12040153 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10025 BYRNE AVE CONTRACTOR:LIOU SITU-CIiUN AND PERMIT NO: 12040153
BROWN EDWIN W III
OWNER'SNAME: LIOU SI-IU-CIiUN AND BROWN EDWIN W III 10025 BVRNE AVE DATE ISSUED:041262012
OWNER'S PHONE: 4088298888 CUPERTINO,C\ 95014 PHONE NO:
❑ LICENSED CONT'RACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lick r r r
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ISSUE PERMIT FOR UNP17RMI TTCD MECHANICAL AIR
(commencing,with Section 7000)of Division 3 of the Business&Professions FLOW
Code and that my license is in full force and effect. UNIT W ITIf EXTERIOR EXHAUST
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 which(his 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 Sq.Ft Floor Area: Valuation:$0
permit is issued.
APPLICANT CERTIFICATION APN Number:35711023.00 Occupancy Type:
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
(o building construction,and herebyauthorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
grinning of(his permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18 Issued -- Dale: T-ter/Z
Signature Dale
Q ❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed If a roof is
the following two reasons: installed without first obtaining an inspection,1 agree to remove ail new materials for
1,as owner of(he property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sce.7044,
Business&Prolessions Code) Signature of Applicant: Date
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code).
\Lh ROOF COVERINGS TO BE CLASS",\"OR RF:TI'E:R
I hereby affirm under penally of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to selGinsure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Ilealth&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ileallh&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
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 I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California 11',after making this certificate of exemption,I
become subject to the Workers Compensation provisions of the Labor Code,I must Own��pp or au(hogf�j7 ey(ag�e/pt: ,h .(
forthwith comply with such provisions or this permit shall be deemed revoked. k�I,AL {Q�-U�{"4-F7��—Datca( 1x -
CONST'RtlCT'ION LENDING AGENCY
APPLIC\NT'CF.RTIFICATION
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of smrk's
correct I agree to comply with all city and county ordinances and state laws relating for which this perni(is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep hamhless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITEC-1"S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18- 1 — 1 understand my plans shall he used as public records.
/ I -'-� ac�e� Licensed Professional
Signature ✓:. (/ Date
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10025 BYRNE AVE CONTRACTOR:LIOU SHU-CHUN AND PERMIT NO: 12040153
BROWN EDWIN W 111
OWNER'S NANIE: LIOU SHU-CHUN AND BROWN EDWIN W 111 10025 BYRNE AVE DATE ISSUED:0426/2012
OWNER'SPHONE: 4088298888 CUPERTINO,CA 95014 PHONENO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.N
M ECH r RESIDENTIAL r COMMERCIAL
Contractor Dale
1 hereby affirm that I am licensed under the provisions of Chapter JOB DESCRIPTION:ISSUE PERMIT FOR UNPERMITTED MECHANICAL AIR
(commencing with Section 7000)of Division 3 of the Business&Professions FLOW
Code and that my license is in full force and effect. UNIT WITH EXTERIOR EXHAUST
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 Sq,Ft Floor Area: Valuation:$0
permit is issued.
APPLICANT CERTIFICATION APN Number:35711023.00 Occupancy Type:
1 certify that I have read this application and state that the above information is
coffee(. 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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued Date:
Signature Date
1� ❑ OWNER-RUILDF.R DECLARATION
RF.-ROOFS:
hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection,
will do the work,and the structure is not intended or offered for sale(Sec7044,
Business&Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505.254J3,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 2M32(a)should 1 store or handle hazardous material.
Additionally,should 1 use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Ouality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505.254533.and 25534.
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 Ow ror authorj�e ge,to Dater L
forthwith comply with such provisions or this permit shall be deemed revoked. 6Ec��444
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I cenify that 1 have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097.Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may acerae 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
9.18. ._ 1 understand my plans shall be used as public records.
Signature t Date"v vc�ov1 Licensed Professional
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35711023.00
DATE ISSUED. . . . . . . : 04/26/2012
RECEIPT #. . . . . . . . . : BS000016637
REFERENCE ID # . . . : 12040153
SITE ADDRESS . . . . . : 10025 BYRNE AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : LIOU SHU-CHUN AND BROWN EDWIN
ADDRESS . . . . . . . . . . : 10025 BYRNE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : EDWIN. W BROWN III
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : LIOUSHU-CHUN AND BROWN EDWIN
ADDRESS . . . . . . . . . . : 10025 BYRNE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY .AMOUNT PD-TO-DT THIS REC NEW SAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 0.00 1.00 0 . 00 1. 00 0. 00
1BREMVENFA NO UNITS 1.00 22 .00 0. 00 22. 00 0. 00
1BSEISMICR VALUATION 0 .00 0.50 0. 00 0 .50 0. 00
TOTAL PERMIT 23 .50 0.00 23 .50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 23 .50 VISA
---------------
TOTAL RECEIPT 23 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
------ -- ---------------------------- -------- ----------------------------
303
-- -------- --
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
503 FINAL MECHANICAL ENERGY 505 FINAL ELECTRICAL
508 FINAL MECHANICAL
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10025 byrne ave. DATE: 04/2612012 REVIEWED BY: bobs.
APN: BP#: 'VALUATION: $
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition/ Repair /
PRIMARY SFD or Duplex PENTAMATION 1RMAP8
USE: PERMIT TYPE:
WORK issue permit for unpermitted mechanical air flow unit with exterior exhaust.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Ventilation Fan 1BREMVENF 1 # $22
TOTALS: $22.00
Meeh. Plan Check 0.0 hrs $0.00 !'hwrh.I'hnr Clrrek £Inc. P6rr.C'ir.:cb
Mech. Perazi &ERwr Plumb, Permit Fee: hie( Pon1ii I cc:
Other Mech. Insp. 0.0 hrs $44.00 Orhe, 11hwrb/asp. El
(b/re,tiler.lrsp.
Meth. lisp.17.•: Phunb. Iasi). Fre: Elec. hr.SP. Pee.
NOTE: This estimate does not include fees due to other Departments(i.e. Planning,Public Works, Fire,Sanitary Sewer District,School
DistricR etc. . These fees are based on the prelindna in ormation available and are only an estimate Contact the Dept for addn 7 into.
FEE ITEMS (Fee Resolution I1-053 h.'(/ 7/11111 FEE QTY/FEE MISC ITEMS
Plan Chec,k Fre:
Suppl. PC: Fre
PME Plan Check: $0.00
Pvrmil Fre:
Suppl. ln.p Fe.
PME Unit Fee: $22.00
PME Permit Fee: $44.00
C'nnslrmc•rion 'l'rn':
Administrative Fee:
Work Without Permit? Yes No $0.00
Advunec:d Planning Fres:
Travel Documentation Fee:
strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
ai
SUBTOTALS: $.152:50 $0.00 TOTAL FEE:'1 $152.50
Revised: 04/01/2012
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
CUPERTI NO (408)777-3228- FAX(408)777-3333•buildlno0cuoertlnD.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 ePu 2 D Yb�s�
OWNER NAME Q W 1 `1 &0 OWNER ADDRESS A
DESCRIPTION OF WORK: clyA 7 _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
(DIREC(T�IONS:Please read and initial each statement below to signify you understand or verify this information.)
Iv�ll. 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
insurance coverage for injuries to workers on my property.
4, 2. 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.
_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.
G,' 4. 1 understand Contractors are required by law to be licensed and banded in California and to list their license
numbers on permits and contracts.
U. 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.
IL-N. 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.
1-7. 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.
DAL8. 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.
On'Bel'Buildel'Fw"u1 2010.doc rerised 04/14/10
,C W19. 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.csib.ca.gov for more information about licensed
contractors.
U10. 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.
L11. 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.)
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 DrOVertV owner's si nature.
Property Owner's Signature: Date: Q a
- ----- ----- --- ---- -- --- ------ - ---- ------- ---------------- ------------- -------- --------- ---- ---- ---- --- -... ----
(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 Descriptlon of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
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 certlfy 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 Signatuie: Date:
DwnerBuilder'Form 2010.doc revised 04/14/10
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
MIS I /ate
CUPERTINO (408)777-3228• FAX(408)77-7-3333•buildingli cuoer6no.orG /v—
PLUMBING 0CfiANLCAL CIELEcnucAL ❑MISCET I ANEOUS
PRo1ECT ADDRESS I ooa5 ; Amo-au�.. �"a3� — — C� _3
OWNERNAMEUukiin Wr ? -nPHONE_4Og,(7/J(f'�t ly(J' ghtpD.l�l(� VIC 1l , �C�
STAEETADDRESS Q'IY,STATE,ZIP CU `I LL'j,/�n /ern FAX
CONTACT NAME C VV PHONE •`�J �lE-MAIL
STREET ADDRESS ,�J` CITY,SLATE,7!P FAX
OWNER ❑ owNER-BUDnER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ AROmFLT ❑E24uWEt ❑ DEVEI.OPER ❑ TFNA.NT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC M
COMPANY NAME v E-MAIL FAX
STREET ADDRESS CITY.STATE,ZIP PHONE
AAC}GTECgQJGINEER NAME ]' T. ^ LICENSE NUMBER BUS.LIC p
COWANY NAME' (�•/ /T E-MAIL FAX
St'=ADDRFSS CITY.STATE.ZIP PHONE
USE OF wDunEx ❑ MOLTT-FAAm.Y PROJECTIN WI DI.AND ❑ YES PROIECTBi ❑m TS THE BLDG AN ❑ YES
BUDDWG: ❑COMMERCAL U.A.RRANO�nWACE AREA of NO FLDOD ZONE ❑NO DCISFR HOSM ❑NO
DESCRIPTION OF WORK ^ , W\O�-V✓ "�%� ��_ `O L✓ L� W + `V1 Qhkn Cy
X IT-
TOTAL VALUATION: V RECEIVED BY: / J
By my signature below,I certify to each of the fallowing: I am the property owner or authorized agent to act on the property owner's bebal£ I have read this
application and the int'mmation I have provided is coDect j have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and stare laws relating to building cons ¢o'In. WthC=representatives of Cupertino to ester the above-ideatiffed fprope ty for inspection pu@oses.
GcaaUAg
Signature of Apprnc r— ' I- Dare: t� r 1 oC()I,7
SUPPLEVENTAL INFORMATION REQUIRED OFFICE Use ONLY
❑-evewTSP,couNTER
y6
F ❑ EXPRESS
Y
u
❑ STANDARD
'u
❑ LARGE
6
❑ MAJOR
MEPMIse4pp_2011.dac revised 06121111