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12040173 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18951 BARNHART AVE CONTRACTOR:YANG ZIIAOXUE AND PERMIT NO: 12040173 "LANG 11E OWNER'SNAIME: YANG--Z.IIAOXUE AND ZANG IIE 18951 BARNHART AVE DATE ISSUED:04/302012 OWNER'S PHONE: 4082190540 CUPF-RTINO,CA 95014-3603 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class Lic.p MECH r RESIDENTIAL COMMERCIAL Contractor Dale 1 hereby affirm that I am licensed under the provisions of Chapter9 JOB DESCRIPTION: INSTALL N17W TUB/SI IOWER,REPLACE WALL TILE.NO (commencing with Section 7000)of Division 3 of the Business&Professions ELECTRICAL,LIGHTING OR MECHANICAL Code and that my license is in full force and effect. 1 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[his permit is issued. 1 have and will maintain Worker's Compensation Insurance,as provided for by Sq.FI Floor Area: Valuation:$800 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:3750902100 Ottupency7)pr. 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 PERMIT EXPIRES IF WORK 1S NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless(he City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue 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-paint source regulations per the Cupertino Municipal Code,Section 9.18. Issued by: Date: Signature Date �E3 OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall he inspected prior to any roofing material being installed.If roof is 1 hereby affirm that I am exempt from the Contractor's License Law for one of installed without First obtaining an inspection.I agree to remote all nLn% materials for the following two reasons: inspection. 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(Sce.7044, Signature of Appliauu: Dale: Business&Professions Code) I,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 penally of perjury one of the following three declarations HAZARDOUS MATERIALS DISCLOSURE I have and will maintain a Certificate or Consent to self-insure for Worker's I have read the hacardous 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,Sections 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 Safely Code,Section 25532(a)should 1 store or handle hazardous material. Section 3700 of the Labor Code,for the perfornance of the work for which this Additionally,should 1 use equipment or devices which emit hazardaus air permit is issued_ contaminants as defined by the Bay Area Air Qualily 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&Safely Code,Sections 25505,25533,and 25534. not employ anyperson in any manner so as to become subject to the Worker's Compensation Imus of Cali fomia. If.after making this certificate of exemption.I e 9w r uloriz a en U r n become subject to the Worker's Compensation provisions of the Labor Code,I must Date: (. forthwith comply with such provisions or[his permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read(his 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 state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon dhe above mentioned property 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 accrue against said City in consequence of the granting of this permit Additionally,the applicant understands and will comply ARCHITECT'S DEC.LAR,VPION with all non-poi source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. �gnature . Date 1 Licensed Professional CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 37509024 .00 DATE ISSUED. . . . . . . : 04/30/2012 RECEIPT #. . . . . . . . . : BS000016667 REFERENCE ID # . . . : 12040173 SITE ADDRESS . . . . . : 18951 BAR14HART AVE SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : YANG ZHAOXUE AND ZANG JIE ADDRESS . . . . . . . . . . : 18951 BARNHART AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-3603 RECEIVED FROM . . . . : ZHAOXUE YANG CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : YANG ZHAOXUE AND ZANG JIE ADDRESS . . . . . . . . . . : 18951 BARNHART AVE CITY/STATE/ZIP '. . . : CUPERTINO, CA 95014-3603 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW SAL ---------- ------------= ---------= --------- ---------- ---------- ---------- -ADMIN HOURS 1 . 00 41 . 00 0. 00 41 . 00 0. 00 1BCBSC VALUATION 800.00 1. 00 0. 00 1 .00 0 .00 1BPFIXTURE NO OF FIXTURE 2.00 18. 00 0. 00 18.00 0. 00 1BSEISMICR VALUATION 800.00 0. 50 0. 00 0.50 0. 00 1PPERMITFE FLAT RATE 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 148.50 0.00 148 .50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 148.50 MC --------------- TOTAL RECEIPT 148.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION ---- ---------------------------- ------- --------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 302 TUB & OR SHOWER 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING 512 FINAL HANDI-CAP CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION 171 ADDRESS: 18951 barnhart ave. DATE: 04130/2012 REVIEWED BY: bobs. APN: BP#: 'VALUATION: $800 *PERMITTYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex PENTAMATION 1 RPFIX USE: PERMIT TYPE: WORK install new tub/shower, replace wall tile. No Electrical lighting, or mechanical. SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Fixture or Trap 1BPFIXTURE 2 # $18 TOTALS: $18.00 Plumb. Plan Check 0.0 hrs $0.00 11"'A I'rnnit Gtr_ Plumb. Permit Fee: IPPERMIT Ifhr. ihhrr hath. lay Other Plumb Insp. Q.0 hrs LWE oder/7/rr. Inap. Li ,IA,i,. hi•p. I"r I'll unh. 6mp. If,- l.'lrr. fa'p /'e NOTE: This estimate does not includefees due to other Departments(ie. Planning, Public Works, Fire,Sanitary Sewer District,School District,etc. . Thesefees are based on the prefindna information available and are only an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolalion 11-053 Eff 711111) FEE QTY/FEE MISC ITEMS Pham (_'hick 1��'i�: Rrppl. PC Fc' PME Plan Check: $0.00 Penni[ his•: sup/4' heap I ce PME Unit Fee: $18.00 PME Permit Fee: $44.00 i:'0r.10111/inn 7'1rc Administrative Fee: - DMIN Work Without Permit? O Yes (F) No $0.00 ,I;hvmr,a(/'harming / O's- Travel Documentation Fee: ITRAVDOC $44.00 A S h'011f: Motion Fec: IBSEISMICR $0.50 0.5 hrs Admin./Clerical Fee Bide Stds Commission Fee: IBCBSC $1.00 $41.00 IAD,LIIN �' SUBTOTALS: J $148.50 $41.00 TOTAL FEE: A+89 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"buildino(a)cuoertino.ore 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 APNBP r—o - o z y o G <? OWNER NAME n% OWNERADDRESS tgy.,L1 Batabart Aff DESCRIPTION OF WORK: N 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 addressIndicated. 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.) AL1. 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 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. _7�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. t' 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. '1� 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. it-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. 8. 1 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. OuwerBuilderFonn 1010.doc revised 04/14110 Z9. I understand I may obtain more information regarding my obligations as an "employer"from the Internal R venue 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 1-800-3217CSLB (2752)or www.cslb.ca.gov for more information about licensed contractors. 1_1 0. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I a e parry 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. :ML12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the in ormation 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 thepermit. 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 si nature. Property Owner's Signature: _ Date: o L -- -- ----- --- ----- ------ --------- - - -- - ---- - --- ----- - -- — ---- ------- 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: I declare under penaltyof 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: 0),nerBuilderForm 2010.doe revised04/14//0 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DMSION 10300 TORRE AVENUE•CUPERTINO, CA 950143255 CUPERTINO (408)777-3228• FAX(408)777-3333• buildina(acupertino ora ❑NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PM,,Cr N FROIECT ADDRESS I... 0. AveaPNf ,'P ' ZOWNEJ6- ,- 0-2- OWNER R NAME �^ ^ PRONE _ EMAR Keva•,QLag Q/100.Q to STREET ADDRESS Ave QTY, STATE IIP I 0 FAX - ax cub CONTACT NAME O DLL VOK8 FOONE O '1/ 'D f E-MAR. .��STREET ADDRESS QTY.STATE t/( ZIP FAx OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONrancroRACENr ❑ ARCIQtECr ❑FNCINEER ❑ DEVELOPER ❑�MgY CONTRACTOR NAME O�J _ LICENSE NUMBER LICENSE TYPE Bus.L'c# COMPAM NAME E-MAIL FAX STREET ADDRESS QTY.STATE ZIP PHONE ARCHTTECT/ENGINEER NAME I/.� LICENSE NUMBER sm.LLC# COMPANY NAME /— E-MAIL FAX STREET ADDRESS S CITY.STATE Z3 PHONE QlS DESITON OF WORK I'tS U�j � NII Q(e Shotver l lA/ 8 N4rde -nr, Cfo,r S r\ D EXL-MG USE PROPOSED USE -CONST0. E #SIORDS USE TYPE OCC SQ-Fr. VALUATION(S) EXly li' NEW FLUOR DEMO TOTAL /+ AREA AREA AREA NET AREA -+ Y7 y� Poo RMAODDOM RIMOUE REMODEL EMOU AA100¢AAEA REM00¢AAEA REM00¢AREA PORCH AAFA DEIXAREA TOTAL DECK/PORCHAREA GARAGE AREADETACH ATTACH #O WELTING[M[R: Ci A SECOND ONT YES SRCON-D STORY YES aHIlYG ADD®t ❑NO ADD0710M. ❑NO PRE-APPLIUITON ❑YES IF YES,PROVIDE COPY OF MTEERLOGA REC73VID BY: - TOTAL VALUATION: PLANNING APFL# []NO PLANNING APPROVAL LETTER RICHI.ER EOMEt ❑NO C By tory signature below,I certify to each of the following: I am the Property owner or aurhoriaed aeeat to act an The pt;yeRy.ownds behalf.'f, have rad this application and the info®adon I have provided is cDoecL I have read the Description of Work and verify it is accorete. I agree to comply With all applicable local ordinances and state laws MLathag m I aarhooia repres®tadves of Cuperdno to cater the above-identified property far msycct on purposes. Signs cfApplicrut/Av r Date: 3 L IZ SUPPLEMENTAL INFO n0N`REQU= PLAN CHECK TYPS AOOTI15G5[.iP New SFD or Multifamily dwellings: Apply for demolition permit for -.�,�otltn.>•r¢ gOD.pprG PLAN REVIEW existing building(s). Demolition permit is required prior t0 issuance of building permit for Dew building. ❑ M7RFSS ❑ PLANNINGPLAN REYLEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PMUC WORIO farm if any Hazardous Materials are being used as part of this project ❑ r RG7 ❑ F=DEPT Copy ofPlaDaing Approval Letter or Meeting with Planning prior to submittal of Building Permit application. ❑ MJOR ❑ SANTI'ARYSEWERDISTRICT ❑ ENvrRopauorrAL EEALTE: B(dgApp_101 Ldoc revised 06121171