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