12040115 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 934 FORT BAKER DR CONTRACTOR:CHANG SZUCHUAN AND PERMIT NO: 12040115
LIHRONG K
OWNER'S NAME: CHANG SZUCIIUAN AND LIHRONG K 934 FORT BAKER DATE ISSUED:04202012
OWNER'S PHONE: 6506046028 CUPERTINO,CA 950144010 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.q
M ECH r RESIDENTIAL r COMMERCIAL
Contractor Dale
I hereby affirm that 1 am licensed under the provisions of Chapter JOB DESCRIPTION:UPGRADE EXISTING MAIN PANEL FROM IOOAMP TO
(commencing with Section 7000)of Division 3 of the Business&Professions 200AMP
Code and that my license is in full force and effect.
1 hereby affirm under penally of perjury one of the following two declarations:
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.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$1200
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:35611027.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and stale that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating
In building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned properly for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accme against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
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. Issued by: v�6191yf/rdW Date: y670 •/a
Signature Date
OWNER-BUILDER DECLARATION _ RE-ROOFS:
All roofs shall be inspected prior to any roofing material beng installed.If a roof is
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
1,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(Sce.7044, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Scc.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penally of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Seelions 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,atter making this certificate of exemption,1 Own aut rite ant:
become subject to the Worker's Compensation provisions of the Labor Code,I must Dele:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGF,NCV
APPLICANT CERTIFICATION I hereby affirm that there is a conslnuclion lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and stale laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned properly for inspection purposes.(We)agree to save Lender's Address
indemnify,and keep harmless the City of Cupertino against liabilities,judgments,
costs.and expenses which may accme against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
_ Licensed Professional
Signature Dat
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35611027. 00
DATE ISSUED. . . . . . . : 04/20/2012
RECEIPT #. . . . . . . . . : BS000016586
REFERENCE ID # . . . : 12040115
SITE ADDRESS . . . . . : 934 FORT BAKER DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CHANG SZUCHUAN AND LIHRONG K
ADDRESS . . . . . . . . . . : 934 FORT BAKER
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4010
RECEIVED FROM . . : SZUCHUAN CHANG
CONTRACTOR . . . . . . . . LIC # *OWNER*
COMPANY . . . . . . . . . . : CHANG SZUCHUAN AND LIHRONG K
ADDRESS . . . . . . . . . . : 934 FORT BAKER
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4010
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 1,200.00 1. 00 0. 00 1.00 0. 00
1BSEISMICR VALUATION 1,200.00 0. 50 0. 00. 0 .50 0. 00
1EPERMITFE FLAT RATE 1. 00 44 . 00 0. 00 44 .00 0. 00
IERT<200 UNITS 1.00 44 . 00 0 .00 44 . 00 0. 00
1TRAVDOC FLAT RATE 1.00 44 .00 0.00 44 . 00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 174 .50 0.00 174 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 174 .50 VISA
---------------
TOTAL RECEIPT 174 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
--------------------------- -------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 934 Fort Baker Dr DATE: 04/20/2012 REVIEWED BY: Sean
APN: BP#: 'VALUATION: $1,200
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION 1REAP2
USE: PERMIT TYPE:
WORK Upgrade existing main panel from 100 amp to 200 amp.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Services CERT<200 200 Amps $44
TOTALS: $44.00
d.heb. Ilan Check Plumh, Plein Cheek Elec. Plan Check 0.0 hrs $0.00
We,:h. Penow Fee: Plnmb. Permit 1"'e: Elec. Permit Fee: IEPERMIT
Orhor 1 k"h. Insp. OtherPlumb In.rp, Other Elec.Insp. 0.0 hrs $44.00
dderh. 11"p. Fee.: Plumb. hsp. Fee: Elec..Insp. Fee
NOTE: This estimate does not includejees due to other Departments(Le. 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 De I or addn 7 info,
FEE ITEMS (Fre Resohrlion 11-053 Elf 711111) FEE QTY/FEE MISC ITEMS
Plan Chec k Pee:
suppl. PC,' Fee
PME Plan Check: $0.00
Permit Fce:
Suppl. h,sp Fee
PME Unit Fee: $44.00
PME Permit Fee: $44.00
C'onsIna-lion Tay.
Administrative Fee: IADhI1N $41.00
Work Without Permit? O Yes (F) No $0.00
;Irhvuic'ed Pluuuing Pees:
Travel Documentation Fee: ITRAVDOC $44.00
Shone Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
131de Stds Commission Fee: iBCBSC $1.00
SUBTOTALS: $174.50 $0.00 TOTAL FEE: $174.50
Revised: 04/01/2012
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT" BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228" FAX(408)777-3333- building gncuoertino.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 ADDRE - APN BP#
OWNERNAME OW R RE
DESCRIPTION OF WORK: to
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
(DIR71.
S:Please read and initial each statement below to signify you understand or verify this information.)
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
t e construction and are not hiring a licensed Contractor to assume this responsibility.
Iunderstand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that I may
p tett myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
Z4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
v' 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.
Z6. 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
me to serious financial risk.
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 prformed under contract with a licensed general building Contractor.
L'/&'l 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.
OrvnerBuilderForm 2010.doc revised 09//4/10
/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.esib.c.a.gov for more information about licensed
cactors.
on0710. 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.
J11. 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.
J/,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.)
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 'ty may be required to be presented when the permit is issued
to verify the property owner's sign t
Property Owner's Signature: Date:
-
- --- ---- 7---- ---- -z---- --------- ----------- ------------I e- ---------------------...----------- ------------- ---- ----
(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:
ai i?erBuilderFanr 1010.doc rei-ised 04114110
L Z vq-( i
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 950143255 M I /�
CUPERTINO (408)7773228•FAX(408)777-3333•buildinD(cDcuoertinD.orD (v'
❑PLUMBING El MECHANICAL ELECTRICAL ❑MiSr-r-TrAnrFDUs
PROJECT ADDRESS n AFN tl
OWNERNAME 4S 2 OirE E-
STREETADDRESS CITY,STATE,ZIP FAX
CONTACT NAME E-MAR
STREETADDRESS ATE, ZS FAX
❑ OWNEt ❑ aWNER-BUILDER . ❑ OWNEIACENT ❑CONTRACTOR ❑CONTRACTOR AGENT ❑ AjtcH T ❑FNOwmt ❑ DEVMZPMt ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC a
COMPANY NAME E-MAIL FAX
STAEEr ADDRESS QTY.STATE ZIP PHONE
ARCH=CC/ENGIiEFR NAME LICENSE NUMBER BUS.LIC a
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE ZIP PHONE
USE OF wDUPIFI( ❑ MULTI-FAMILY PROJECTIN WILDL.WD ❑ YES PROJECT IN ❑YES IS THE BJDO AN ❑Yas
BUDDING: ❑COMMEERcLAL URBAN INTERFACE AREA ❑ NO FLOOD ZONR ❑NO F]dIPRHOI� ❑Na
DESCRIPTION OF WORK
li �1
TOTAL VALUATION: r/O RECEIVED BY:
By my signature below,[ to eichh of the fallowing: I'am the property owner or authorized agent to act on the property Iwaet's behalf I have read this
application and the i�'mmation I have provided is correct]have read the Description of Work acrd vm*it is acezzate. agree to comply with all applicable local
otdmanca and state laws relating to 'ding consttoction. I mdwi=representatives of Cupertino to enter the abov..e-idku ed pmpgdy for inspection pufpases.
Signature of AppticanVAgent Dere:
SUf AL O 0 REQUaM r OFFICE USE ONLY
m
OVER-THF`COUNTEt
6
❑ EXPRESS
u
m ❑ STANDARD
x
u
❑ URGE
6
❑ MAJOR
MEPMtrcApp 1011.doc revised 06/11/71