130301174.t
CITY Off CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7514 HOLLANDERRY PL
CONTRACTOR: CHEN SHAUN H AND
PERMIT NO: 13030117
LIPING W TRUSTEE
OWNER'S NAME: CHEN SHAUN H AND LiIP1NG W TRUSTEE
7514 HOLLANDERRY PL
DATE ISSUED: 03/22/2013
OWNER'S PHONE: 4085948347
CUPERTINO, CA 95014
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIP'T'ION: RESIDENTIAL COMMERCIAL
INSTALL (N) EV CHARGING STATION IN GARAGE AREA
License Class Lie. #
Contractor Date
I hereby affirm that I 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.
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<permitis issued.
Sq. Ft Floor Area:
Valuation: $1520
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 36229015.00
Occupancy Type:. -:
Section 3700 of the Labor Code; for the performance of the work for which this
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 state 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, property for inspection purposes. (We) agree to save
180 DAYS FR S LED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City inconsequence of the
Iss Date: 2-2 1
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.
RE- 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
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two 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 do the 'work, 'and the structure isnotintended or offered for sale (Sec.7044,
Business & Professions Code)
I, 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. 1 will
I hereby 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(a) 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 Quality Management District I
of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
performance
I have, and will maintain Worker's Compensation Insurance, as provided for by
for this
the Health &Safety Code, Sections 25505, 25533, and 25534. `
Section 3.700 of the Labor Code, for the performance of the work which
Owner or authorized age.,..
permit is. issued:
I certify 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
CONSTRUCTION LENDING AGENCY
Compensation Jaws of California. If after making this certificate of exemption, I
become :sub1ecl to the Worker, s Compensation previsions of the Labor Code, I must
I 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
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 herebyauthorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City-of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public re cords.
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.
CUPERTINO
ALTERNATIVE ENERGY PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 • building (aacupertino.org
D\`1�AE
PROJECT ADDRESS 26-19-f 1'10 //�4
�"'"/
APN # 36 Z — Z-7 ` D /
OWNER NAME �l6 Pih
PHONE �j', -_A j Q
E -MAIL SC !�
STREET ADDRESS
/ ((- CC
CITY, STATE, ZIP O
FAX
CONTACT NAME %
PHONE
STREET ADDRESS
CITY, STATE. ZIP
FAX
❑ OWNER ❑ OWNER - BUILDER ❑ OWNER AGENT
❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
3) C
LICENSE NUMBER
92 J
LICENSE TYPE
BUS. LIC #
COMPANY NAME �_(� G � C
E-MAIL C17 C� C ^ 19, cG K CGS
FAX �7
STREET ADDRESS
CITY, STATE, ZIP
PHO
ARCHITECT /ENGINEER NAME /�jJ
/ V
-7
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E -MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF SFD or Duplex ❑ Multi- Family
STRUCTURE: ❑ Commercial
PROJECT IN WILDLAND
URBAN INTERFACE AREA ❑ Yes No
PROJECT IN
FLOOD ZONE ❑ Yes kNo
❑ SOLAR PANELS
I<ELECTRIC VEHICLE CHARGING STATION
❑ SOLAR WATER HEATING
❑ OTHER:
FOR SO /AR PANELS: NUMBER OF PANELS /UNITS:
# KILOWATTS:
TOTAL VALUATION.
DESCRIPTION OF WORK •�, �� /j s �4� �lQ �j/ � (� C / i
7/(7
By my signature below, I certify to each of the following:
application and the information I have provided is correct.
ordinances and state laws relating to building co tion.
Signature of Applicant/Agent:
I am the property owner or authorized agent to act on the property owner's behalf. I have read this
I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
I authorize representatives of Cupertino to enter the above - identified property for inspection purposes.
Date:
SUPPLEMENTAL INFORMATION REQUIRED (
OFFICE USE ONLY
VER- THE - COUNTER
a
EXPRESS
U
W
x
❑ STANDARD
U.
❑ LARGE
❑` MAJOR
PVApp_2012.doc revised 06 120112
CITY OF CUPERTINO
UU1V T' a rlrl%4 A rrnlD RTTTT .i1TATC IIlVlClnN
NOTE. This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc). These-fees are based on the prelinmuna m ormanon avaccaoce ana are onty an esunuue. ntuu Inc -v z vi u
FEE ITEMS. (Fee Resolution 11 -053 E . 711112) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1 # Alternative Energy System
Suppl. PC Fee:. O. Reg. O OT 0.0 hrs $0.00 $102.00 1CHRGSTA EV Charging Station
PME Plan Cheek:. $0.00
Permit Fee: $0.00
.Supp1. Insp. Feeig Reg. O OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
CA) nsiructio n Tax:,'
Adin i nistrati:ve .Fee:
Work Without Permit? O Yes O No $0.00 O
Advanced Planning Fee: $0.00 Select a Non - Residential 1
Travel Doeuinentation Fees': Building or Structure ®,
Strong? Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
1BCBSC $1.00
S 11
$1.501 $102.00
Revised: 01/01/2013
ADDRESS.:. 7514 HOLLAN DERRY PL
DATE: 03/21/2013
REVIEWED BY: MELISSA - .
APN: 362 29 015
BP #:
"VALUATION:
$1,520
*PERMIT TYPE:. Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Du lex
p
PENTAMATION SOLAR -RES
PERMIT TYPE:
USE:
WORK
INSTALL N EV CHARGING STATION IN GARAGE AREA
SCOPE
NOTE. This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc). These-fees are based on the prelinmuna m ormanon avaccaoce ana are onty an esunuue. ntuu Inc -v z vi u
FEE ITEMS. (Fee Resolution 11 -053 E . 711112) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1 # Alternative Energy System
Suppl. PC Fee:. O. Reg. O OT 0.0 hrs $0.00 $102.00 1CHRGSTA EV Charging Station
PME Plan Cheek:. $0.00
Permit Fee: $0.00
.Supp1. Insp. Feeig Reg. O OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
CA) nsiructio n Tax:,'
Adin i nistrati:ve .Fee:
Work Without Permit? O Yes O No $0.00 O
Advanced Planning Fee: $0.00 Select a Non - Residential 1
Travel Doeuinentation Fees': Building or Structure ®,
Strong? Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
1BCBSC $1.00
S 11
$1.501 $102.00
Revised: 01/01/2013
CUPERTINO
OWNER- BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 - buildino(d�cuoertino.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:
SITE ADDRESS 2�+/ 1 APN BP#
OWNER NAME /o " / OWNER ADDRESS �5��� L �e
DESCRIPTION OF WORK: S-��
� c P
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
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
--4074t1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
Builder" building permit that erroneously impiies.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.
.-4W-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.
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.
-. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
. I 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.
_46rn. 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.
- lL. I 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.
_An. 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.
O��nerPuilderFonn 2010.doc revised 04114110
r' I 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 wv✓v✓.cslb.ca.gov for more information about licensed
contractors.
J�10. I 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.
X11. 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.
I 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 property owner's signature.
Property Owner's Signature: Date: u /
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating -a- n
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 Properly 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:
Pi!ne;EuilderForns 2010.docrevised04114110
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014 -3255
Telephone: 408- 777 -3228
C U P E RT I N O Fax: 408 - 777 -3333
CONTRACTOR / SUBCONTRACTORLIST
JOB ADDRESS: �l AC-I
PERMIT
OWNER'S NAME: C14,11
PHONE.#
GENERAL CONTRACTOR:
BUSINESS LICENSE #
ADDRESS: �' <S��ry„ ( ,
CITY /ZIPCODE: S ,4yukpk 4A 4CD
*Our municipal code requires all businesses working in the city to have a City of Cupertifio 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.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information.
SUBCONTRACTOR BUSINESS NAME '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
COMMUNITY
BUILD
BUILDING DIVISION ECUPERT NO ENT
APPROVED
This set of plans and specifications MUST be kept at the
job site during construction. it is unlawful to make any
changes or alterations on same, or to deviate
therefrom, without approval from the Building Official.
The stamping of this plan an cations z)rlAL-iL- H89
be held to ovaI of the violation
.. an%i nr nance or S tate Law.
DA
NO.
7514 Hoollanderry PI.
Cupertino, CA 95014
Charging
Garage
Charger Information
Model Name: Siemens Versicharge 30 Amp Nema- 4Indoor /Outdoor Electric Vehicle Charger
Model #: VC30BLKB
UL Listed: Yes
CUPEIRTINO
liiding Department
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P�E`?, VVED FOR CODE CO
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By:
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MAR Z 2 2013
BY• -- --.�I�
Front View
Charging Station
5'
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Charging
3
Garage
Top View
18.5'
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OFFICE COPY
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JOB ADDR.C,SS:.
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PERM{1'. #:_:
OWNER'S NAME-::/
16 N I' L CONTRACTOR:
I3USTNTS,.5tiCriNsu 71
ADDRESS'
Aw-
V. SU.6CONTRACTOR BUSINESS:NAIViE: EtJ5IlYF :51 C I�c:1 i isF: #:.
CAA in&t * Millwotk
Cement Finishing
Owner / Conti- Actor:SiL;Witure': na to