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151100140 H_ CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10381 BRET AVE CONTRACTOR: CYNTHIA GROUP LLC PERMIT NO: 15110014 OWNER'S NAME:` CYNTHIA GROUP LLC 10229 SCENIC BLVD DATE ISSUED: 11/03/2015 OWNER'S PHONE: 4088938007 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL E] License Class Lic. # INSTALL TEMPORARY POWER 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.1hat my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have andwill 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: $300 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 APN Number: 37510025.00 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 PERMIT 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 saveS F T CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs; -and 'expenses which may accrue against said City in consequence of the Is 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. iI 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) Bas 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, Sections 25505, 25533, and 25534. Section 3700 of the Labor CodeJor the, performance of the work for which this Owner or authorized ag�[`ts Date�� 3 ` it is issued: rtify that in the performance of the work for which this permit is issued, I shall not employ anyperson 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. 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. Signatu',D1 � a=tnmen �l _ GENERAL PERMIT APPLICATION .`�. COMMUNITY DEVELOPMiiENT DEPARTMENT • BUILDING DIVISION 10300 I.ORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 •FAX (408) 777-3333 • build! na(b)cuoerino.or � �� Z/CUPERi"[rt0 ❑ PLUl,sNe ❑ II ECHA?\TICAL ,� ELECTRICAL ❑ h nSCELLA-,N7-- PP.OIECT ?.DDR SSS 1��\n '.P*^� = bye, � � / �" � Q OWTtRNA1I�B Ci'nA (�> S T REIT ADDRESS CITY, STATE, ZIP I FAX COTTTACT NAIME JV Hs V v�V-AI STREET A-DDP=- S I CITY, STATE, ZIP FAX ❑ OFA.=ROR'1.ER-BUILD ❑ ACIE -1 ❑ CONIP 4CTOR EDCo,7TRACTORAGD-ZT ❑ ARCHi-i7FCT El`NGL\'_R 11D=VELOP-=-�, ❑ EKL,, COINTR4CTORNFj'LI LICENSE ER I LICENSE T BUS.LIC_� I COMPANY N."IM-7/` E-MAIL FAX STREET ADDRESS I CITY, STATE, ZIP P ZONE ARMTECTIENGWEERNAHE LICENSENUbf3ER I BUS. LIC C0IV2A-1,TYNAI✓E E-IJAII I FAX STREET ADDRESS I CITY, STATE, ZIP I PHONE USE OF ❑ SF] ., DUPLEX ❑ MULTI-iAbULY . PROJECT LN WIL7Lf NTD ❑ Y: -:s PROTECT IN ❑ YES LS TEE BLDG AN ❑ ti _S B u=LNG:❑COI i. -PC JA T LTRB ANLNTERF ?.CE ARRA ❑ NO I FLOOD ZOME ❑ NO I EICHLER Homm? ElNo DESCP.IPTION OF WORK ` 1()Mn,40 P k TOTAL VA i U.-.TIONT: By my signature below, I ce. Lify to each of the followinE: I am the propertymw _Lo on the pe. e all. ead this application and the information I have provided is correct. I have read the Description of Worlw - erify it is cu _ ee to comply with all applica cal crci-ances and state laws relit ng t uild' g Eonsu on. I z ` orae representatives of Cupe lino to ent - ve-idea, pro -,l'LV for inspection purposes. SI�att,re of A.oplican JAQent: �' Date: T 1 ,- I 1 i- SUPPLE AI L�rORvIATIO>\ RE LL�ED Q s OVER Ti3F COL�'4N7 a Y ,a7w S ii ;- /SPI%isc4vp_2011.doc revised 06121/11 ,vim CITY OF CUPERTINO FF.F. FRTTMATOR — BUILDING DIVISION a 10381 BRET AVE DATE: 11/0312015 REVIEWED BY: MELISSA liADDRESS: APN: 375 10 025 BP#: *VALUATION: F$300 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1REAP14 USE: PERMIT TYPE: WORK $0.00 SCOPE ,If( ch. 111an 111.=.1116. 11,1(2 Check- Elec. Plan Check 0.0 1 hrs $0.00 Illlsir lb. Pei rra t l '.,: Elec. Permit I it Fee: ]EPERMIT Otherllhtrib lhsp- Other Elec. Insp. 0.0 hrs $48.00 Afech, Insy). 11"ee: 1,11mb-1aw. Fee: Map. bell: TOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Pfre, Sanitary Se-werVistrict, Aycnooj District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Deptfor addn'l info, FEE ITEMS (Fee Resolution 11-053 fff. 7/1/132 FEE QTY/FEE MISC ITEMS Phin ("heck Sup/1L PC .FC;[' A PMFE Plan Check: $0.00 Pernd� 17ee: PMEE Unit Fee: $48.00 PMEE Permit Fee: $48.00 C"Onsfruction 711X: Administrative Fee: 1ADMIN $45.00 Work Without Permit? 0 Yes (F) No $0.00 Advance4lPhmning J.."ees: Travel Documentation Fee: ITR,4VDOC $48.00 A Stron'a Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.001 SUBTOTALS $1 90.501 $0.001' rI'(JTAL FEE$19 0.50 Revised: 10/01/2015 R R CUPERTINO OWNER -BUILDER DISCLOSURE FORM COIAMiUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 • build ina(a 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: - `�O SITE ADDRESS .��I '- .. b 77. `r�1� I : _ .....APIC.. BP# OWNER NAME .I. ' �.....: .... OV�NER ADDRESS- Nvd i n c; DESCRIPTION OF WORK: CA� Qti� We are providing you with an Owner -Builder Ackhowledgment 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 novice 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 1, 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 p r nally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an`u nlicensed person and his or her employees while working on my property. My homeowner's insurance may not o ide coverage for those injuries. I am willfully actin as an Owner -Builder and am aware of the limits of m p �: 9 j Y" 9 Y ints� rance coverage for injuries to workers on my property. 2. 1 understand. building permits are not required to be signed by property owners unless they are responsible for t e` construction and are not hiring a licensed Contractor to assume this responsibility. 43. 1 understand as an "Owner -Builder" I am the responsible party of record on the -permit. I understand that I may ct myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her n+ar e instead of my own. R� 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license Prr�;- nurlbers on permits and contracts. ix r Cit hj,,{ 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 coif idered an "employer" under state and federal law. !r GH _ 6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and fe"A�ral government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to uz,�nployment compensation for each "employee." I also understand my failure to abide by these laws may subject rri'ef#o serious financial risk. 7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family ential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by >ed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work rormed under contract with a licensed general building Contractor. C,H-@t; u. • 8. I 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 a " 9.1 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 (CS LB) at 1-800-321-CSLB (27 52) or www.cslb.ca.gov for more information about licensed cbtn: ractors. G,N;� '� 10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am fhe party legally and financially responsible for proposed construction activity at the site address listed above. �N' N,11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide G` byt;_0 applicable laws and requirements that govern Owner -Builders as well as employers. G�f X12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the mfor` ation-1 have -provided on this form. Licensed contractors are regulated bylaws designed to protect.the..public. If yo ,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 maybe in civil court. Itis also important for yo -u -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 and wish to hire Contractors, you will be responsible for verifying whether or note 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 aff-irm, 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 drivers 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 Signatu, -� li Date: ��¢� �;;• --- ------------------------------------------------------------------------------------------------------------------------------------------ {NOTE: The follov✓ing Authorization Form is required to be completed by the property ov✓neronly when o'esignating 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 owners drivers license, form notarization, or other verification acceptable to the city may be required to be presented when the pen -nit is issued to verify the property owners signature. Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revised N11411 0 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: (ti 'y o- A-VP- PERMIT # 'f` l O 4 - OWNER'S NAME: S PHONE # GENERAL CONTRACTOR: �,.L p��Q S US "fSS LICENSE # Z ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Please check applicable subcontractors and complete the following information: Date Owner / Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date