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11030149 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10372 ANN ARBOR AVE CONTRACTOR:JENNIFER CHEN PERMIT NO: 11030149 OWNER'S NAME: JENNIFER CHEN 10372 ANN ARBOR AVE DATE ISSUED:03/30/2011 (V"INER'S PHONE: 4084469700 CUPERTINO,CA 95014-3907 PHONE NO: L LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:CONVERT EXISTING DEN ON 2ND FLOOR INTO (commencing with Section 7000)of Division 3 of the Business&Professions BEDROOM(114SQFT);NON-STRUCTURAL 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. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$1500 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:32628055.00 Occupancy Type: APPLICANT CERTIFICATION 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 WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. 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. Issued b ., �— Date: Signature Date OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. I,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date: Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worke�Rc, I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air 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 Compensation laws of California. If,after making this certificate of exemption,1 Owner(or an ori ag �') Date:— become subject to the Worker's Compensation provisions of the Labor Code,I must Date:----�� I forthwith comply with such provisions or this permit shall be deemed re ed. l(�y//e�J!�/l CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities,judgments, c--,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 v,.,.,all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. `{ O a ' Licensed Professional o- kilt Signature Date ✓� 0 t ` CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228• FAX(408)777-3333•building (a)cupertino.org CtJPERTINO ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS c> Z Iq .A u� APN# -.S_z. 6^ p ^b a O OWNER NAME PHONE E-MAIL e�hi Y c(.eH -44.6 ,9700 �e-tA �-eY A 1de%A e •CC. STREET ADDRESS CITY, STATE ZIP FAX l o3?z,. -q IQ �l �Au-a6R .A T Into c-r9 c-448)4 CONTACT NAME Y 11J PH46(5`qq0-79 B$ E-MAIL C4 q e v� &uct 1 I,- �V Ems. l •�\ STREET ADDRESS V x{I a CITY,STATE, ZIP a Q�a'� FAt4�� ( 6--7%6 I o 2 68 $QI/AC1 I e r t h c4 ❑OWNER ❑ OWNER-BUILDER kOWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME © LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT/ENGINEERNAME � 1 LICENSE NUMBER C 2 I BUS.LIC# D COMPANY NAME �-F E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE DESCRIPTION OF WORK CO v, 1 T p � J%r­?J ,p �R•` ^�� ls;£D-P-a b r"r EXISTING USE .1� PROPOSED USE CONSTR.TYPE #STORIES Y S.41P. 'J 1 9.I. —,!j ^L. occ, TYPE DESCRIPTION EXISTG NEW FLOOR DEMO TOTAL A AREA I AREA I AREA I NET AREA C L\� V17 // BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA ` PORCH AREA DECK AREA TOTAL DECK/PORCH AREA I GARAGE AREA:❑ DETACH ❑ ATTACH #DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? ❑NO I ADDITION? ❑NO PRE-APPLICATION ❑ YES IF YES,PROVIDE COPY OF PLANNER'S NAtvfE. RECEIVED BY' T TItAL VVAAL.U�AnbN: PLANNING APPL# ❑ NO PLANNING APPROVAL LEITER 1 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 r building constructi authorize representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: '— 30 SUPPLEMENTAL INFORMATION RE IR PLAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for VER-THE-COUNTER' ❑ BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. EXPRESS ❑ PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH B1dgApp2011.doc revised 03/16/11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 10372 ann arbor ave. DATE: 03/30/2011 REVIEWED BY: bobs. Its I APN: I BP#: 'VALUATION: 1$1,500 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION 1 R3SFDREM USE: PERMIT TYPE: WORK convert existing den on 2nd floor to bedroom non structural. SCOPE NOTE: These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addh7 info, FEE ITEMS (Fee Resolution 09-0511,,L-7,110) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = s.f. Remodel,Other Suppl.PC Fee: G Reg. 0 OT 0.0 hrs $0.00 $380.00 IREMRESOTH PME Plan Check: $0.00 Permit Fee: $0.00 Suppl.Insp. Fee-0 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Acoustical Fee: 0 Yes (F) No $0.00 0 Work Without Permit? 0 Yes E) No $0.00 Planning;Fee: $0.00 Select a Non-Residential Building or Structure Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $1.501 $380.00 TOTAL FEE: 1 $381.50 Revised: 01/15/2011 CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32628055. 00 DATE ISSUED. . . . . . . : 03/30/2011 RECEIPT #. . . . . . . . . : BS000013047 REFERENCE ID # . . . : 11030149 SITE ADDRESS . . . . . : 10372 ANN ARBOR AVE SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : JENNIFER CHEN ADDRESS . . . . . . . . . . : 10372 ANN ARBOR AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-3907 RECEIVED FROM . . . . : JENNIFER J CHEN CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : JENNIFER CHEN ADDRESS . . . . . . . . . . : 10372 ANN ARBOR AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-3907 TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 1, 500 .00 1. 00 0. 00 1. 00 0. 00 1BSEISMICR VALUATION 1, 500 . 00 0 .50 0 . 00 0.50 0 .00 1REMRESOTH SQ FEET 114 . 00 380 . 00 0 . 00 380 .00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 381.50 0. 00 381 .50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 381.50 #2988 --------------- TOTAL RECEIPT 381.50 0 0 PR%�Z__ M� H pC�OC� MNo 12JAMPLIEW P12. #vm (rM7upmmvomg Q ao ow4 ��� o Quo �gc���� o �, o Q�©O009-To� (DaEEHI�B UHTE TM2 aDMMUo/��n nn /��/7 LaDDG3[E�% �@,OTR L%mm In 0 OW L�1�'J R❑ SCOPE OF WORK: CONVERT EXISTING BONOUS ROOM @ 2ND TO BEDROOM #4 vo ti WALL LEGEND f EXIST. WALL TO REMAIN OPEW TO LR, NEW 2X STUD WALL W/ GYP. BD. " OPEN TO ENTRY *BEDROOM ESCAPE OPENING: 7'-s" (E) Bi-FOLD'G 1 NET CLR. OPEN'G 5.7 S.F. 2 NET OPEN'G HT. MIN. 24" o Pais 3 NET OPEN'G WIDTH MIN. 20" 1 CLO. ) 4) BOTTOM OF OPENING MAX. 44" AC Bi-PASS "/ z fn(n / 0 SMOKE & CARBON DIOXIDE DETECOTR .� � °�/ W/ HARD WIRED & BATTERY BACKUP. ma ca w B.R. #4 <N) ARC—FAULT CIRCUIT—INTERRUPTER PROTECTION OUTLET AT NEW BEDROOM. IN _ � SAUNA M• B R. 1� n F. TF�'� N EXP. -31- `�� C-21376 9rF�' cA�-�F� PARTIAL 2ND FLOOR PLAN S: 1/8"-V-0" OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 950143255 CUPERTINO (408)777-3228• FAX(408)777-3333•buildinoQCuoertino.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# (©3?'2 r�tvl�l 'i7'R�OR f�IIF' 32fo-- � a—OSS OWNER NAME t-4 1�1 OWNER ADDRESS J I;tJ►v 1 :E'iz c DESCRIPTION OF WORK: C�aill�1�T D� TD fi�L�-li�i6o M 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.) X1. 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 homeowners 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. ___�(_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. _.�<_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. __X^5. 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. ' a' _K_6. 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 a//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 financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. OwnerBuilderForn: 2010.doc revised 04/14/10 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: D; 7 Y, PERMIT# OWNER'S NAME: PHONE# GENERAL CONTRACTOR: Q 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. 3�1, 1 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/Con actor Signature Date