12010117 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 6751 CLIFFORD DR CONTRACTOR:LIN YEONG CHYI AND PERMIT NO: 12010117
CHEN TRACY SHUMI
OWNER'S NAME: LIN YEONG CHYI AND C'HEN TRACY SHUMI t4 6751 CLIFFORD DR DATE ISSUED:O1/18/2012
OWNER'S PHONE: 4085170109 CUPERTINO,CA 95014 PHONE NO:
®
LICENSED CONTRAC'TOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT a PLUMB '
License Class Lia# £--- �--• �......
MECH' RESIDENTIAL COMMERCIAL
Contractor Date
1 hereby affirm that i am licensed under the provisions of Chapter 9 JOB DESCRIPTION:CLEAR CODE ENFORCEMENT CASE:ONEO WINDOW
(commencing with Section 7000)of Division 3 of the Business&Professions AND
ONE(I)DOOR REPLACEMENT AT GARAGE LOCAL,ADD
Code and that my license is in full force and effect.
SIX(6)NEW LIGHT FIXTURES AT GARAGE LOCAL.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-"insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$355
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:36911046.00 Occupancy Type:
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, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18. / p
Signature Date Issued by:' Date: /—/ ,O-,,-'Z
ONyNFR-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
tale following two reasons: All roofs shall be inspected prior to any rooting material being installed.If a roof is
1,as owner of the property,or,my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Protcssions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant Date:
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm trader penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the
pertorrnance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or at torized gent:
t-)rthwith comply with such provisions or this permit shall be deemed revoked. Date: l�8 y
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the pet-Cormance of vwrk`s
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnity and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.(8.
y
Signature Date
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
19ADDRESS: 6751 Clifford dr. TDATE: 01/18/2012 REVIEWED BY: bobs.
1 APN: BP#: VALUATION: $355
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Repair
PRIMARY SFD Or DU I@X PENTAMATION 1GENRES
USE: p PERMIT TYPE:
WORK To Clear Code Enforcement Case:1 window and 1 door replacement at garage local add 6 new light
SCOPE fixtures at garage local.
Elec.Plan Check 0.0 hrs $0.00 T7
Elec.Permit Fee: IEPERMIT
Other Elec.Insp. El hrs $44.00
NOTE:This evtimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These ees are based on the relinina information available and are o!A an estimate. Contact the De t or addn'1 in o.
FEE ITEMS ', l: t? 1 t';�' ff ? l%1I; FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 2 # Window/Sliding Glass Door
Suppl.PC Fee.: Q Reg. C OT 0.0 hrs $0.00 $392.00 I WINREP Replacement
PME Plan Check: $0.00 6 Electrical
Permit Fee: $0.00 $65.00 1BREWIXT Fixtures,Lighting
Suppl. Insp. Fee-0 Reg. Q OT 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $44.00
Administrative Fee: ]ADMIN $41.00 0
Work Without Permit:' G) Yes 0 No $436.00 0
",__g �' i F _. $0.00
. Select allon-Residential
___..._.__._..._._..m_...__..
Travel Documentation Fee: ITRA VDUC $44.00
Building or Structure ('
1BSEISMICR $0.50 Select an Administrative Item a
B Im>i_._C= l_nx._.j�.}ion.Fee IBCBSC $1.00 jJ
SUBTOTALS: $566.50 $457.00 TOTAL FEE: $1,0_ .50
Revised: 1101/2012
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OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228- FAX(408)777-3333- buildna(a-)cuoertino.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 7 (� / C( � -� �'j' �)r APN 3 / !l /o / , /BP# /
OWNER NAME '(�o'�/J Chr/ / n OWNER ADDRESS (, C�) o V
DESCRIPTION OF WORK: W ik d-C eA d '�' o-✓a �'
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.)
t 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.
�- 2. 1 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.
- 3. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
4. 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. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer' under state and federal law.
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.
l 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.
Z �8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
O mnerBuilderFornz 2010.doc revised 04/14/10
` - 9. 1 understand I may obtain more information regarding my obligations as an "employer"from the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB)at 1-800-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed
contractors.
11 1 L.. 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.
'L' --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.
'`�2. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers'compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
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: Date: / �Z
---------------------------------------------------------------------------------------------------------------------------------------------
(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: Tel No
Address of Authorized Agent:
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:
GvnerBuilderFornz 2010.doc revised 04/14110
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE -CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-3228 • FAX(408)777-3333- building@cuper6no.org
❑NEW CONSTRUCTION ❑ ADDITION [5/ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS CJ` 7J /jG ✓ `�( n V�� ✓ e APN# - /7
OWNER NAME l ( C�
Z//47
/h f, E-MAL
ONE �., e , I.
STREET ADDRESS C n CITY, STATE.ZIP
FAX
/S
CONTACT NAME PHONE E-MAIL
STREET ADDRESS CITY,STATE, ZIP FAX
❑OWNER INNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
rCAtV-V ark ck d�CV 1-7 9ak �
EXISTING USE PROPOSED USE CONSTR TYPE I #STORIES
USE TYPE OCC. SQ.F-I'. VALUATION(S)
EXLSTG NEW FLOORDEMO TOTAL
AREA AREA AREA NE AREA < _�£
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA DETACH
ATTACH
#DWELLING UMTS; IS A SECOND UNTr 13 YES SECOND STORY []YES
BEING ADDED? []NO ADDITION' []NO El I
PRE-APPLICATION [3 YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: TOTAL VALUATION:
PLANNING ADPL# []NO PLANNING APPROVAL LETTER EICHLER HOME? ❑NO C/J� 4 -�-, v d
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the prpperty 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 construction uthorize rep entatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent Date:
SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for Q—eMTri couNRBIJ Uu nrrtG PLAN RL+viEw
existing building(s). Demolition permit is required prior to issuance of building
permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD C1PVBLICWORKS
Form if any Hazardous Materials are being used as part of this project. LARG7E❑ ❑ FIRE WEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application. ❑ MAJOR ❑ sANTTARY SEWER DLSIRICT
❑ ENVMONMF14TAL FMAT TH
Bld&4pp_2011.doc revised 06/21/11