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15070231CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20852 CHERRYLAND DR CUPERTINO CA 95014 (359 20 03 1) OWNER'S NAME: SUEJANE HAN OWNER'S PHONE: 408-568-0616 LICENqFDCONTRACTOR'S DECLARATION License Class Lic. # 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. hereby affirm under penalty of perjury one of the following two declarations: 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. 2. I have and will maintain Worker's Compensation hrsurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICAn CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date 5/2/2016 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: r. 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 ($ec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed 7 contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: 1. I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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. i�I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. Ifj after making this certificate of cxernption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPI.IC NT CU'R MCATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, Judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Date 22a= CONTRACTOR; ;PHON;ENO: O: 15070231 ED: 10/29/2015 BUILDING PERMIT INFO: —BLDG —ELECT _ PLUMB _ MECH _ RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: CONSTRUCT NEW 2 STORY SFD (3777 S.F.) WITH ATTACHED GARAGE (465 S.F.) AND NEW PORCH AREA (432 S.F.) REV #1- CHANGE PILES FOUNDATION INTO RAISED FLOOR, RESUBMIT S-2 FOUNDATION PLANS ISSUED: 5/2/2016 Sq. Ft Floor Area: $677000.00 APN Number: Occupancy Type- 35920031 ype:35920031 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. by: ALEX VALLELUN .A Aj,Qqrab /2 /2 1 RE -ROOFS' .All roofs shall be inspected prior to any roofing material being installed If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: 5/2/2016 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSI RE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. :Owner-or_autftQdzedagerlt:)l Date: 5/2/2016 CONSTRU I hereby affirm that there is a constructionending agency, for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHi ECT'S DFCI ARAUM I understand my plans shall be used as public records. Licensed City of Cupertino Pemit renewal Date: April 10, 2017 Building Address: 20852 Cherryland Drive, Cupertino Permit No: 15070231 Owner Name: Cherryland LLC/ Suejane Han Owner address: 20846 Dunbar Drive, Cupertino The building completion has been delayed. A lot of outside improvement on the private street need be done. The heavy rains has impacted the work schedule for the last few months. The estimated building completion date is the end of July 2017. Owner Cherryland LLC/ Suejane Han CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDINGDIVISION ` r 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 C V I CUPERT[NO (408) 777-3228 • FAX (408) 777-3333 • buildingacuoertino.org ❑ N0V CONSTRUCTION ❑ ADDITION ❑ .4LTER.4TION / TI ❑ REVISION / DEFERRED ORIGIlNIAL PERMIT n PROTECT ADDRESS. o E-h4A1L 01AINTERNAME I PHONELy STREET ADDRESS 'Zr�(L,_ , I /�% �S CITY, TATE, ZIP I FAX CA 0 CONTACT NAME/ PHONE N Q JL�ZI (.!Cs STREETADD Q Sfe ^r CITY, uTE, ZIP rP_ ❑ O-ANa ❑ OWT'ER-BUILDER ❑ OWNERAGENT ❑ CONTAACTOR ❑CONTRACTORAGENT ❑ ARCHITECT E.'vGWEER ❑ DENr.LOPER ❑ TENANT CONTTRACTOR N.AJX4E LICENSE NL14BFR LICENSE TYPE BUS. LIC R COhIPANY NAM�E E-MAIL FAX STREET ADDRESS I CITY, STATE, ZIP PHONE ARCHITECT.ENGLNTEERNAh1E ^ LICENSENUI�IBERC65�65 CC— BUS.LIC� NI COP.AhY NAS Et4"_ EA,1AIL. FAX 1 �" 1 ra , C STREET RESS, lasy� CITY, ATE, ZIP C� PH E 93�),.-E .if �C)Q� �0 ��- .54? DESCRIPTION OF WORK Ycla_V l Ya S of uye, ubw�_t _+ so EXISTING USE PROPOSED USE CONSTR. T1PE n STORIES 1 L'SE TYPE I OCC. I SQ.FT. I \'?1L'A-.G'd (S) EGSTG NEW FLOOR DEMO TOTAL AREA I AREAARr 4 TET AREA BATHROOM KITCHEN OTHER REMODELAREA REMODEL AREA REMODELARE.A PORCH AREA DECK AREA TOTAL DECK'PORCH R.EA Ga3 SGE .AREA: DETACH ❑ ATTACH I #DNVELLTNGUNtTS: IS A SECOND tNrr 1'E5 SECOND STORY ❑1'Es BELNGADDED? NO ADDITION? ❑NO PRE-AP?LICA7,1oN ❑ YES IF )7_S, PROVIDE COPY OF 1S THE BLDG AN ❑ 1---S RECEIVED BY`TOTAL VALUATION: PLA1.T-TNG ADPL R ❑ NO PLAN -TNG APPROVAL LETTER EICHLER HOME? [:]AO �I 1 1 r 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 Us 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 la -\,.•s relating to build' g construction. uthorize representatives of Cupertino to enter the above-identi=red propertyforinspection purposes. Signature of Applicant/Agent: Date: ' 2-.3 SL'PPLEI`4ENTAL INFO TION REQUIRED FLAN c::FC I'E ew SFD or 1\4ultifamily dwellings: Apply for demolition permit for _ existing building(s). Demolition permit is required prior to issuance of building permit for new building. Commercial Bldgs: Provide a completed Hazardous N4aterials Disclosure _. GT.: , _ foi_n if any Hazardous \Iaterials are being used as part of this project. - — _ . _ F;'r':E DEPT Copy of Planning Approval Letter or Nfeeting , pith Planning prior to — _ submittal of Building Permit application. - Bldg.2pp_7011.doc revised 06/71/11 I CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20852 CHERRYLAND DR I CONTRACTOR: CHERRYLAND LLC PERMIT NO: 15070231 OWNER'S NAME: CHERRYLAND LLC 20846 DUNBAR DR 1 DATE ISSUED: 10/29/2015 OWNER'S PHONE: 4084645030 CUPERTINO, CA 95014-2958 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑ CONSTRUCT NEW 2 STORY SFD (3777 S.F.) WITH License Class Lie. # ATTACHED GARAGE (465 S.F.) AND NEW PORCH AREA (432 S.F.) 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: 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. 2. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: t. I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed contractors to 4 construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: 1 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. a. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against 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. Date (0 —)-J —W I Sq. Ft Floor Area: I Valuation: $677000 APN Number: 35920031.20852 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 D S FROM LAST CALLED INS C ION. Issued by: ULO I,(,LUV& Date: 19 W 15 RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant: I Date ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authoriz gent: n � Date: U CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional CITY OF CUPERTINO 15040,93) FEE ESTIMATOR - BUILDING DIVISION OCCUPANCY TYPE: IADDRESS: 20852 CHERRYLAND RD (LOT 3) DATE: 07/31/2015 REVIEWED BY: PAUL PC FEE ID APN: 359 20 031 BP#: *VALUATION: 1$677,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: New Construction PRIMARY USE: SFD or Duplex 2nd Unit? Yes • No PENTAMATION PERMIT TYPE: 1 R3SFD i WORK Construct new 2 story SFD 3777 S.f. with attached Garage 465 S.f. and New Porch Area 432 S.f. SCOPE OCCUPANCY TYPE: TYPE OF CONSTR. FLR AREA s.f. PC FEES PC FEE ID BP FEES BP FEE ID R-3 (Custom) II-B,111-B,IV,V-B 4,674 $3,327.11 IR3PLNCKI $3,915.51 1R31NSP $0.00 PME Plan Check: $0.00 Permit Fee: $3,915.51 Suppl. Insp. Fee:Q Reg. Q OT 0.Q hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS: 4,674 $3,327.11 Construction Tax: IBCONSTAXR $3,915.51 # new units NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.. Thesefees are based on the preliminar information available and are only an estimate. Contact the Dept for addn7 info. FEE ITEMS (Fee Resolution 11-053 E„f: 71 11113) Rech. Ilan Check FT !'lamb. flan (.'heci 'i;ec. Plan Check iZelt. Permit Nee: Plumb. Permir Fee: Elec. Permit Fee lrer.,idei:lt. Insp. )rher Phmrb hap, )ther Elec. hap. Li ;,,ch. Insp. F-U I" ., Insp. Fee: NOTE. This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.. Thesefees are based on the preliminar information available and are only an estimate. Contact the Dept for addn7 info. FEE ITEMS (Fee Resolution 11-053 E„f: 71 11113) FEE QTY/FEE MISC ITEMS Plan Check Fee: $3,327.11 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: E) Reg. OT0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $3,915.51 Suppl. Insp. Fee:Q Reg. Q OT 0.Q hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: IBCONSTAXR 1 # new units $684.98 0 E) Work Without Permit? Yes (F) No $0.00 Advanced Planning Fee: IPLLONGR $654.36 % Select a Non -Residential Building or Structure 0 0 �/ (!IZ'11 )i!, iU/1C79tLf/CUrI /c'i'1. Strong Motion Fee: IBSEISMICR $88.01 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $28.00 SUBTOTALS: $8,697.97 $0.00 TOTAL FEE: $8,697.97 Revised: 07/02/2015 FA CUPERTINO 1 NEW CONSTRUCTION CONSTRUCTION PERMIT APPLICATION COM10UNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ��j 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 )5D9 ^� J"' (408) 777-3228 • FAX (408) 777-3333 • buildina(5cupertino.org lJ Ilil ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION /DEFERRED ORIGINAL PER MIT PROTECT ADDRESS /� " Q_ t5 r2/ J tv /w (J` • C/ j l 1 ou OWNER NAME \ PHONE E -MP IL STREET ADDRESS CITY, STATE, ZIP FAX �uh D p �Y % Y CONTACT NAME PHONEE MAII D / , t1J (� f Kms• irar coH, STREET ADDRESSCITY, STATE, ZIP FAX - o`? o LL -9,A -4P4-60 i OWNF-R ❑. oWN-R-BuazER ❑ oANERAGDvT ❑ COA RACTOR ❑ CONTRACTOR AGENT WARCHITECT ❑ENGLII*rMR ❑ DEVELOPER ❑ IE,11, CONTRACTOR NAME LIC>~TSENUMBER LICENSETYPE I BUS. LIC f COMPANY NAME E-M.A1L FAX STREET ADDRESS CITY, STATE, ZIP PHONE AR /ENGINEER NP.ME LICENSE NUMBER / C— zi 2- BUS. LIC R h COMPANFY NAME E-MA.IL FAX — — STREET P.DDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK ac q rA -'P- -- EXISTING USE PROPOSED USE CONSTR. TYPE r STORIES N I` ' _ V � / t3'Z USE TYPE OCC. SQ.FT. VALUATION (S) EXTSTG AREA NEW FLOOR AREA -1 DEMO p TOTAL AREA N NET AREA q -1--\ '[ Li V ► �� p� bC)C� BATHROOM y REMODEL AREA KITCHEN REMODEL AREA OTTER REMODEL AREA Q� / R- (' b� PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA`-: DETACH TDWELLINGUNTr lSASEOONDt1NrC ❑YES SECOND TORY []YES ADDED! BEINC ADDED! UPO ADDITION' NO PRE -APPLICATION 'ES IF YES, PROVIDE COPY OF PLANNING NO PLAhT'II�GAPPROVALLETTER IS THE BLDG AN ❑ YES EICHLERHOME? IVEDBY `"'; TOTAL VALUATION: APPLR X140 - -T pOb By my signature below, I certify to each of the followina: I am the property owner or authorized agent to act on the property owner's behalf. I ave 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 construction. I authorize representatives -of Cupertino to enter the above -identified property for inspection purposes. Signature of Appl icant/Agent: Date: SUPPLEMENT—AL INFOP MATION REQUIRED New SFD or Multifamily dvvellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building.�f _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure form 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. B1dgApp_2011.doc revised 06/11/11 The City of FREMONT UNION HIGH SCHOOL DISTRICT 589 WEST FREMONT AVENUE SUNNYVALE, CALIFORNIA 94087 408-522-2200 Developer Impact Fee Compliance Building permits will not be issued without a completed Certificate of Compliance CuWumo Building Permit Application has received a request for a Building Permit described as follows: New Residential Development _ Residential Addition (501) sq. ft. or more ( Uame`of Owner %peveIoper. + Project Address: CH FRRAPND R0 W t •j Square Footage T-! :�.�. � Dlesc`ription: Permit / Plan Check #71-�`� t Date: Cobb By: o 1, City Building Inspector Commercial Development Lot/Parcel # (jOOJ i 50 Square footage verified by the city prior to issuance of a building permit; fees may be adjusted accordingly. Feeder Elementary District SCHOOL DISTRICT DEVELOPER IMPACT FEE CERTIFICATE OF COMPLIANCE The authorized representative of the Fremont Union High School District has reviewed the City of , I 1'0'V. ,h V 10 Building Permit Request described above and hereby certifies that the developer or authorized representative has met the requirements of the District's Developer Impact Fee requirements. Dated: !'' - � Cl C By: Certificate not valid without District Seal, Initial, and Date Distribution: Facilities Planning —White Fremont Union High School District Authorized Representative Fee $ r ' City — Yellow Requestor — Pink Accounting — Gold Dev. Impact Fee Compliance (Rev. 11/22/05) [12/08 — 1000] Cupertino Union School District 10301 Vista Drive, Cupertino, CA 95014 Tel (408) 252-3000 • Fax (408) 865-0326 N° 10680 Developer Impact Fee Compliance The Cupertino Union School District has adopted Resolution Nos. 1403 and 1404, imposing developer impact fee pursuant to Government Code 53080. Building Permit Request The City of `'�') iv has received a request for a Building Permit described as follows: Residential Development Project F]Commercial/Industrial Development Project CDD\11 nt\ifl i 1 r Name of Developer: RQ%'' `- Project Address. &O`-^'''^ Description: Square Footage: Date: "11 1 M, tworla, WA - L-0!SULL-I V -P City Authorized Representative Square footage will be verified by the city prior to issuance of a building permit; fees may be adjusted accordingly. Important Notice: Cupertino Union School District gives no credit for total demolition of existing square footage area, which makes way for new construction as mandated in the Government Code Sections 53080, 53080.6 and 65995. SCHOOL DISTRICT DEVELOPER IMPACT FEE CERTIFICATE OF COMPLIANCE The authorized representative of the Cupertino Union School District has reviewed the City Of C U PEK1 r-IAID Building Permit Request described above and hereby certifies that the developer or authorized representative has met the requirements of the Districts Developer Impact Fee requirements. Dated: % By: Authorized1fepresentative Cupertino Union School District Certificate not valid without District seal, initial, and date. Fee: $ 7. fU G 9 " -s Check No.: T& s Facilities Planning - White City - Yellow Requestor - Pink Accounting - Gold C CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (406) 777-3228 • FAX (408) 777-3333 • building gQcuDertino.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 ADDRESS APN.3� CV'I SP ;� OWNERR NAME OWNER ADDRESS. � 1 DESCRIPTION OF WORK: 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.) 4*1. 1 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. I understand building permits are not required to be signed by property owners unless they are responsible for e c honstruction 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 ote t myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. �24. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the oal 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. W6. 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 top serious financial risk. 4' b. 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. `7&. 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 4�2JI9. 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 v✓ww.cslb.ca.gov for more information about licensed contractors. 5aji10.1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I am the party legally and financially responsible for proposed construction activity at the site address listed above. 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. 42.1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information l 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. . Property Owner's Signature: .�S1a `�` Date: ( n —1=:f�7-o) I,— (NOTE.' The following Authorization Form is required to be completed by the property ow- ner only w- hen 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 pen -nit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revised 04/14/10 1Ism Ea Permit #: 17967 Property Owner: Mailing: 20840 MC CLELLAN RD C APN #: CUPERTINO, CALIFORNIA 96014-2164 PHONE (408) 253.7071 FAX (408) 253-5173 www.c u pe rti nos a aitarydistrV-t.org Connection Permit Date Issued: Tract/Lot #: Telephone ll/We), being owner(s) (owner's agent), hereby make application for connection of the property at 20840 MC CLELLAN RDC I X 3C Consisting of the following type of Building: Type of Building: Units: Do hereby request a permit to connect to the sewer system of the Cupertino Sanitary District PERMIT CONDITIONS IN CONSIDERATION OF THE GRANTING OF THiS PERMIT, THE OWNER AGREES:'r'�� 1. To comply with all existing Ordinances. Rules and Regulations of the Cupertino Sanitary District as now or hereafter amended 2. To maintain the House Sewer (that portion of the sewer within private property) which includes a cleanout (raised to grade and accessible) located at the point of connection with the Lateral Sewer (that portion of the sewer in the street right-of-way or District 3 To acquire a Plumbing Permit from the City of Cupertino, Building Department and obtain onsite inspection and approval by said Building Department prior to covering of the work or use of the sewer. 4. To first expose and inspect for serviceability the Lateral Sewer (th at portion within the street right-of-way or easement), prior to starting construction of the house sewer. 5 That this permit does not constitute a request for the issuance of an encroachment permit for sewer construction in the street/public right -of-way of the agency having juhsdictlon thereover. 6 To call Underground Service Alert (USA) 1 -800-227-2600 , at least 48 hours prior to starting grading or digging operations 7 To connect to sever with one (1) calendar year from the date of issuance of thi s permit S. Special Permit Conditions (Exhibits): SUBMITTAL #2 [] A BACKFLOW Protective Device shall be installed on the above property by the owner. Type of device and snstaliation shali compiy with the Plumbing Code Requirements of the jurisdiction shown in 3 above. FEES: Connection Permit Fee: Sewer Service charges to: S / Month X mo: Inspection Fee for Backflow Protection device: 76.00 0,00 0.00 Total: 76.00 Considerations and Restrictions of this Sanitary Sewer Connection Permit with attached Exhibits (when noted), are hereby agreed to and acknowledged by the undersigned Owner (or Owner's Agent). Failure to comply will void this permit. !,l Acknowledgement i; Owners/Agent (Prin ame) i� — //A 1A k " & Ich , Cupertino Sanitary District. District Staff RECEIVED BY