Loading...
15060007V/y CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1648 PRIMROSE WAY CONTRACTOR: SHANMUGAM PERMIT NO: 15060007 SIVASHANKER AND SIVASHANK OWNER'S NAME: SHANMUGAM SIVASHANKER AND SIVASHANK 1648 PRIMROSE WAY DATE ISSUED: 09/15/2015 OWNER'S PHONE: 4088288706 CUPERTINO, CA 95014-5230 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL ADDITION TO CREATE 2 NEW BEDROOMS AND SITTING License Class Lic. # AREA (838 SQ FT); ADD 60 SQFT (N) PORCH; REMODEL (E) Contractor Date KITCHEN(160 SQ FT); OTHER REMODEL AREA (180 SQ I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Revision #1 - Upgrade (E) 100 Amp Panel to ( 200 Amp Panel — issued 12/17/15 Code and that my license is in full force and effect. (`./1 � FI VISI w N #—L-- I hereby affirm under penalty of perjury one of the following two declarations: I 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 Sq. Ft Floor Area: \'Auation: $150000 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 APN Number: 36615006.00 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 180 DAYS OF 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 save 180 DAYS FROM LAST CALLED INSPFfTJON. 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 by: V V6� Date: 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. J 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) 4, 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 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, (hd 25534. Section 3700 of the Labor Code, for the performance of the work for which this 4- permit is issued. Owner or authorized agent: Date: -1 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. 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, 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. 11 Signature Date J, CITY OF CUPERTINO REVISION #-L W FF7 ESTIMATOR — BUILDING DIVISION t ADDRESS: 1648 Primrose Way FEE ID DATE: 12/17/2015 REVIEWED BY: PAUL APN: 36615 006 RP#: 15 "VALUATION: Iso ,PERMITTYPE: Electrical Permit 1ERT<200 PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY USE: SFD or Duplex Amps PENTAMATION PERMIT TYPE: 1 REAP WORK Revision #1 - Upgrade E 100 Amp Panel to N 200 Amp Panel SCOPE (/'c'rmii lPME APPLIANCE / EQUIP TYPE FEE ID QTY/FEE QTY UNITS BP FEES Services 1ERT<200 200 Amps $48 P";C, (/'c'rmii lPME Unit Fee: $48.00 PME Permit Fee: $48.00 Administrative Fee: 1ADMIN $45.00 Work Without Permit? O Yes (j) No $0.00 TOTALS: Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: ie h. t'l:ar< Elec. Plan Check 10.0 1 hrs $0.00 Elec. Permit Fee: IEPERM17 -t [IF Other Elec. Insp. ETrs $48.00 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School oil COB/art tho I)Pnt %nr a/Idn 'l inla_ F(EEITEMZS (Fee .Resolution 11-053 F�: 7.-1/13) FEE QTY/FEE MISC ITEMS TT JJ an PME Plan Check: $0.00 P";C, (/'c'rmii lPME Unit Fee: $48.00 PME Permit Fee: $48.00 Administrative Fee: 1ADMIN $45.00 Work Without Permit? O Yes (j) No $0.00 Travel Documentation Fee: ITRA VDOC $48.00 Strong Motion Fee: $0.00 Select an Administrative Item Bld17 Stds Commission Fee: $0.00 SUBTOTALS: 1 $189.00 $0.00 TOTAL FEE: $189.00 Revised: 10/01/2015 CCNSTRUCTION PERMIT APPLICATION CONNUNI I Y DEVELOPP�4ENT DEPARTMENT. BUILDING DIVISION 10300 T ORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - buildinge.cuDertino.org CUPERTINO• I ��/ //-��, ') ❑ NTEW CONSTRUCTION ❑ ADDITION ❑ AI TE�a T10N / iI 20REVISION / DEF= -D ORIGNAL PZ?-1ZT � 566 000'7 F?RO cCt ADDRESS nI .4PNk L?4C74 ?HONE 0b _ e� S 1047i��� STREET ADDRESS 49 -1 -MES I Ci i Y, STA T c, ZIP I FAX COYI-ACT NAME PHONE I E NSII STRE T ADDRESS 2 ^, ^✓ / CITY, STAII- ZIP K❑ (OAIIIMRAGTZ 941 NL'; r ❑ OAINE R ❑. OWILii-BUIIAER ❑ C01,,-KA.0 OR ❑ c0i'MUCTORAGT? ❑ FRCh 7i'-CTGLC—R ❑ DEVELOPER ❑ —�f COh ACTORNANE I LICBNSENUI,SER I LICENSE TYFB I BUS. LIC 9 COt✓3ANYNAlr'- E -N SII. I FAX STRtET ADDRESS MY, Y, STA i n, ZIP I PRONE AR=ECTrGNG1N-EFRN/ ./B I LICENSEh"JEER BL'S. LIC I C01✓3ANY NA- M E-1✓.P3L FP.X STREET f.DDRESS I CITY, STATE, ZIP I Pi301 T DESCR271ION OF WORK rf ®„ L E),7STD4GUSE( PROPOSED USE CONST R.TYPE RSTOR S I I U' F i TYPE OCC. SQ.FT. V.d.LUATiCN Sj EXISTG NEIVFLOOR DET40 TOTAL ---- F.REA AREAf ( R. EA 1�T AREA I I - I BA71-2,00M KTITCIMN oT-HER RF.VfODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKTORCi ARBA Gf.RAGE AR'-_A:LJD=TACH ❑ ATTACH I R D\k'ELLINGL-WITS: 15 A SECOND UNIT ❑ YES SECOND STORY ❑1.5 BEING ADDED? ❑NO ADDITION? ❑NO PRE- PPLICATION ❑)=S IF1S,PROVIDECOPY OF PLAN ING `.PPL R ❑ NO PLA ,N7I2\G APPROVAL LETTER IS THE BLDG AN ❑2n5 EICHLER HOME? []NO �C--` ,I TOT.4LVALUA110N: t - _ By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I 'e 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 const I authorize representatives of Cupertino to enter the above-identifle ropeYy ' inspection purposes. SignarilreofApplicant/A;ent: Date: Z SU-PPLEAQENTA INFORINQATION REQUIRED- ' NOW ..'0_L,RGSL(ax New SFD or?`Qultifarnily &-vellin_s: Apply for demolition pe unit for eXisting building(s), Demolition permit is required prior to issu_-Ice of building permit for new building. _ Commercial Bldgs: Provide a completed Hazardous Materials Discloss,Ire cD ren = LB 5, fore if any Hazardous Materials are being used as part of this project. _ Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. F 10A Bldgfpp_2011.doc revised 06/21/11 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1648 PRIMROSE WAY CONTRACTOR: SHANMUGAM PERMIT NO: 15060007 SIVASHANKER AND SIVASHANK OWNER'S NAME: SHANMUGAM SIVASHANKER AND SIVASHANK 1648 PRIMROSE WAY DATE ISSUED: 09/15/2015 OWNER'S PHONE: 4088288706 CUPERTINO, CA 95014-5230 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ ADDITION TO CREATE 2 NEW BEDROOMS AND SITTING AREA License Class Lic. # (838 SQ FT); ADD 60 SQFT (N) PORCH; REMODEL (E) KITCHEN(160 SQ FT); OTHER REMODEL AREA (180 SQ 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 that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: Sq. Ft Floor Area: Valuation: $150000 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. APN Number: 36615006.00 Occupancy 'Type: 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. PERMIT EXPIRES IF WORK IS NOT STARTED APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR 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 180 DAYS FROM LAST CALLED INS E TION. to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save Lo �jj�����jl� �% DOW indemnify and keep harmless the City of Cupertino against liabilities, judgments, Issued by: " ' Y ' Date: {� Kl 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. 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. if 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 t. I, as owner of the property, or my employees with wages as their sole HAZARDOUS MATERIALS DISCLOSURE compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed contractors to I have read the hazardous materials requirements under Chapter 6.95 of the construct the project (Sec.7044, Business & Professions Code). California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & I hereby affirm under penalty of perjury one of the following three declarations: Safety Code, Section 25532(a) should I store or handle hazardous material. i. I have and will maintain a Certificate of Consent to self -insure for Worker's Additionally, should I use equipment or devices which emit hazardous air Compensation, as provided for by Section 3700 of the Labor Code, for the 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 performance of the work for which this permit is issued. Health & Safety Code, Sections 25505, 25533, and 25534. 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 Owner r author' agent: permit is issued. ,. Date: 3. 1 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I I hereby affirm that there is a construction lending agency for the performance of work's become subject to the Worker's Compensation provisions of the Labor Code, I for which this permit is issued (Sec. 3097, Civ C.) must forthwith comply with such provisions or this permit shall be deemed Lender's Name revoked. Lender's Address APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is ARCHITECT'S DECLARATION correct. I agree to comply with all city and county ordinances and state laws relating I understand my plans shall be used as public records. to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save Licensed Professional 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 Cupertino Municipal Code, Section 9.18. J�jthe r /�: � 0 1 Signature t\+ �" Date Q «� CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(aDcupertino.orq 10M ❑ NEW CONSTRUCTION PTADDITION ❑ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT # PROJE(7f ADDRESS OWNER NAME ^HONE O� Q�Q� E-MAIL V, lJ STREET ADDRESS 1 n CITY,' STATE, ZIP(J FAX i' f� G CONTACT NAME C PHONE E-MAIL Z 4 HG£s�ofs0.c L.01? 14 STREET ADDRESS 3� T ✓f CITY, STATE, ZIP 45 FAX , r k,9041- El ❑ OwTIER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT _ ❑ ARCHITECT /ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORNAME LICENSE NUMBER FCENSETYPE BUS. LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PI4ONE ARCHITECT/ENGINEER NAME �} G / LICENSE NUMBER ^ / BUS. LIC # COMPANY NAME E-MAIL ^, r[� �����L• L, C FAX STREET ADDRESS � / ^, J� t ' CITY, STATE, ZIP PHONE/ DESCRIPTION OF WORKnLt�� x_:P \7. nx/q -T -- A€e> w1,Jb-o) Li — 7a Q`IQ EXISTING USE PROPOSED USE TYPE # STORIES nC7 LONSTR_ USE TYPE OCC. SQ.FT. VALUATION (i) EX2STG AREA /a j 7�C� J NEW FLOOR, DEMO AREA AREA _g � TOTAL NET AREA z7,1 7 .. BATHROOM KrfC OTHER REMODEL AREA REMODEL AREA 0 REMODEL AREA /Q 0 PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREAL; DETACH ❑ ATTACH # DWELLING UNITS: 1S A SECOND UNIT ❑ YES SECOND STORY [3 YES BEING ADDED? W0 ADDITION? ®RO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES -$y ' 'r 3;^- K - TOTAL VALUATION: PLANNING APPL,' qNO - PLANNING APPROVAL LETTER G EICHLER HOME? .CNO _ - mum By my signature below, I certify to each of the following: I am the property owner or author ed agent to act on the property 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 building constructi uthorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Appl icant/A Rent: _ �� Date: SUPPLEMENTAL INFORMATION REQUIRED 100Pry c>cxT]TE ROIIru�csLrP New SFD or Multifamily dwvellings: Apply for demolition permit for Eli, ` ❑ existing building(s). Demolition permit is required prior to issuance of building NR r� OVERTffi COUTE BLTIIDPVGPLANREViE�V x permit for new building. J ❑zPAEss A °❑ PLANRIIvGPLANi2EVTEFv :' Commercial Bldgs: Provide a completed Hazardous Materials Disclosure f -� T� i lg �WC� ❑ sTArIDARD 3 t } ` ai iS?r' -cTS ❑ PUBLICRORxs _ form if any Hazardous Materials are being used as part of this project. ��, ,«g7A ❑ LARGI+: rte_ fl-tM 99 Nli7h_ x ,v�' i'%� r _ Copy of Planning Approval Letter or Meeting with Planning prior tof ❑�MA70R - ���=��� `❑�SAI�TPAR submittal of Building Permit application. S RDISTRI BldgApp_2011.doc revised 06/21/11 t�7 ���``,,``��,� CITY OF CUPERTINO 1�►i*'_'Yl1Sl FF.F. FRTIMATOR - BUILDING DIVISION OCCUPANCY TYPE: 1648 PRIMROSE WAY DATE: 06/01/2015 REVIEWED BY: PAUL IQADDRESS: APN: 366 15 006 BP#: 'VALUATION: 1$150,000 rtPERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY USE: SFD or Duplex 2nd Unit? 0 Yes G NoPENTAMATION OTC? © Yes 0 N 1 R3SFDADD PERMIT TYPE: WORK Addition to create 2 new bedrooms and sifting area 838S Ft add 60 S Ft nporch. Remodel E SCOPE kitchen(160SgFt),Other remodel area (180SgFt), Add New Sub Panel(100 Amp),Add 2 exterior p OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) II-B,III-B,IV,V-B 898 $2,654.00 IR3PLNCK $1,666.00 IR3INSP PME Plan Check: $0.00 Fl -00-1 amps $48.00 Electrical 1 IBELEC200 I Services Permit Fee: $1,666.00 Suppl. Insp. Fee -.0 Reg. Q OT 0.0 hrs $0.00 160 s.f. Remodel, Kitchen (<=300 sf) $645.00 IREMRESKIT PME Unit Fee: $0.00 PME Permit Fee: $48.00 180 s.f. $431.00 Remodel, Other IREMRESOTH TOTALS: F 898 $2,654.00 $1,666.00 MECH, HOURLY ® Yes G No PLUMB, HOURLY Q Yes Q No ELEC, HOURLY O Yes Q No ---- ---- - - MISC ITEMS Elec. Plan Check 1 0.0 hrs $0.00 $2,654.00 0 # $1,006.00 Elec. Permit Fee: IEPERMIT LiOther Elec. Insp. 0.0 hrs ii0ol NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public works, fire, Sanuary newer [IJJJI ILE, ULrluuJ !_ __ _ _ L_ -_J __•L...._,.1:.....:........:..ln.•..,n/inn aj,a;tnh1P aJJd arP nniv an Pstimate. Contact the Dept for addn'l info. Ulsrrid, eic. . i nese ee" ure uu3cu urs tic , o.u..u.... FEE ITEMS (Fee Resolution II -033 Eff. TT`131 .,.—........,.. ».»..-.--- FEE ----- --- - QTY/FEE ---- ---- - - MISC ITEMS Plan Check Fee: $2,654.00 0 # $1,006.00 Window / Sliding Glass Door iwINNEwNST New (Non -Structural) Suppl. PC Fee: (F) Reg. Q OT 0.0 hrs $0.00 PME Plan Check: $0.00 Fl -00-1 amps $48.00 Electrical 1 IBELEC200 I Services Permit Fee: $1,666.00 Suppl. Insp. Fee -.0 Reg. Q OT 0.0 hrs $0.00 160 s.f. Remodel, Kitchen (<=300 sf) $645.00 IREMRESKIT PME Unit Fee: $0.00 PME Permit Fee: $48.00 180 s.f. $431.00 Remodel, Other IREMRESOTH L 0 Work Without Permit? Yes Q No $0.00 Advanced Planning Fee: IPLLONGR $125.72 Select a Non -Residential Building or Structure ©A Travel Documentation Fee: ITRAVDOC $48.00 Strony, Motion Fee: IBSEISMICR $19.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $6.00 SUBTOTALS: $4,567.22 $2,130.00E TOTAL FEE: $6,697.22 Revised: 05/07/2015 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: 1&,49 T��SG PERMIT # X -Cb & -- nO0,7 OWNER'S NAME: Si✓��,y}q��ir�-�Q. PHONE # 40� cK-lo, 3 GENERAL CONTRACTOR: 9ri/l4x>6Y /,S SINESS LICENSE # 3 Lc -2- ADDRESS: ADDRESS: -&44, QTY/ZIPCODE: *Our municipal code requires all businesses working in the cffy 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. --1 I am not using any subcontractors:, �a2' IT q. Signature Please check applicable subcontractors and complete the following information: C21 -7 , Date V 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 CUPERTINO SMOKE / CARBON MONOXIDE ALARMS OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(a)cupertino.org Permit No. 150 CJ' O 6 O Do "7 Address 6 4& PR , In go se Yr Ci;i� ni0 # of Alarms Smoke: `7 Carbon Monoxide: PERMIT CANNOT BE FINALED AND COMPLETED UNTIL THIS CERTIFICATE HAS BEEN SIGNED .NED AND RETURNED TO THE BUILDING DIVISION PURPOSE This affidavit is a self -certification for the installation of all required Smoke and Carbon Monoxide Alarms for compliance with 2013 CRC Section R314, 2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for inspections are required. GENERAL INFORMATION Existing single-family and multi -family dwellings shall be provided with Smoke Alarms and Carbon Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds $1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon Monoxide Alarms be installed in the following locations: AREA SMOKE ALARM CO ALARM Outside of each separate sleeping area in the immediate vicinity of the bedroom(s) X X On every level of a dwelling unit including basements X X Within each sleeping room X Carbon Monoxide alarms are not required in dwellings which do not contain fuel -burning appliances and that do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal. Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated. In existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do not result in the removal of wall and ceiling finishes or there is no access by means of attic, basement or crawl space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for alarms which must be connected to the building wiring. As owner of the above -referenced property, I hereby certify that the alarm(s) referenced above has/have been installed in accordance with the manufacturer's instructions and in compliance with the California Building and California Residential Codes. The alarms have been tested and are operational, as of the date signed below. I have read and agree to comply with the terms and conditions of this statement Owner (or Owner Agent's) Name: V�1S�Tt�Tli9 S�vaS4r�`t` } 1 Si nature...... �C,.•.•.••I�'1 Date: �.1. Contractor Name: Signature................................................................... Lic.#...................................... Date: ................... Smoke and CO form.doc revised 03/18/14 WATER -CONSERVING PLUMBING FIXTURES OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-32 , • FAX (408) 777-3333 • building aC-cupertino.org 1,5-c) d p 67 Owner Name V n S A, N! (� I VA SH &21 K C a Permit No. Address 8 PR i mo ; E CI V f CPJ _% l t✓y 1. Is your real property a registered historical site? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. 2'1�o Go to Question 2. 2. Does your real property have a licensed plumber certifying that, due to the age or configuration of the property or its plumbing, installation of water -conserving plumbing fixtures is not technically feasible? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. ❑ The licensed plumber's certification has been provided to the Building Division. Skip the rest of the form and sign bottom of form. 0 No Go to Question 3. 3. Is water service permanently disconnected for your building? ❑Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. '❑, No Go to Question 4. 4. Is your real property built and available for use or occupancy on or before January 1, 1994? ❑ No My real property is built and available for use or occupancy after January 1, 1994. Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. E21'YeS My real property is built and available for use or occupancy on or before January 1, 1994. Civil Code Sections 1101.1 through 1101.8 apply. Check one of the three following statements and sign bottom of form.. Please check ONE of the following: Z My property is a single-family residential real property. See Civil Code Section 1101.4. On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures throughout the building. On or before January 1, 2017, all non- compliant plumbing fixtures shall be replaced with water -conserving plumbing fixtures (regardless of whether property undergoes alterations or improvements). ❑ My property is a multifamily residential real property. See Civil Code Section 1101.5. On and after January 1, 2014, specified building alterations or improvements shall require non- compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures. On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water - conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). ❑ My property is a commercial real property. See Civil Code Section 1101.5. On and after January 1, 2014, specified building alterations or improvements shall require non- compliant plumbing fixtures to be replaced with water -conserving plumbing fixtures. On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). I, as the owner or owner's agent of this property, certify under penalty of perjury that non-compliant plumbing fixtures will be replaced prior to date specified above with water -conserving plumbing fixtures in accordance with Civil Code Sections 1101.1 through 1101.8, the current California Plumbing Code and California Green Building Standards Code, and manufacturer's installation requirements, and that the water -conserving plumbing fixtures comply with the requirements as indicated in the table on the following page. _ n 11", , Owner or Owner Agent's Signature: 1V\Cn/'�% Date: _l�1 b 1 I b Upon completing and signing this Certificate, please return it to the Building Division in order to final your building permit. SB407 2015.doc revised 08126/15 BUILDING PERMIT CANNOT BE FINALED AND COMPLETED UNTI] CERTIFICATE HAS BEEN SIGNED AND RETURNED TO THE BUILDING THIS:.. 1. If the existing plumbing fixture water usage/flow rate is equal to or lower than the figure shown, it is not required to be upgraded. SB4072015.doe revised 08126115 Non -Compliant Water -Conserving Plumbing Fixture Plumbing Fixturel (Fixture Complying with Current Code Applicable to New Construction) Maximum Water Usage/Flow Rate Fixture Type Water Usage 2013 CPC Ch. 4 2013 CPC Ch. 4 2013 CPC Ch. 4 /Flow Rate 2013 CALGreen Div. 4.3 2013 CALGreen Div. 4.3 2013 CALGreen Div. 5.3 Single -Family Multi -Family Commercial Residential Residential Water Closets Exceed 1.6 Single flush toilets: 1.28 gallons/flush (Toilets) Gallons/flush Dual flush toilets: 1.28 gallons/flush effective flush volume (the composite, average flush volume of two reduced flushes and one full flush Urinals Exceed 1.0 0.5 gallons/flush Gallons/flush Showerheads Exceed 2.5 2.0 gallons per minute @ 80 psi. Also certified to the performance criteria of gallons per minute U.S. EPA WaterSense Specification for Showerheads (A hand-held shower is considered a showerhead.) For multiple showerheads serving one shower, the combined flow rate of all showerheads and/or other shower outlets controlled by a single valve shall not exceed 2.0 gallons per minute @ 80 psi, or the shower shall be designed to allow only one shower outlet to be in operation at a time. Faucets — Exceed 2.2 gallons Maximum 1.5 gallons per Within units: 0.5 gallons per minute @ 60 Lavatory per minute minute @ 60 psi; minimum Maximum 1.5 gallons psi Faucets 0.8 gallons per minute @ per minute @ 60 psi; 20 psi minimum 0.8 gallons per minute @ 20 psi In common and public use areas: 0.5 gallons per minute @ 60 psi 1.8 gallons per minute 60 psi Faucets — Exceed 2.2 gallons 1.8 gallons per minute @ 1.8 gallons per minute 1.8 gallons per minute @ 60 Kitchen per minute 60 psi @ 60 psi psi Faucets May temporarily increase May temporarily up to 2.2 gallons per increase up to 2.2 minute @ 60 psi, and must gallons per minute @ default to maximum 60 psi, and must 1.8 gallons per minute @ default to maximum 60 psi 1.8 gallons per minute Where faucets meeting @ 60 psi the above are unavailable, Where faucets meeting aerators or other means the above are may be used to achieve unavailable, aerators or reduction. other means may be used to achieve reduction. 1. If the existing plumbing fixture water usage/flow rate is equal to or lower than the figure shown, it is not required to be upgraded. SB4072015.doe revised 08126115 CUPERTINO Date: 6/2/15 Building Department CITY OF CUPERTINO 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 TELEPHONE: (408) 777-3228 • FAX: (408) 777-3333 OUTSIDE AGENCY PLAN CHECKING FEES Agency Name: 4 -LEAF Permit Number: 15060007 (Add 838 sq ft, other remodel area) Project Address: 1648 PRIMOSE WAY Plan Check Fees: $1,725.10 Hourly plan check fees: Number of hours: Plan check based: 1St & 2nd plan checks included in initial plan check fee: $1,725.10 (Agency Fee -65% already calculated) 3rd plus plan checks: Number of hrs ($143.00 per hr, 2hr min. minus 10%) Please attach this form with the number of hours spent on the 3rd plus plan checks and send with the plan check comments or if plans are approved, with the plans & approval letter. Please email the plan check comments to: Melissan(cr�,cupertino.org *Please do not give plan check comments directly to the customer. We don't give out the comments until we have all of them back from each department. N f NTIAL CHECKLIST — MANDATORY Is I COMMUNIIClOPMENT DEPARTME I�DIN DIVI N OR P.E. C.B.O. BUILDING OFFICIAL t: C CUPERTItVO � ALBERT SALVADOR, to 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building0-cuRertino.om PURPOSE: RECEIVED i The 2013 CalGreen Code applies to additions or alterations of existing residential buildings where the addition] or alteration increases the building's conditioned area, volume, or size and also applies to JLAI l llviaia i residential buildings, high-rise residential buildings, or both. Existing site and landscE ping improvements that r are not otherwise disturbed are not subject to the requirements of CALGreen. BY: Project Name: _�-/ VA -H K.FS IDEW IIAL- L / a-J-'-�) I J c -V Project Address: _i 64& i H kc6p "cy \y r Nr i�T%illy CA Project Description: j- ,�,�T T- ,{?-E�,Q ,¢DD/�/C�1 4£J►yr7J>E�- cc rw, ' T�C� C��� /ver -rte � M Instructions: 1. The Owner or the Owner's agent shall employ a licensed professional experienced with the California Green Building Standards Codes to verify and assure that all required work described herein is properly planned and implemented in the project. 2. The licensed professional, in collaboration with the own design pro(WiiWaRTINGial Column J -� 1 2 of this checklist, sign and date Section 1 - Design Ve ,at the end[�f;thi.%phWAtVtwW have the checklist printed on the approved plans for the project. . r 3. Prior to final inspection by the Building Department, the I�professbnal shall complete Column 3 and sign and date Section 2 - Implementation Verifica at the end of this checklist and submit the completed form to the Building Inspector. kFVIFVVEU FUR UWE COMPLIANCE E wl kaviewaa BY. ..�`Xi ` h4 Column 2 Column 3 MANDATORY FEATURE OR MEASURE Project Verification Requirements Planning and Design - Site Development 4.106.2 Storm water drainage and retention during construction. A plan is ❑ developed and implemented to manage storm water drainage during construction. 4.106.3 Grading and paving. The site shall be planned and developed to ❑ keep surface water away from buildings. Construction plans shall indicate how site grading or a drainage system will manage all surface water flows. Ilage 1 45 CalGreen_2014.doc revised 11104/14 A4.2 General 4.201.1 Low-rise residential buildings shall meet or exceed the minimum ❑ ❑ standard design required by the California Energy Standards. A4.3 WATER• ` • Indoor Water Use 4.303.1 Water conserving plumbing fixtures and fittings. Plumbing fixtures (water closets and urinals) and fittings (faucets and showerheads) shall comply with the following: ❑ 4.303.1.3.2 Water Closets. The effective flush volume of all water closets shall not exceed 1.28 gallons per flush. Tank -type water closets shall be certified to the performance criteria of the U.S. EPA WaterSense Specifications for Tank -type Toilets. ❑ 4.303.1.3.2 Urinals. The effective flush volume of urinals shall not exceed 0.5 gallons per flush. ❑ 4.303.1.3.1 Single Showerheads. Showerheads shall have a maximum flow rate of not more than 2.0 gallons per minute at 80 psi. Showerheads shall be certified to the performance criteria of the U.S. EPA WaterSense Specification for showerheads. ❑ 4.303.1.3.2 Multiple Showerheads serving one shower. When a shower is served by more than one showerhead, the combined flow rate of all showerheads and/or other shower outlets controlled by a single valve shall not exceed 2.0 gallons per minute at 80 psi, or the shower shall be ❑ ❑ designed to allow only one shower outlet to be in operation at a time. ❑ 4.303.1.4.1 Residential lavatory faucets. The maximum flow rate of residential lavatory faucets shall not exceed 1.5 gallons per minute at 60 psi. The minimum flow rate of residential lavatory faucets shall not be less than 0.8 gallons per minute at 20 psi. ❑ 4.303.1.3.2 Lavatory faucets in common and public use areas. The maximum flow rate of lavatory faucets installed in common and public use areas (outside of dwellings or sleeping units) in residential buildings shall not exceed 0.5 gallons per minute at 60 psi. ❑ 4.303.1.4.3 Metering faucets. Metering faucets when installed in residential buildings shall not deliver more than 0.25 gallons per cycle. ❑ 4.303.1.4.4 Kitchen Faucets. The maximum flow rate of kitchen faucets shall not exceed 1.8 gallons per minute at 60 psi. Kitchen faucets may temporarily increase the flow above the maximum rate, but not to exceed 2.2 gallons per minute at 60 psi, and must default to a maximum flow rate of 1.8 gallons per minute at 60 psi. 4.303.2 Standards for plumbing fixtures and fittings. Plumbing fixtures / and fittings shall be installed in accordance with the California Plumbing Code, LJ ❑ and shall meet the applicable standards referenced in Table 1401.1 of the California Plumbing Code. Page 2 of 5 CalGreen_2014.doc revised 11104114 Outdoor Water Use 4.304.1 Irrigation controllers. Automatic irrigation systems installed at the time of final inspection shall be weather -based. ❑ 4.304.1.1 Controllers shall be weather- or soil moisture -based controllers that automatically adjust irrigation in response to changes in plants' needs as weather conditions change. ❑ ❑ ❑ 4.304.1.2 Weather -based controllers without integral rain sensors or communication systems that account for local rainfall shall have a separate wired or wireless rain sensor which connects or communicated with the controller(s). Soil moisture -based controllers are not required to have rain sensor input. .. .4 MATERIAL CONSERVATION AND RESOURCE EFFICIENCY Enhanced Durability and Reduced Maintenance 4.406.1 Rodent proofing. Annular spaces around pipes, electric cables, conduits, or other openings in plates at exterior walls shall be protected ❑ ❑ against the passage of rodents by closing such openings with cement mortar, concrete masonry or similar method acceptable to the enforcing agency. Construction Waste Reduction, Disposal and Recycling 4.408.2 Construction waste management plan. Where a local jurisdiction does not have a construction and demolition waste management ordinance, a ❑ ❑ construction waste management plan shall be submitted for approval to the enforcing agency. Building Maintenance and Operation 4.410.1 Operation and maintenance manual. At the time of final inspection, ❑ ❑ an operation and maintenance manual shall be provided to the building occupant or owner. A4.5 ENVIRONMENTAL Fireplaces 4.503.1 General. Install only a direct -vent sealed -combustion gas or sealed ❑ ❑ wood -burning fireplace, or a sealed woodstove. Pollutant Control 4.504.1 Covering of duct openings and protection of mechanical ❑ equipment during construction. Duct openings and other related air distribution component openings shall be covered during construction. 4.504.2.1 Adhesives, sealants and caulks. Adhesives, sealants and caulks ❑ shall be compliant with VOC and other toxic compound limits. 4.504.2.2 Paints and coatings. Paints, stains and other coatings shall be ❑ compliant with VOC limits. 4.504.2.3 Aerosol paints and coatings. Aerosol paints and other coatings ❑ shall be compliant with product weighted MIR Limits for ROC and other toxic compounds. Page 3 of 5 CalGreen_2014.doc revised 11/04114 4.504.2.4 Verification. Documentation shall be provided to verify that ❑ ❑ compliant VOC limit finish materials have been used. 4.504.3 Carpet Systems. Carpet and carpet systems shall be compliant with 1:1 ❑ VOC limits. 4.504.4 Resilient flooring systems. Eighty (80) percent of floor area receiving resilient flooring shall comply with the VOC-emission limits defined in ❑ ❑ the Collaborative for High Performance Schools (CHPS) Low -emitting Materials List or be certified under the Resilient Floor Covering Institute (RCFI) FloorScore program. 4.504.5 Composite wood products. Particleboard, medium density ❑ ❑ fiberboard (MDF), and hardwood plywood used in interior finish systems shall comply with low formaldehyde emission standards. Interior Moisture Control 4.505.2 Concrete slab foundation. Required vapor retarders and capillary 0 ❑ breaks are also required to comply with CalGreen Section 4.505.2.1. 4.505.3 Moisture content of building materials. Moisture content of building 12( ❑ materials used in wall and floor framing is checked before enclosure. Indoor Air Quality and Exhaust 4.506.1 Bathroom exhaust fans. Exhaust fans which terminate outside the ❑ ❑ building are provided in every bathroom. Environmental Comfort 4.507.2. Duct systems are sized and designed and equipment is selected using the following methods: 1. Establish heat loss and heat gain values according to ACCA Manual J or equivalent. ❑ ❑ 2. Size duct systems according to ACCA 29-D (Manual D) or equivalent. 3. Select heating and cooling equipment according to ACCA 36-S (Manual S) or equivalent. INSTALLER AND SPECIAL INSPECTOR QUALIFICATIONS Qualifications 702.1 Installer training. HVAC system installers are trained and certified in ❑ ❑ the proper installation of HVAC systems. 702.2 Special inspection. The Licensed Professional responsible to verify ❑ ❑ CALGreen compliance is qualified and able to demonstrate competence in the discipline they inspect and verify. Verifications 703.1 Documentation. Verification of compliance with CALGreen may include construction documents, plans, specifications, builder or installer certification, inspection reports, or other methods acceptable to the enforcing ❑ ❑ agency which show substantial conformance. Implementation verification shall be submitted to the Building Department after implementation of all required measures and prior to final inspection approval. Page 4 of 5 CalGreen 2014.doc revised 11104/14 CALGREEN SIGNATURE DECLARATIONS Project Name: S j yAQ/ eF_si _,y -n L Cn Project Address: j 6 8 ��) %-� �C�c �;� C"Pc(Z,-n A n . C�} Project Description: Py?ot4 % At:;11>1 P C� _ iQ Q &D�'Ti ©4 tekFalQb E- 1Q 7-r_flclJ% Gc�r�YErZTIN C'TC' 41'4 SECTION 1 - DESIGN VERIFICATION Complete all lines of Section 1 — "Design Verification" and submit the completed checklist (Columns 1 and 2) with the plans and building permit application to the Building Department. The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and certify that the items checked above are hereby incorporated into the project plans and will be implemented into the project in accordance with the requirements set forth in the 2013 California Green Building Standards Code as adopted by the City of Cupertino. G D z Ow r s Signature Date S i y i✓I ti l<V-: Owner's Name (Please Print) Design Professional's Signature Date RA kr- Design Professiona ' Name (Please Print) Signature of License Professional responsible for CalGreen compliance Date Name of License Professional responsible for CalGreen compliance (Please Print) Phone sF-!CZ0L_ ' Email Address for License Professional responsible for CalGreen compliance SECTION 2 - IMPLEMENTATION VERIFICATION Complete, sign and submit the competed checklist, including column 3, together with all original signatures on Section 2 to the Building Department prior to Building Department final inspection. I have inspected the work and have received sufficient documentation to verify and certify that the project identified above was constructed in accordance with this Green Building Checklist and in accordance with the requirements of the 2013 California Green Building Standards Code as adopted by the City of Cupertino. Signature of License Professional responsible for CalGreen compliance Date Name of License Professional responsible for CalGreen compliance (Please Print) Phone Email Address for License Professional responsible for CalGreen compliance Page 5 of 5 CalGreen_2014.doc revised 11/04114 OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building alcuoertino.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: SITE ADDRESSp /^ ��J 16U�I� �Mi�dSr �"n-� 71API `.",w BP# OWNER NAME OWNER ADDRESS- _ OMOO /#4 o. DESCRIPTION OF WORK: AD 6h] N?r M 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.) !�L1. 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. gLL2. 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. 'te3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may p'Foct 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. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license n mbers on permits and contracts. _5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the of tai 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. YV - 6. 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. 7.1 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. 8. 1 understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for dny 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 �� 9. 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 Accidents. I also understand I may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed contractors. '9�: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 b all applicable laws and requirements that govern Owner -Builders as well as employers. '12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the Wormation 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 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. r Property Owner's Signature: Date: 0 (� ---- - ---- ----------- -- -- -- ---- ----- --- --- ------ --------- ---------------------------- (NOTE: The following-- Authorization- - -Form-is required to be completed by the property owner only when designa-ting 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 pen -nit is issued to verify the property owners signature. Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revised 04/14/10