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11080097-F CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20628 CLEO AVE CONTRACTOR:HABITAT FOR PER NO: 11080097 HUMANITY SILICON VLL OWNER'S NAME: HABITAT FOR HUMANITY SILICON VLLY 513 VALLEY WAY / ATE ISSUED:01/27/2012 OWNER'S PHONE: 4089426444 MILPITAS,CA 950 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATIONIr (r BUILDING PERMIT INFO: < BLDG ELECT PLUMB License Class Lic.# r— F_ MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION': NEW TWO-STORY SFDWL-LOT 3(959SQFT)&PORCH (42SQFT)-TOTAL 1,001 SQ FT.NO GARAGE (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 7/12/12 DEFERRED SUBMITTAL-TRUSSES-ISSD 7/19/12 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 die Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$170000 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 APN Number:36231004.20628 Occupancy Type: 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 WITHIN 18®DAYS�� PERMIT ISSUANCE�� 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 DAYS FROM LAST CALLED INSPECTIOIN. 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 Issued b Date:�� r 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) 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 1 have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 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 1 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,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this e ) �� permit is issued. Owner or authorized agent: r Date- .—?L) 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.1 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 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. �y Signature Date a loia CITY OF(CUII ERT>INO BUILDING PERMIT BUILDING ADDRESS: 20628 CLEO AVE CONTRACTOR:HABITAT FOR HUMANITY PERMIT NO: 11080097 SILICON VLLY OWNER'S NAME: HABITAT FOR HUMANITY SILICON VLLY 513 VALLEY WAY DATE ISSUED:01/27/2012 OWNER'S PHONE: 4089426444 MILPITAS,CA 95035 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO. BLDG F ELECT r PLUMB{ License Class Lic.# M1ECH f— RESIDENTIAL r COIOIIY[,ERCIAL 1— Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:NEW TWO-STORY SFDWL-LOT 3(959SQFT)&PORCH (commencing with Section 7000)of Division 3 of the Business&Professions (42SQFT)-TOTAL 1,001 SQ FT.NO GARAGE 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. 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:$170000 permit is issued. APPLICANT CERTIFICATION APN Number:36231004.20628 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may acciue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ESSUA N CE OR granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. ION. with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Issued by. Date: l Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: �Ih,ereby affirm that i am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material beuhg installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(See.7044, Business&Professions Code) Signature of Applicant: Date: 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER i hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. i will maiutaiu i have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should f use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District i wilt I certify that in the performance of the work forwhich this pemhit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 arid the not employ any person in any manner so as to become subject to the Worker's health&S ety Code,Sections 25505,25533,and 25534. 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 O forthwith comply with such provisions or this permit shall be deemed revoked. Date: *7/�� APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point sou 8 regulations per the Cupertino Municipal Code,Section 9.13. ^� I understand my plans shall be used as public records. Signature Date �O Licensed Professional CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTIN0 (408) 777-3228 a FAX(408)777-3333- building cDcupertino.org P ❑NEW CONSTRUCTION ❑ ADDPTION ❑ ALTERATION/TI N e �REVyISaION T/JDZEF�ERR , ®O�RG((�lINAq®L�"P�IE�cR�N�9�7'# PROTECTADDRESS ®/ / ] APIN9 / J () OWNERNAMEAL}4,,1 MAILI 5� titT STREET ADDRESS CITY.STATE ZIP pd '`S©3/S FAX CONTACT NAME ���� 1 L�Q✓`�\ PHONE/��O 7 f�^S � E MAII. 1_I/ r At`F�y STREET ADDRESS`- I e Je:l q CITY,STATE, IIP pa`/ ` 1 s „ e � FA(el6 ❑OWNER 07 /WNER-BUTLDERV ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT 0 ARCffiTE�cr ❑J ENGINEER (❑7 DEVELOPER El TENANT CONTRACTOR NAMELICENSE NUMBER LICENSE TYPE BUS.LIC M �ciNn� 4S cC��f� COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITELT/E[JGINEER NAMEper, �C C LICENSE NUMBER BUS.LIC p 13 S'_� Ll COMPANYNAME _t4r-ic-NrC1 E-MAIL FAX STREET ADDRESS S�►��iS� !� ^ CITY STATE.ZIP 6,P-S C-� fy PHONE (grs DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTIL TYPE I STORES USE TYPE OCC. SQFI'. VALUATION(S) EXISTO NEwFLOOR DEMO TOTAL AREA AREA AREA NET AREA ® - BATHROOM KITCHEN OTTER REMODEL AREA REMODEL AREA REMODEL AREA PORCH ARE4 DECKAREA TOTAL DECK/PORCHAREA GARAGEARE4: DETACH ATTACH t<DWELLING UNITS: LSA SECOND UNTT DYES SECOND STORY ❑YES BEING ADDED? ❑NO ADDMON? []NO PRE-APPLICATION []YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY; TOTAL VALUATION: PLANNINGAPPL# ❑NO PLANNING APPROVAL LETTER UCELER 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 prMerty 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 buil ' onstructi I authorize tives of Cupertino to enter the above-ideentiifed property for inspection purposes. Signature ofApplicanUAgent Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER ❑ BuILDING PLAN REVIEW 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 ❑ s'rArmmw ❑ mLICwORKS farm if any Hazardous Materials are being used as part of this project. ❑ r.dRG$ ❑ FnRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ ~tAJOR Cl sANrrARY SEWER ntsTRiCT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH Bldg,Ippj011.doC revised 06/21/11 < I CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE ^CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333 ^build ing(a)cupertino.org CUPERTINO NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PRLECT ADDRESS 1.6r 3 ;;—' 0(0c28C« 3r—&04 0 N �� F ANIf� SuCv�J VAU4 P 6 Q a-Idf�� 'L� E-MAIL y-rh-C V.� CONTACT N 'r44 6) 3Yy- /� vlri�p®►�V.Pte/ STREET ADDRE V L ^� Cm' i,-J 1 1 W' O 1 jf�-lp"Y ❑ OWNER OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS_LIC# CO ANY NAME E MAIL i Wq-1 e� STREETj1S5 ` CrIYoY\ �-Y(1 fTS eq ARCHITECT/ENGINEER A LICENSE NUMBER 1�' BUS.LIC iW COMPANY NAV G (,�►•-OW? NC. E�fAII +S STREET ADDRE D �N ST `^bU Com'16KF RA CA 'W417 2T� nI-al DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR TYPE I I STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISAREA AREA AARREA�OOR DEMO AREANNE-TA�REA 699 'W ®® 1�' l BATHROOM KITCHEN OTHER REMODELAREA REMODEL AREA REMODELAREA PORC4AREACy DECKARE.,A TOTALDECK/PORCHAREA GARAGE AREA: DETACH � �1 -& �p�' NONE ATTACH #DWELLL14G UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES IBEING ADDED? .RNO ADDITION? o PRE-APPLICATION S IF YES,PROVIDE COPY OF IS THE BLDG AN r0`YES RECEIVED BY- TOTAL VALUATION: PLANNING APPL I ❑No PPLAANNINAPPROVAL LETTER EICHLER HOME? 'NO �l POO By my signature below,I certify to each of the following: I am the property owner or authorized agent to ac o the pr_rperty owner's behalf. I ha4e(ree(ad this application and the information I have provided is t. 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 co . I authqfize representatives of Cupertino to enter the above-identitiled pr erty for inspection purposes. Signature of ApplicantlAgent: ��eP1 Date: SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE-COUNTER � 13UMDINC.PLAN REVIEW emsting 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 O�STANDARD Puatic 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 �y MAJOR SANITARY SEWER DLSTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH B1dgApp_1011.dcc revised 06/21/11 I l _:> �-) MY ®IF cC>I PER'ICffNO Y EIE IES'ICMATOR—BUI LDIIN G DWI[SRON ADDRESS: lot DATE: 08/12/2099 REVIEWED BY. bobs APN. a 1BP#: "VALUATION: 1$170,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY SFD or Duplex 2nd Unit? 0 Yes E)No PENTAMATIION 1 R3SFDR USE: PERMIT TYPE: WORK construct new 2 story sfd SCOPE OCCUPANCY TYPE: TYPE OF IFILIR AREA PC]FEES PC]FEE ID IBP]FEES BP]FEE IDD CONSTR. s.4 R-3(Production Phase) II-B,III-B,Iv,v-B 1,008 $1,257.93 1R3REPPLN( $1,586.38 1R3REPINSP TOTALS: 1,008 $1,257.93 1 $1,586.38 117i1),C,et. tlj ,mi crlu,, Lie'.. .crit _r'urh. Fee: ,.,.. v'ernait(, • <.l,trrr':9:'cia,1;,f1; t !;;cr 'i1s:,u,.,•.. . c?r;'r . Fee. NOTE.These ees are based on the preliminag in ormation available and are onl an estimate. Contact the 1De t or addh 7 info. FEE ffT EMS (Fee Resolution 11-053 Ej'. 7'1./11) ]FEE QTY[F EIE M11SC RTIEI�Ii S Plan Check Fee: $1,257.93 Select a Misc Bldg/Structure Suppl.PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 or Element of a Building PME Plan Check. $0.00 Permit Fee: $1,586.38 Suppl.Insp.Fee-.0 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee. $0.00 PME Permit Fee: $0.00 Constr.Tax: IBCONSTAXR 1 #new $579.61 units Acoustical Fee: 0 Yes 0 No $0.00 Q Work Without Permit? 0 Yes G No $0.00 0 Planning Fee. PLLONGRNGR $131.04 Select a Non-Residential G F 1Y,tr 1:?rzc:ruarer rG€tir.�Ir.7�'e��r. Building or Structure Strone Motion Fee: IBSEISMICR $17.00 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $7.00 SUBTOTALS: $3,578.96 $0.00 'TOTAL]FSE:E $3,578.96 Revised: 07/04/2011 lea tiding IDeparimena City Of Cupertino 10300 Tone Avenue Cupertino,CA 95014-3255 Telephone: 408-777-3228 C U P[ERT 1 M® Fax: 408-777-3333 CONTRACTOR SUBCONTRACT02 UST JOB ADDRESS: a.06�;Ly(-:,-16:,,6 C(eo ,4vv-- PERMIT# F a OWNER'S NAME: gul;-��-(,. p1uw Loos$ 4EAWPHONE# S(® - a_5f - (joy GENERAL CONTRACTOR:94 4r BUSINESS LICENSE# ADDRESS: -'>619 aratl cl CITY/ZIPCODE: 6-,V-)0,4 j`(,6 C a *Our municipal code requires all 6sinesses working in the city to have a Clay of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTII, THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CU?ERTINO BUSINESS LICENSE. I ani not using any subcontractors: Signature Date Please check appllicabRe subcontractors and complete the fogRowing inffoirmnan®ne V SUBCONTRACTOR BUSINESS NAME BUSINESS LICIENSIE # Cabinets & Millwork P Cement Finishing o qty (a,C Electrical Excavation Fencing Flooring/Carpeting Linoleum/Wood Glass/Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing if Septic Tank .,/ Sheet Metal Sheet Rock Tile saner/Contractor Signature 347�-s'I,�e� vwlk7� tDate OWNER-BUILDER WSCL SURE FORM COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DfVISION 10300 TORRE AVENUE>CUPER T INO,CA 95D14-3255 CUPERTINO (408)777-3228 e FAX(408)777-3333 o buiIdlnoQcuDerbnQ.OrQ 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 2 / ? erg ) p!� 4PN p BPS O N ME CJI l�pC /LC�UV OWNS M DESCRIPTION 0FWORK: )_UaJ /&gffgmW W S btJa- e 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 venry this information.) ONO. 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. �2. 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. (VA—)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. 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license ((11 numbers on permits and contracts. cau 5. 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. WB. 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. ()4�7. I 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. W8, 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 04114110 W9. 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 wwvv.cslb.ca.gov for more information about licensed confactors. 10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I (W am-he party legally and financially responsible for proposed construction activity at the site address listed above. 1. 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.-P_lease_complete_th.e following-construction-lending-agency informa.tion.) --. ---- -- - — -- 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 N suing the permit. Note:A copy ofthe property owner's driver's license, form notarization, or other verificatio 7616�11, �abie t the city may be required to be presented when the permit is issued to verifythe propertyowner's sign a Property Owner's Signature: Date: Z*. S --------------------------- ------- ------- ------------------------ ---------------------------------------------------------- ------------ (NOTE. The following Authorization Form is required to be completed by the property owner only when designating an agent of tha 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: 1 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: Oi17i.eTBvilde'FCTl77 1010.doc revise 04114110