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12050060 CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: 20559 RODRIGUES AVE CONTRACTOR:CHEN TSU KUANG AND PF-RNIIT NO: 12050060 LIAO YU TING OWNER'S NAME: CHEN TSU KUANG AND LIAO YU TING 20559 RODRIGUES AVE DATE ISSUED:05/04/2012 OWNER'S PHONE: 4087539786 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL-D W\IAIERCIAI. LJ License Class Lic.q REMODEL FAMILY ROOM (380 SQFT)AND REMODEL WET Contractor Date INTO A BATHROOM (49 SQFT) 1 hereby affirm that l 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 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. Sq.FI Floor Area: Valuation:$30000 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:35910047.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this 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 stale laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned properly for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilitics,judgments, l 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: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18, RF.-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 em exempt from the Contractor's License Law for one of Signature of Applicam Date the following Iwo 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 du the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) h as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will 1 hereb} affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(x)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I 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 Qualiry Management District performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipai Code.Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safely Code.Sections 25505,25533.nd 25534. Section 3700 of the Labor Code.for the performance of the work for which this U permit is issued. /7 Owner or authorized agent: - Date: I cenily that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must 1 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 1 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 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 1 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. r Signature /Sn l 1 L� - LGtU Dale � `i /I 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(aDcuoertino.oro 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: EAD RMS /+ BP�b BPI{ Y C J �L OR AM L^G O NER ADDRESS 7 , N ) DESCRIPTION ORK:. We are providing you with an Owner-Builder Acknowledgment and Information Verification Farm 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.) �1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner- 66i12Yer" 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. A� 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for -zhKonstruction 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 'rToTect myself from potential financial risk by hiring a licensed Contractor and having the permit fled 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. AJ5. 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. 7 ; & 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. /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. OmnerBuilderForm 2010.doc revised 04/14/10 l � 9. 1 understand I may obtain more information regarding my obligations as an "employer"from the Internal evenue 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. 60. 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. 11. 1 agree that,as the party legally and financially responsible for this proposed construction activity, I will abide al ��1� Appl applicable laws and requirements that govern Owner-Builders as well as employers. 412. 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 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 verifythe roe owner's si nature. Property Owner's Signature: Date: / ---------------------------------------------------------------------------------- (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: Tei 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 certify its accuracy. Note:A copy of the property owner's drivers 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:_ Y4, 0 Date: MD arnerBuilderForm 1010.doc revised 04114/10 CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: counter COPY # 1 Sec: Twp: Rng: Sub: Elk: Lot: APN . . . . . . . . . 35910047. 00 DATE ISSUED. . . . . . . : 05/04/2012 RECEIPT #. . . . . . . . . : BS000016722 REFERENCE ID # . . . : 12050060 SITE ADDRESS . . . . . : 20559 RODRIGUES AVE SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . OWNER CHEN TSU KUANG AND LIAO YU TIN ADDRESS . . . . . . . . . . : 20559 RODRIGUES AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : YUTING LIAO CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : CHEN TSU KUANG AND LIAO YU TIN ADDRESS . . . . . . . . . . : 20559 RODRIGUES AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : - FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 30, 000.00 2 .00 .0 . 00 2 . 00 0 . 00 1BSEISMICR VALUATION 30, 000 .00 3 . 00 0 . 00 3 . 00 0 . 00 1REMRESBAT SQ FEET 49.00 588.00 0 . 00 588 .00 0 . 00 1REMRESOTH SQ FEET 380.00 457.00 0 . 00 457.00 0. 00 ---------- - ----- ---- -- - - --- - - - ------ --- - TOTAL PERMIT 1050 .00 0. 00 1050.00 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER - ---------------- --------------- -------------------- CREDIT CARD 1, 050. 00 MC --------------- TOTAL RECEIPT 1, 050.00 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 20559 Rodriguez Ave DATE: 05/04/2012 REVIEWEDBY: Sean APN: BPk: -VALUATION: $30,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration I Repair PRIMARY SFD Of Duplex PENTAMATION 1R3SFDREM USE: PERMIT TYPE: WORK Remodel familyroom 380 s ft and remodel wet into a bathroom 49 s ft). SCOPE 11,,'h l9un(.I"A 1'lruuh. l'1nu C h",Ak litre. Phu,(.7f,'ck .11,,:L. 1'.•i),if!br: Plwnh. 1'e,ow I.", 1C1, I" ),if I, 4hrr 11rrh. /nap_ Orher I'll Imp. Li 1 Ulhc•r lilrr_/nap. J/nr5. b,y). /,., Nw'lh. h,op. Pi•c /ih•r_7mp. /tr: NOTE: This estimate does not include fees due to other Departments(i.e. Planning,Public Works, Fire,Sanitary Sewer District,School District,etc. . These ees are based on the relimina information available and are on1v an estimate Contact the De t or arldn'l info. FEE ITEMS (I'ee Resulnlion 11-053 E(/.' 711/11/ FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 DTIs.f. Remodel, Bath (<=300 sf) Suppl. PC Fee: Q Reg. Q OT 0.0 Tilts $0.00 $588.00 1RE,LIRF_SBAT 1 19 PME Plan Check: $0.00 380 I s.f. Remodel, Other Permit Fee: $0.00 $457.001 IREMRESOTI! Suppl. Insp. Fee:Q Reg. Q OT 0,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 C'„am w limn To :I,Gni(Iirlr,nirr 1�u Work Without Permit? Ci Yes 0 No $0.00 Advanced I'lamm�e Fce: $0.00 Select a Non-Residential Building or Structure 7S,ncd U,.crmnunl,li,1u l.'1.'ce': 0� Suone Motion Fee: IBSBISMICR $3.00 Select an Administrative Item Ride Stds Commission Fee: IBCBSC $2.00 SUBTOTALS: $5.00 $1,045.001 TOTAL FEE: $1,050.00 Revised: 04/01/2012 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228•FAX(408)777-33331 buildinD(EDcuoertino.orD ❑NEW CONSIRUCIiON ❑ ADDRTON ALTERATION/TI ❑ REWSION/1317a ED ORIGNAL PERMIT R PROTECT AD[7RE55'-.v5 c, , vio �LQ Lino ( APNp� ln G Sv (V owNmNAME I \ 7 PHONE E RTAS aVl 11 (Cf f �� /�l r WI U I I STREET ADDRESS l_ crrY. STATE,ZIP FAX L�rLl i p CONTACT NAME PHONE `i E-MAIL. SR=AODRESS CRY.STATE ZIP FAX ❑OWNER ❑ OWNER-Hums) ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHC[ECt' ❑ENGINEER ❑ oEVELopm ❑TENANT CONTRACTORNAME LICENSE NUMBER LICENSE TYPE BUS.TIC 0 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY.STATE,ZIP ?HONE ARCIETRCT/FNOLNEER NAME LICENSE NUMBER BUS.RIC O COMPANY NARM E-MAIL FAX STREET ADDRESS CRY.STATE ZIP _ PHOTS DESCRIPTION OF WORK PROPOSEQj4SE 1 VI-3 CONSIATYPE $SUSE TYPE OCC SQFf. VALUATION(S) EXISTNEW FLOOR DEMO TOTAL /., ��J/ Q AREA �DDO AREA ' AREA NET AIiFA� (i/ '1/ /�/ .34 ' 00 BATHROOM KITCHEN OTHER REMODECARFA L./q REMODELAREA RamDELARZA JIio PO0.� OFAC/AREA TOTAL OECR?�f RCHAAEA ERAGEARPA/�/ DErnat / ATTACH 0 DWIS.LING VN[rS: ISASRCOrm UNIT YES SECONTl STORY YES f BSDIG ADDZDT ;wO ADDITION. 1F PRE-APPLICA/TIONDYES I+YES,PROVIDE COPY OF IS THE BR LDG AN ❑ro RE BY: TOTAAL VALUATION: FLANNIlG"PLp O PLANNING APPROVAL IS= RICHIJHOMaPWM E�9 JG GOO By my signature below.I certlfy m each of the followiDg: I am the property owner or authorized aaeor to act on the prppertyownee5 trhalf.•f have read this applimdm and the mfo=zdm I have pmvidcd is.,,Act I have reed the Dmcriptim of Wark and verify it is accurate. I agree to comply with an applicable local mdotacces and state lav relating to diag .o . I orize represmtadves of Cupertino to cater the above-identified property for inspection pmposm. Si fpa�e of Apphc mt/Ageot �� l pate: n J 1, o — / SUPPLEIVIENTAL INFORMATION REQ= PrANCRECICTYPS ROVmSGSLEF New SFD or Multifamily dwellings: Apply for demolition permit for G�,I.�-comrTLR BtiD.Durc?cAN xsvtEw existing building(s). Demolition permit is required prior to issuance of building permit for new building ❑ ZXPBMS ❑ PLINHIISGPLINREVIEW -Commercial L'mercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ SARD ❑ PUBLIC WORD form if airy Hazardous Materials are being used as part of this project ❑ LARGE ❑ YOU:bur _Copy of Playing Approval Letter or Meeting With Planning prior to ❑ MAJOR C1SANITARYSEWER Drsnucr submittal of Building Permit application. ❑ zmDtarinunrALBEALTa. BlagApp_201 l.doc revised 06/21/71 . � \ -)Yc�_ LIGo CUPERTINO U c F-,IVEa D Building Department MAY 0 4 Z01Z MAY 0 4 2012 BY: REVIEWED FOtklm PLIANCE �jAfZ j7En�o�7rL_ Reviewe Famllyroom Awl � �l 7>"i- ¢d1,,h Family Y Recessed ceilFaml room G MSI Ell 3'8" laundery _ qP � 94" 3'$" Iaundery light switchqP �(smoke detectorno,,, CO2 tletector Amt celing light Bath Bedroom wet bGFCI lc� rtvvwall li t t rte ansink w faucet 8' gKwall ligh ElKitchen 85,'rGFCI rimae�o7aa 6 -=� Qp outlet Q A� G E�Hf3 1Hs ca �� BUILDING DIVISION-CUPERTINO `G tiO�Efi Gc N( �� APPROVED G� wrzoKcrl �✓i7, ��2 This set of plans and specifications MUST be kept at the AFTER o64vPWn'% Job site during construction. It is J f N1310 make any l�PTrf�� changes or alterations on same,or to deviate 5Fi✓�o /^ therefrom,without approval from the Building Official. F ++ ' FFICAM- ,� The stamping this plan end specifications SHALL NOT 1p! C% i—AMr be held to permit or to be an approval of the violation of any provisions of any Cii!y?clinancce or State Law. By ✓Ffln/ /�q��/T DATE feet 12ft 24ft 36ft PERMIT NO. aS/GYo/� -- floor@