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B-2016-1292CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1292 10600 CULBERTSON DR CUPERTINO, CA 95014-3555 (375 34 633) OWNER -BUILDER OWNER'S NAME: LIN ROCKY AND ALICE fI JDATE ISSUED: 06/07/2016 I OWNER'S PHONE: 949-334-7259 1 I PHONE NO: License Class Lic. # i 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. 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 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 ofthis permit. Additionally, the applicant understands and will comply with all rion-point source regulations per the Cupertino Municipal Code, Section 9 11 18. Signature Date W07/201 6 OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License 11w 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 (Sec.7044, Business & Professions Code) 1/%✓2. 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 performance of the work for which this permit is issued. I 2. I have and will maintain Worker's Compensation Insuranc , as provided for by Section 3700 of the Labor Code, for the performance of th I work for which this permit is issued. 4, s. 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 for 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 saidl 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.iI , Date BUILDING PERMIT INFO: X BLDG —ELECT -PLUMB _ MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: Construct one story addition (371 sq ft); Interior remodel 741 sq ft); Reroof remodeled area (900 sq ft). Sq. Ft Floor Area: 742 1 Valuation: $160000.00 APN Number: Occupancy Type: 37534 033 Deferred Submittal (R -3),R-3 (Custom) PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT P, 9UJ ANCE OR 180 DAYS FROM LAST VALLED INSPECTION. by: Alex Vallelunea 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: 6/07/2016 TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air 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, Sectio 25505, 25533, and 25534. C Owner or authorized agent: Date: 6 2016 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 I understand my plans shall be used as public records. Licensed Professional i CONSTRUCTION PERMIT APPLICATION COM7f DEVK0PIJi N T 'DEPAR T h/iEN T t BUILUIN'G DIVISION r 10300 TORRE AVENUE • CUPER T INO, CA 0501.4-3255 CUPERTINO, (408) 777-3228- FAX (408) 777-3333 - buildino ..cuoerino.ora �� Z10 (6 r Zq[ 2 ❑ Ntw CONSTRUCT }0\T LJ ADD} 1 iON ( 0 J_7EZkTi0:1 /TI ❑ RE1 iSION 1 DEFERR D OnGrOAL PERIvi1T F RDicCf f..DAPESS ( 0610 CU 1.AeW' S-a7hJ 1) I OtiR::.B?:/I✓. I P;10?�3 _ �� I �y9- 3 3i� 7Z � �I g.IJt,1Z �-a�� it �. [...ri ► l �� �. ,,�,�; ��•i, STREETiUDDR:SS q L� L�L e �rS� I C, 1-Y' ST/,TH,Ze? l�tC- COMACT NAYS L Flio� imp) gq2 �D�I P•1��7 S?RF_ I f.DD?,ESS Y (Q.I{• 1 �SPWLPM0 � UC:; Y. STATE, Zaa o�} �'lb�lO l `Ax l ,� 13 O'Artax 13.. 011T:.R•BUT-LDEJt ❑ O(wx--P, AG -E-17' ❑ CO'\riZtiCTOR ❑ COhT.'?L i C i OR AGE]v'T AJ f.? C1Z_'ECT ❑ F''GL'I� L ❑ Dt_-l'ZLOP:-X ❑ iLXwf r CG147RAC,j0? WJICB IJ — ^ LIC=NSFX ,lMc?, LIC�S___ Ty?s BUS, LIC CO3�°fhlhAlrTr -N_4IL I Ppm STS Ef ADDILSS d I CIT v. STAT-, ZIP I PHONE; I� f3C 7i'-.CTr SOD�c't:RI fJ.i3 C�/�}►p� X (��j f �� LIC T�SRT�uTu=R I BUS, LIC GON.PA��'1:.�J.tB _ � E-1✓.�-IL �~ ` PAX MXFT ADDR Ss I �__._�.Y.�.—.' CIM MIFF, ZIP I Pi3or Fall 04 WOM --- — m �' ��" s- 3 sP� •r, II 1I11 rear- p 6v_�v _4�1—.(nU51,&f srvikcSa,w�_ t rYi`0?osmL'Sc DOST -IM us= jf ICO?JS .TYPB STORMS USE TYPE OCC, SQ.FT. vALUATION,i1 f_•r,Is;c�WT �A ©x A:V, Jr� 97 l AREA BATEMOOId 1GTCr'-� Rt'T10D5L �R=A P..-'�..QOA�L fREA � �.I OTi' R FJ.+ODEL f R=A PGRLiIA_R_.A DECkA A T011:LD5G:lPD`r.0 JA WJLAGEPA.A: DETACH I I RDV.=LLD"OU?ITS; ff 25ASECOhD UKTI i]YES S£COND STORY [-SN hDDLD? ❑1 0 I ADDrr}Ot ? (J -'NO P?"S.??LICATiOA' '�c5 !F'!'=-, PROVIDE COPY OF n r o �J 1:0 PL.AnGf-?,.DVf..-_TR IS TRE DLDG -H [l 1'=S c r^ u v ]CY...cR ..OALE, O - •4-w- _ + ;•_ V; tUAIIOTlt _010 By ,my signature below, I6 -ti -Py to each of the iello%ving: I am the properjy ov; sLA It he propery opt per's behalf. I has*e 7--,d this application and the inrormation I have provided is cc„eq I have read the Description of work an ny it is accwste. I egree to comply,,,ith all aoplicaole local ' ordinances and state laws relzti s to b+ ' ;cons ctio . I a+ thor e representatives'of CLrx.rtino to enter the above -i entified property :or inspection purposes. SiahreofApplicant!4gent; Date:_ SL�PLFD�?�TAL IhYOR�? TIO?\ R QUD:''r; s1 = _. '�e1r �� Or lt:u:fii it dv=,.lungs; pp) e'i s' �r��, �. _-� �y A,: c _ •J� o Y ,o� demolitio7p , it or-;�"r_;=_ �R=Tr=e:.GOL+"*tTa �:; l;tr � ' K `DSG �...-� _i TFd S_bn��.5�% h, mi �- L- \, i5 ,Q , S ..ST:Iif is eOi} red„ l .. ��`.:•°',F:`'`"`". ,.•,T -a. E?: tiL building(s), , i -prior fo iS_iiz7ce of bu ding -.., - ' IOr bLlldii?Q �c =__ '-=��s.5�, nermif Heli' -a-may--:.� PL.'�'�'1rEL+.'n t F, _� Co-: nerciel Bldes: Provide a coT_plettd k-zard�+!s Ndaferials Disclosure ��� f oz -r if a -:y Flaza dour hp7erials are being used as ,part of Phis project, Copy Approval Letter M,eetine ith Pla -Drior ofPlan ling or �; v�P to c f 1 iia ubmittal o_ Bui_di Pe7tit apnlicaticn, ����:3wz.=t':•-�,�'3s-:���ai.Ct-a�eR'=��?�;F'.I`n0fi ' -- B12g;4R7_3011,doo-aI,i.red 0612)/.11 z 3s' . OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX 1(408) 777-3333 • bulidinolacuoertino.oro — I _ Dear Property Owner(s): An application for a building permit has be n submitted in your name listing yourself as the builder of the property improvements specified at: . SITE APD R//E-��SS.....AP N.. 3 [� B P _2.01 1Z O NER ftEX .... _ o � �.._ ..: • OWNER ADDRESS Q DESCRIPTION OF WORK: �S l v�{,.e e / PN(.is%(�� Dnerd We are providing you with an Owner -Builder Ackhovdledgment and Information Verification f=orm 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 verity this information.) 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 workbrs on my property. Vi, -2. I understand building permits aie not required to be signed by property owners unless they are responsible for the construction and are not hiring a lic'pnsed Contractor to assume this responsibility. d'v —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. Y`'-4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. ,/ L_R'1 understand if I employ or othe Invise engage any persons, other than California licensed Contractors, and the L otal 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, '�8. I 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. 1("U7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally builtl them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the numbed 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. k�understand as an Owner -Build r 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 04114/10 . 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 lZcidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or wvAv.cslb.ca.gov for more information about licensed contractors. V'1-10. 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. &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, -T2. 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 niay be unable to assist you with any financial -loss you may sustain as a. result of a complaint -Your only remedy against unlicensed Contractors maybe in -civil court. If 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 maybe held liable for damages. If you obtain a permit -as Owner -Builder end wish to hire Contractors, you will be responsible for verifying whether or not-- those otethose Contractors. are properly license and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the followiing construction lending agency information.) I hereby affirm that there is a construction ending 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 v✓hen the permit is issued to verifv the property owner's signatuc& Property Owner's Signature) �� (I Date:, (6 / i / ?,a/& I (NOTE: rhe follov✓ing Authorization Form is required to be completed by the properly ov✓ner only when designating an agent of the property owner to apply for a cbnstructlon permit for the Ov✓ner-Builder). ORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BE Excluding the Notice to Property Owner, they 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: I 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 ov✓ner's signature. Property Owner's Signature: Date: CrvnerEuilderForm 2010.doc revised 04-114110