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11100058 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19040 BARNHART AVE CONTRACTOR:NG PAUL AND VAN PERMIT NO: 11100058 OWNER'S NAME: NG PAUL AND VAN 19040 BARNHART AVE DATE ISSUED: 10/10/2011 /°--"NER'S PHONE: 4084407428 CUPERTINO,CA 95014 PHONE NO: Li LICENSED CONTRACTOR'S DECLARATIONr BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH F RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE SEWER LINE FROM HOUSE TO LATERAL (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 permit is issued. Sq.Ft Floor Area: Valuation:$2200 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 permit is issued. APN Number:37537038.00 Occupancy Type: t� APPLICANT CERTIFICATION N' \ 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 W TARTED upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS P U NCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DA RO INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Issued by �/ Date 9.18. Signature Date .s✓i i RE-ROOFS: OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law 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 Applicant: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I 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 Health&Safety Code,Sections 25505,25533,and 25534. I will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. 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&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Owner or uthoriz d agent: Compensation laws of California. If,after making this a°tificate of exemption,I Date: �a O become subject to the Worker's Compensation provisions o`the Labor Code,I must forthwith comply with such provisions or this permit shall be eemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of%wrk's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) 1 certify that I have read this application and state 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, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION ng of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. WiLn all non-point source regulations per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 37537038. 00 DATE ISSUED. . . . . . . : 10/10/2011 RECEIPT #. . . . . . . . . BS000014988 REFERENCE ID # 11100058 SITE ADDRESS 19040 BARNHART AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER NG PAUL AND VAN ADDRESS . . . . . . . . . . : 19040 BARNHART AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM ERIC NG CONTRACTOR LIC # *OWNER* COMPANY NG PAUL AND VAN ADDRESS . . . . . . . . . . : 19040 BARNHART AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- -ADMIN HOURS 1. 00 41. 00 0 . 00 41.00 0 . 00 1BCBSC VALUATION 2,200 .00 1. 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 2, 200. 00 0.50 0. 00 0 .50 0. 00 1PPERMITFE FLAT RATE 1. 00 44 . 00 0 . 00 44 .00 0. 00 1PRSEWER UNITS 1 .00 22. 00 0 .00 22 .00 0 .00 1TRAVDOC FLAT RATE 1.00 44 . 000. 00 44 . 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 152 . 50 0. 00 152 .50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 152. 50 VISA --------------- TOTAL RECEIPT 152 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ------------ 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTiNO (408)777-3228 • FAX(408)777-3333- building(aDcupertino.org misc PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROTECT ADDRESS APN# ' f -?^ �V L�IO.NO rnAve- �' .5 _ OWNER NAME PHONE Fpr Vl �- (� O �t o- y 2 STREET ADDRESS CITY, STATE,ZIP FAX d o rn oar ve- S O 1 lk CONTACT NAMEe e-1 G 1 PHONE -4 tl -2y 2 G EMAIL STREEI'ADDRESS 11 N /� CITY,STATE, ZIP (�h C�j FAX ��Cl 0UO 0�rYIV-tC"',4- 1ANQ 07 OWNER ❑ OWNER-HUIIDER ❑ OWNER AGENT 13 CONTRACTOR ❑CONTRACTOR AGENT 11ARCHITECT 11 ENGINEER 13DEVELOPER 1:1 TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHrrECTIENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME' E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF FD or DUPLEX ❑ MULTI-FAMILY PROTECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE ❑NO EICHLER HOME? NO DESCRIPTION OF WORK f �c � evv`e v- ��►1 er o►-►� �.ou,s2 �a l��e��. . TOTAL VALUATION: 1,ECI CIV RECEIVED BY: By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. i have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buildin ns tion.`I authorize representatives of Cupertino to enter the above-identified property for inspection pu{poses. Signature of ApplicandAgent- Date: tot SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY OVER-THE-COUNTER c ❑ EXPRESS Y U _T ❑ STANDARD V ❑ LARGE G ❑ MAJOR MEPMiscAppj011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10040 Barnhart DATE: 10/10/2011 REVIEWED BY: gs APN: BP#: "VALUATION: $2,200 ;'PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair PRIMARY PENTAMATION 1 RPSS USE: SFD or Duplex PERMIT TYPE: WORK Replace sewer line from house to lateral SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1PRSEWER 1 # $22 TOTALS: $22.00 Plumb.Plan Check 0.0 hrs $0.00 Plumb.Permit Fee: 1PPERMIT Other Plumb Insp. 0.0 hrs $44.00 Li NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc. . Theseees are based on the prelinina in ormation available and are onl an estimate. Contact the De t or addn'l info, FEE ITEMS Lee Resolution 11-053 Ef. T 1.;"111 FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 PME Unit Fee: $22.00 PME Permit Fee: $44.00 Administrative Fee: ]ADMIN $41.00 Work Without Permit? Yes (j) No $0.00 Travel Documentation Fee: ITRA VDOC $44.00 Strop r Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $152.50 $0.00 TOTAL FEE: $152.50 Revised: 10/01/2011 OWNER-BUILDER DISCLOSURE FORM Is COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 GUPERTINO (408)777-3228- FAX(408)777-3333• building g)cupertino.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 BP# Boyo V, e OWNER NAME OWNER ADDRESS Ave.. Cv ff= DESCRIPTION OF WORK: e wtnr o 10 Sst 4-o [, 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 (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) EN1. 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. FN 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. FO 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. 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. EtJ 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. �O 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. 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. E4J8. 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. avnerBuilderForm 2010.doc revised 04/14/10 1439. 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. 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. 'F-0 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. F-� 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 city may be required to be presented when the permit is issued to verify the property owner's signture. Property Owner's Signature: Date: 1 D --------------------------------------------------------------------------------------------------------------------------------------------- (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: G rvnerBuilderForm 2010.doc revised 04/14/10 0 5 A N 11'ARY DISTRICT MANAGER ENGINElrR ��'+ � BOARD OF DIRECTORS WILLIAM A. MARK THOMAS(k COMPANY,INC. JOHN M.CAYTO'T'rO TH RICHARD K.TANAKA STEVE C.ANDREWS DISTRICT COUNSEL Ff �y� WENDELL H.KERR,JR. ATKINSON.FARASYN,LI.-P. l'4B(1SHE' CHRISTOPHER C.LEE HAROLD S.TOPPEL 20833 STEVENS CREEK BOULEVARD,SUITI;104 CUPERTINO,CALIFORNIA 86014.2154 (408)2537071 PHONE • (408)7.L3.5173 FAX www.cup9rtin0ae11itarydISirlct.com October 10, 2011 File: CSD—MOP Building Dept,—Cupertino City of Cupertino Building Department 1.03 00 Toire Ave, Cupertino, CA 95014-3202 Subject: Residential SFWD Name: Ng Residence Address: 19040 Bwmhart Avenue APN: 375-07-038 Permit No. N/A T Cupertino Sanitary District has reviewed the plans for tale subject project: IN Sanitary sewer is not provided by the District to the subject location, please contact: City of Sunnyvale—Osie Stop Ccaiter 456 West Olive Avenue Sunnyvale, CA.94086 (408) 730-7444 Yours very truly, MARK THOMAS & COMPANY, INC. District Manager-Engincer q- &4&AAA� for Richard.K. Tanaka If you have any questions or need additional information, please call Nichol Bowersox at 408-253-7071.. S:\WORI)S\CUSD\LCT'1'IrRS\BUIL01NO DEPT LP-T'FERS\N0T IN TFIE DISTR1CTWut in District 20111N/A—NID 19040 belnhnrV Avo Sub 1 N)D 10.10.20)I,doc SUPPLYING SANITARY SEWERAGE SERVICES FOR:CITY OF CUPERTINO,PORTIONS OF TIRE CITIES OF SARATOGA,SUNNYVALE,Los ALTOS AND SURROUNDING UNINCORPORATED AREAS 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/ SUBCONTRACTOR LIST cc JOB ADDRESS: 1 qp o Qa,rh ve CV +j, °1SaI PERMIT# �J OWNER'S NAME: PFkvA\. t,3rA PHONE# A d k- Z S z— 90 61 GENERAL CONTRACTOR: BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: *Our municipal code requires 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. 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/ ntractor Signature Date