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12100220 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10397 PALO VISTA RD CO,NTRACFOR:CHANG GEORGE.CIiIA- PERM fI'NO: 12100220 JUNG AND CI'IUNG SU OWNEWSNAME: CHANG GEORGE CILIA-JUNG AND CHUNG SU 10102 IMPERIAL AVE, DATE ISSIIFD: 1081/2012 OWNER'S PRONE: 2069104185 CDPERTINO,CA 95011 1'11ONE NO: ❑ LICENSIiD CO\PRAC`fOR'S DECLARA'T'ION BUILDING PERMIT INFO: BLDG r ELECT❑ PLUMB C, License Class Lie.q M ECH . RESIDENTIAL - COMMERCIAL —' Contactor Date herebyalTirm that l am licensed under the provisions of Chap(er9 -JOB DESCR I PTION: INSTALLATION OFTEMPORARY POWER(IOOAMP) (commencing with Section 7000)of Division 3 of the Business& Professions Code and that my license is in full force and effect. hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a cenificate 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.FI Fluor Area: Valualion:$500 I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for Ore performance of the work for which this permit is issued APN Number:35703027.00 OccupancyType: ,\PPLICAN'1'CER'I'IPIG\"PION I certify that I have read this application and state that the above information is correct.l agree to comply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting o(this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Issued by, 9.18. Signature Date REI-ROOFS: OWNER-BUILDER DECLARA'T'ION All tool's shall be inspected prior to any rooting material being installed If a roof is installed wilhora fust obtaining mi inspection,I agree to remove all nnv materials for I hereby affirm that I am exempt from the Contractor's License Lay for one of inspection, the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Appli©nl: Date: 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 ALI,ROOF COVERINGS TO BEI CLASS"A"OR RE 1"f ER construct the project(Seea7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three IIA%ARDOUS MATERIALS DISCLOSURE declarations: 1 have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Ile:dth&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Compensation,as provided for by Section 3700 of the Labor Code,(or the compliance with the Cupertino Municipal Code,Chapter 9.12 and the IteaRh& performance of the work for which this permit is issued. Safety Code,Section 25532(x)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should 1 use equipment or devices which emit hazar111111V air Section 3700 of the Labor Code,for the perfomumce of the work for which this cunt:uninanU as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the permit is issued Health&Stifely Code,Sec " as 255115,25533,and 25534. I certify that in the performance of 0ac 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 0, er or authoriz Compensation laws of Califomia. If,after making this certificate of exemption,I J/Il�atr. become subject to the Worker's Compensation provisions of the Labor Code,I muss forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUC`FION LENDING AGENCY I hereby affirm that there is a construction leading agency for the performance of wurk's APPLIG\N"I'CF.R'1'IFICA'I'ION for which this permit is issued(Sec.3097,Civ C.) I certify that 1 have read this application and sate that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, .\RCIII'1'FCI"S DECLARATIONcosts,and expenses which may aceme against said City in consequence o(Ihe granting of this permit.Additionally,the applicant understands and will comply I undersumd my plans shall be used as public records. with all non-point so a regulatia s per the Cupertino Municipal Code,Section 9.18. / Licensed Professional Signature Date ( O/3 =' 12-1 vu Zz� GENERAL PERMIT APPLICATION M E d G COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 R A ' SC CUPERTINO (408) 777-3228 • FAX(408)777-3333• buildina0guoerino.oro 1\a(' ❑PLUMBING ❑ '� MECHANICAL I 'LECTRICAL MISCEL cOUS PRornAES nDRS /0. 3 f/ 7 14,`o 12W I Ate'" 3 ( 0 U Z 7, Uv OWNER NAME / PHONE zo69/p YIDS E-MAII, . eD C/tA C� Mail. Cu sTxEETADDRESS CITY, STATE,2m G4 9T- FAX . CONTACT NAME PHONE E-MAIL � � S.,TR.ec—T ADDRESS I CT—.y'STATE c3 F.AX O/OWN]t ❑ OWT .BUILDER ❑ OWNEH AGENT" ❑ CONi =R. ❑CONTR =R.A AGENT ❑ AR=E:Cr ❑ENGT=Zk ❑ DEVELOPER ❑ T'_NANi CONRACTORNAME/ ` LICENSE NUNOR LICENSE TYPE BUS.LICtl COMPANY NAME I MATL FAX ST-=-TADDRESS I C'TY,STATE LT PHONE ARC=zC7/E9CW.Et NAME LICENSE NUMBER BUS.LIC p COMPANY NAME' E-M.AIL FAX STFLEET ADDRESS I CITY,STA iR,IlP PRONE :ZL D'NG: ❑COMMRCIAI.DUPLEX ❑ MVLTLFAMIl.Y I URRAAh Pk=��ACT_AREA t'NO I PR01EC7 IN EI �zs IS MIE BLDG AN FLOOD LONE 0 I El} - HOME INO DESCRIPTION OF WORK L� TOTAL VALUATION: �' DO '"-' I RECEIVED BY: By my signature below,I certify to each of the following: I am:he property owner cr authorized agent to act on the prupery owner's behalf. I have mad this application and d.a information I have provided is correct 1 have read the Description of Work and verity it is acn:ratc. I agree to comply with all applicable local OTCHTIMCeS and sate laws relating to'ouiiding svucdom I an- rta representatives of Cupertino to enter the above.idati5ed pmperry for i.specrion puf�oses. Sigaattre ofADplicandAgene / Date: /U 3 /'//i SUPPLEMENTAL INFOR-V-ATION REQUIRED OFFICE USE ONLY t, OVER.THE-COUNTER f ❑ EXPRESS U J ❑ STANDARD V i ❑ LARGE 5 ❑ nvwoR MFP.dAuc4pp_201l.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 10397 Palo Vista Road DATE: 10/31/2012 REVIEWED BY: Sean APN: BP#: 'VALUATION: $500 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD Or Duplex PENTAMATION 1REAP14 USE: PERMITTYPE: Al WORK Installation of temporary ower 100 amp). SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1ERT<200 100 Amps $45 TOTALS: $45.00 blech. Plan Check Plumb. Plan Check Elec. Plan Check 0.0 hrs' $0.00 Mech. Permit Fee: Plumb. Permit Fee: Elec. Permit Fee: 1EPERMIT Other,5fech. larp. Ll I Other Plumb Imp, Ll I Other Elec. Insp. 0.0 hrs $45.00 Herb.Imp.Fee: Plumb. lasp. Fee: Elce.Insp.Fee: A'OTE: This estimate does not include fees due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Seiner District,School District,etc.). These eer are based on the prelitninan information arailahle and are onb,an estimate. Contact the Dept for addn'I info. FEE ITEMS (Fee Resolution 11-053 F1 7/1/12) FEE QTY/FEF. MISC ITEMS Plan Check Fee: Snpp1. PC Fee PME Plan Check: $0.00 Permit Fee.: SuppL Insp Fee PME Unit Fee: $45.00 PME Permit Fee: $45.00 Constreuction Tac: Administrative Fee: LtDMIN $42.00 Work Without Permit? O Yes Q No $0.00 Advanced Planting Fees: Travel Documentation Fee: ITRA VDOC $45.00 Stron¢Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Olde Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $178.501 so.001 TOTAL FEE: r $178.50 Revised: 10/01/2012 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333- buildinar@cuDertino.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 /O 3 Y 7 ��� r�, /^ le',( APN �...-7 O3 O Z .�,Uv BP# n OWNER NAME C/g pl/ OWNER A�OR��2 ae � A,- DESCRIPTION OF WORK: re-o--4-01 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.) 41. 1 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. 4L-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. 4-L-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 fled in his or her name instead of my own. !W_4. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. 6 1' 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( 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. L 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. y L 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. OloserBuilderForin 2010.doc revised 04/14110 �9. I understand I may obtain more information regarding my obligations as an "employer"from the Internal Revenue Service, the United Stales 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.cslb.ca.gov for more information about licensed contractors. ,1L 10. 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 by all applicable laws and requirements that govern Owner-Builders as well as employers. 4_L_12. 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 cit may be required to be presented when the permit is issued to verifythe prope owner's si ature. 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: 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 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: On nerBuilderFornr 2010.doc revised 04/14/10 Building.Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-773-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: 039 at' PERMIT# / 2 1 wZ-Z " OWNER'S NAME: L PHONE # 2o6 /o Y /;F�J GENERAL CONTRACTOR: (j ��y - BUSINESS LICENSE # ADDRESS: o/LTz- , t �, e. CI"rY/ziPCODE: C �e Clfl 9So/y *Our municipal code reymres all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. 1 um not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAtNIE BUSINESS LICENSE # Cabinets-& Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass /Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date