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B-2016-1157CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1157 1538 PRIMROSE WAY CUPERTINO, CA 95014-5230 (366 15 015) OWNER'S NAME: WOODBURN RICHARD LAND SHERIL P TRUSTEE DATE ISSUED: 01/12/2016 OWNER'S PHONE: PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class. Lic. # Contractor Date 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: Replace (e) water heater with new 50 gal in the same location 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 Sq. Ft Floor Area: Valuation: $1600.00 this 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 66 366 15 015 3 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 PERMIT EXPIRES IF WORK IS NOT STARTED expenses which may accrue against said City in consequence of the WITIIIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal 180 DAYS FROM LAST CALLED INSPECTION. Code, Section 9.18. Issued by. -JAR -27' Signature Date Date: OWNER -BUILDER DECLARATION RE -ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed. If a roof is following two reasons: installed without first obtaining an inspection, I agree to remove all new materials for 1. I, as owner of the property, or my employees with wages as their sole inspection. compensation, will do the work, and the structure is not intended or offered for sale (Scc.7044, Business & Professions Code) z Signature of Applicant: I, as owner of the property, am exclusively contracting with licensed Date: contractors to construct the project (Scc.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the 2. I have and will maintain Worker's Compensation Insurance, as provided for California Health & Safety Code, Sections 25505, 25533, and 25534. I will by Section 3700 of the Labor Code, for the performance of the work for which maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the this permit is issued. Health & Safety Code, Section 25532(a) should I store or handle hazardous 3. I certify that in the performance of the work for which this permit is issued, I material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I shall not employ any person in any manner so as to become subject to the will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and Worker's Compensation laws of California. If, after making this certificate of the Health & Safety Code, Sections 25505, 25533, and 25534. exemption, I become subject to the Worker's Compensation provisions of the C Labor Code, I must forthwith comply with such provisions or this permit shall Owner or authorized agent: _'� be deemed revoked. Date I* jZ-2-()4G APPLICANT CERTIFICATION ONSTRUCTION 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 correct. I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued (Sec. 3097, Civ C.) relating to building construction, and hereby authorize representatives of this city Lender's Name to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address judgments, costs_, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant ARCHITECT'S DECLARATION understands and will comply with all non -point source regulations per the I -understand my plans shall be used as public records. Cupertino Municipal Code, Section 9.18. Licensed Date � �= %z Z,a16 Professional Signature .��� CUP RTINO GENERAL PERMH i APPLICATION CC)MfJiUNITY DEVELOPIh/iENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014 3255 (408) 777-3228 - FAX (408) 777-3333 • buildino5cnerino.org ,2-1G ❑lviEC L4,\TlCAL, ❑ELEECT1LiCAL ❑J,,,1SCELLA�t-OUS PRorcrADDPEss S 39 O K09--cJ 19 Oik2iRNA1J_= t PHO W. S T R=ET i.DDPMS Y-3 (,W �3 I CITY, STATE c, I FAX I I IM 1/` G CONTACT15 W G c v' U ST11 ET DDRESS CITY, STATE, ZIP F X 0ti 1-a ❑ Owl.=? -BT- Dz ❑ 07,N-tRAGE1,T ❑ CO!MLACTOR ❑ CO.\TMkCTORAG=NT ❑ AaCl="ZCTl❑ EN-GiN=_R ❑ DEVELOPER ❑ -IHK KP CONTR=,CTORNAI�� 6) I LIC`I�SE?�L�+SER I LICENSEP? SU TY I BUS. LTC �l C-_ i 312 03c -a n COIJPA N. NA]J� E-WIATL Fa;, STREET A-DDRESS CITY, STATE, ZIP PriONE AR CHIT TFCDUN GINFERN: J,, Z, I LICENSE NUMBER EUS. LIC COMJ,PA_NY NAhr FAX STRER1 ADDRESS I CITY, STATE, ZIP I PHOhi USE OF ❑ SP] or DUPLEX ❑ NUL TI -F.41+51 Y PRO��CT LN WILaL<�i ❑ Y: -:s PROI-RCT IN ❑ Y: -:s is T-' BLDG tN ❑ )^S BU EDNIG: ❑ C01+9+jam- CIAL URBM, I2NrTEK A.CE A�.L0. ❑ NO FLOOD WKS ❑ 2\0 =ICHLME HOME? i] NO DESCRIPTION OF w0. --RX r ouQ� 707AiVeTUATION: ( WO ��U �-' I �.C�I\ D�,l _. a '+• m. �`�y? tx 'y° $. 1 By my signage below, I certify to each of the followi g: I am the prop--.-ty owner or authorized agent to act on the prop-,.. Ly owner's behalf. ve read this application and th-- infor a -ion I have provided is correct. I have read the Description of \York and verify it s accurate. I afire-- to comply;viu all applicable local ordinances and smote laws relaLMg to12ild1'ng COPS',/ui 'ion. I eutho e representativeum s of Ce:�ino to enter the, abovid e-enti-5ed property for inspection pw-poses. f Date: S E 1 ^-7L DINT ORvATI0NT FQUT 2z `OFFSCELSEOELIY..:... j a f 1111FPM,isc,4Dp_?011.doe revised 06121/11 - CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - building ancuDertino.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 MP improvements specified at: X �'�, s fr. SITE ADDRESS _ - APN... BPn OWNER NAME l OG�l!l� .� 01�✓NER D RESS- 1..1� ..p DESCRIPTION OF WORK: Ck C..- VV-?J--Q-V—I _QJQQ ✓ - 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 infonnation.) 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- er" building permit that erroneously implies that the property owner is providing his or her own labor and material orally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by ilicensed person and his or her employees while working on my property. filly homeowner's insurance may not de coverage for those icijuries. I am willfully acting as an Owner -Builder and am aware of the limits of my ance coverage for injaries to workers on my property. 2. 1 understand. building permits are not required to be signed by property owners unless they are responsible for onstruction and are not hiring a licensed Contractor to assume this responsibility. . I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may t myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her instead of my own. L I understand Contractors are required by law to be licensed and bonded in California and to list their license ers on permits and contracts. 5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the value of my construction is at least five hundred dollars ($500), including labor and materials, I may be idered 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 ral government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to nployment compensation for each "employee." I also understand my failure to abide by these laws may subject o serious financial risk. 1 7. 1 understand under California Contractors' State License Law, an Owner -Builder who builds single-family dential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by nsed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work eriormed under contract with a licensed general building Contractor. '8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction cts in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/19/10 9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal enue Service, the United States Small Business Administration, the California Department of Benefit Payments, the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State nse Board (CSLB) at 1-800-321-CSLB (2752) or wvnv.cslb.ca.gov for more information about licensed `10. I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I he party legally and financially responsible for proposed construction activity at the site address fisted above. _11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide all applicable laws and requirements that govern Owner -Builders as well as employers. k 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the MMformation-1 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 maybe in civil court. Itis also important for you -to understand that if an unlicensed Contractor or employee of that individual or irm 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 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: ,t 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, a. 3 form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to veriy the property owner's signature. ' Property Owner's Signature: Date: 1'JZ- Zc)(6 --------------------------------------------------------------------------------------------------------------------------------------------- (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: OwnerBuilderForm 2010.doc revised 04/19/10