12030162 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10185E ESTATES DR CONTRACTOR:CHINN WILSON S AND PERMIT NO: 12030162
SELINA
OWNER'S NAIVE: CHINN WILSON SAND SELINA 10185 B ESTATES DR DATE ISSUED:03/302012
OWNER'S PIIONF.: 4082579218 CUPERTINO,CA 95014-3303 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL13
License Class Lic.q PROPOERTY LINE CLEAN OUT
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.
1 hereby affirm under penally 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 whichthis permit is issued. Sq.Ft Floor Area: Valuation:$500
1 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:36908005 00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read(Itis 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 ISSUANCEOR
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 DAY F OM LAST CALLED INSP T N.
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: Dat
with all nun-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.
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following len 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)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). �eO 1 have read the hazardous materials requirements under Chapter 6.95 of the
/A
14-91California Health&Safety Code,Sections 25505,25533,and 25534. [will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
declarations: Ileallh&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 1 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 1
performance of the work for whichthis permit is issued. will maintain compliance with the Cupertino Municipal Cade.Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505.25533,and 25534.
Section 3700 of the labor Code,for the performance of the work for which this
Owner or authorized agent` Dale:
permit is issued.
I certify that in the performance of the work for which this permit is issued,l shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of Cali forma. If,affer making this certificate of exemption,1 CONSTRUCTION LENDING AGF.NCV
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
cored.I ague(o 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.
Signature 2% -,i Date Ze Z
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO,CA 95014-3255 '
CUPERTINO (408)777-3228- FAX(40B)777-3333• buildmo5cuoertino.ora
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 �. cAPN B
i9; c, C5-rWAcs PRO Lm row
OWNERNAME OWNER ADDRESS
(.i//L S N 5• CIIIAOA/ /oi cs - E. E5747ES 1P_ Cu E2TiuQ
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.)
A - 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 homeowners insurance may not
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
j insurance coverage for injuries to workers on my property.
/rt� . 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.
LL. 3. I 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.
l L$L4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and.contracts.
L�&5. I 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.
V.—k-6. I 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
rm/e. to serious financial risk.
w%e 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.
"` 5�—iB. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable fcr
any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
Olrnel'Buflde!'Foo"nl 2010.doc revised 0,/19/10
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36908005 .00
DATE ISSUED. . . . . . . : 03/30/2012
RECEIPT #. . . . . . . . . : BS000016411
REFERENCE ID # . . . : 12030162
SITE ADDRESS . . . . . : 10185 E ESTATES DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . e CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CHINN WILSON S AND SELINA
ADDRESS . . . . . . . . . . : 10185 E ESTATES DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-3303
RECEIVED FROM . . . . : WILSON CHINN
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : CHINN WILSON S AND SELINA
ADDRESS ... . . . . . . . . : 10185 E ESTATES DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-3303
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS 1.00 41.00 0. 00 41.00 0. 00
1BCBSC VALUATION - 500 .00 1.00 0.00 1.00 0. 00
1BSEISMICR VALUATION 500.00 0.50 0.00 0 .50 0. 00
1PPERMITFE FLAT RATE 1 .00 . 44.00 0.00 44 .00 0. 00
1PRSEWER UNITS 1 .00 22.00 0 .00 22 .00 0. 00
1TRAVDOC FLAT RATE 1 .00 44 .00 0 .00 44 .00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 152 .50 0. 00 152 .50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 152.50 CHK
----------------
TOTAL RECEIPT 152.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----- ----------
106 SEWER &'WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 400 SEWER/LATERAL
507 FINAL PLUMBING
CITY OF'CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10185 LIEstates Drive DATE: 03/30/2012 REVIEWED BY: Sean
APN: BP#: 'VALUATION: $0
TPERMITTYPE: Building Permit PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex PENTAMATION 1RPSS
USE: PERMIT TYPE:
WORK Install sewage Glean out.
SCOPE
tkdh. Ilan Check Plumb.Plan Check 0.0 hrs $0.00 !:ler:. Plan Check
111ech. Permit Fre: Plumb. Permit Fee: 1PPERM/T ftec. Pan»6 l'ee:
r7rher dlech. Insp. Other Plumb Insp. 0.0 hrs $44.00 Other EICC. Lup. El
,N,xh. Gr.,p. F,<C: Plamh. l»sp. Fee fanr. 6rsp. Fcc.
NOTE: This estimate does not include fees due to other Departments(i a Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc.). Thesefees are based on the prelimina information available and are only an estimate Contact the Dept for addn7 info.
FEE ITEMS (Fcc Resolution 11-053 E(! 711111) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = # Plumbing
Suppl. PC Fee: Q Reg. Q OT 0.0 hrs $0.00 $22.00 1PRSEJVER I Sewer, Sanitary
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee-.0 Reg. Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $44.00
Construrrion Tax:
Administrative Fee: IADMIN $41.00 O
Work Without Permit? O Yes0 No $0.00 E)
Advanced Plannine Fee: $0.00 Select Non-Residential (F)
Travel Documentation Fee: iTRAVDOC $44.00 Building or Structure 0
Strong Motion Fee: $0.00 Select an Administrative Item
Bldg Stds Commission Fee: $0.00
SUBTOTALS: $129.00 $22.00 TOTAL FEE: 1.00
Revised: 1/19/2012
GENERAL- PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 950143255 M Is
C
/ate
CUPERTINO (408)777-3228• FAX(408)777-3333• buildinaCcDcuoerdno.org'Log
g O%� / I
-EbFLUMBING MECHANICAL r.Tp ICAL MISCELLANEOUS
PROJECT ADDRESS 1/ 1gC.
S E. 40 4/TES D s APN# E/LU
OWrNERNAME !/Il^LS+ zW 5� CHiN O —757 ,?-1 /T[A E-MAIL
STRFFI'ADORE l55/�I/ IIP �� 1 FAX
CONTACT NAME NIL'50/JCHIAJA)�(,7v^Y�r� ,PHONE J z 57 L � 5 E M.11L
STREET ADDRESS — .CITY,SLATE, ffi
/0/ SS t, X37 Ecxp6ZT/Llc).LoA� FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑CONTRAcrot ❑CONTRACTOR AGENT ❑ ARamEcr ❑ENtBNmt ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY.STATE.ZIP PHONE
ARCi4TERJPNGINEER NAME LICENSE NUNOTER BUS.LIC#
COWANY NAME E-MAIL FAX
SIREEr ADDRESS CITY.STATE,ZIP PHONE
USE OF N.SFD.DUPLE]( ❑ muLTT-FANDLY PROSECT IJWDD[.WD ❑ YES PitanL DJ ❑YES ISTHERLDGAN ❑YES
BUDDING: ❑ct)K% Rner URBAN nfTAiFACPAREA sr FLOOD TANS ($NO EICHIER HOME/ NO
DESCRIPTION OF WOAX
/VST,}-ZL :5C?uACTE CLEfFN 0 (4-T
TOTAL VALUATION: SOD •V� RECEIVED BY:
By my Signature below,I certify to each of the following. I am the property owner or antheriud agent to act ou the property owner's behalf I have read this
application and the ialbrmation I have provided is emtmt j have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and apse laws relating toig conshnctioe I authorize mtativm ofRCnpertiao to enter the above-idmti5ed property for inspection pull oscs.
Signatme ofAppfi t/Agmt - Dare: ) 2U 2
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
u ❑ OVER-THGCOUNTER
d
❑ ®(PRESS
Y
U
m ❑ STANDARD
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3 ❑ LARGE
6
❑ MAJOR
MEPWucApp_7011.doc revised 0621/11