _Co ofPlanrinApproval- Copy I Letter orMee ' ':•ns'-��=�: :..-. t;Meeting with Planning to prior .,_ submittal of Building Permit application. i�- alAaGa2 r F sayT X`:$EIVER'AISa1tI = BkdgApp_ Ol1.dvc revised 06121111 001 OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTIN€> (408) 777-3228 FAX (408) 777-3333 • building aacuaerlino.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 t J i% Ca o 3-/ A v t; to V. C �i'tr_rr APN �r "a BP# ZA�(p_ OWNER NAME AM1; Gr S A, t-1 OWNER ADDRESS G i't � Cv s'fi�y2 o DESCRIPTION OF WORK: �►•TH ra to £ M uni_- tt 0 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.) Vilder' . 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - 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. VI understand building permits are not required to be signedby property owners unless they are responsible for thconstruction and are not hiring a licensed Contractor to assume this responsibility. 3. 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. YI understand Contractors are required by law to be licensed and bonded in California and to list their license nbers on permits and contracts. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the al 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. I understand if I am considered an "employer" under state and federal law, I must register with the state and ederal 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 esidential 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 perfor med under under contract with a licensed general building Contractor. 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. OwnelBudderForm 2010.doc remised 04114110 -may 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.csib.ca.govfor more information about licensed contractors. S)/10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that am the party legally and financially responsible for proposed construction activity at the site address listed above. 1. 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. . 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 owners driver's license, form notarization, or other verification r eptable to the city may be required to be presented when the permit is issued to verify the pEoperty owner's si:g re. Property Owner's Signature: Date: S 2S 1 4 - ---- -- -------------------- ----- ---- ------ ----------------------------------------------------------------------------- (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 owner's signature. Property Owner's Signature Date: OwnelBuilderForm_2010.doe revisedG4114110