11030059 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10618 LA RODA DR CONTRACTOR:SHIN-CHYI HSIEH PERMIT NO: 11030059
OWNER'S NAME: SHIN-CHYI HSIEH 10618 LA RODA DR DATE ISSUED:03/11/2011
OVINER'S PHONE: 4089183367 CUPERTINO,CA 95014 PHONE NO:
L LICENSED CONTRACTOR'S DECLARATIONF
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:CODE ENFORCEMENT CASE-REMOVE ILLEGAL
(commencing with Section 7000)of Division 3 of the Business&Professions STRUCTURE
Code and that my license is in full force and effect. ATTACHED TO REAR OF SFDWL
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
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$600
permit is issued.
APPLICANT CERTIFICATION APN Number:36933017.00 Occupancy Type:
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
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this pen-nit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: Date:_,
Signature Date
OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
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
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner uthorizedd ag / /
forthwith comply with such provisions or this permit shall be deemed revoked. � ' L= � ,L Date: I/ 2 1
APPLICANT CERTIFICATION J t4— CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
C, and expenses which may accrue against said City in consequence of the
ig of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
�._.:.all non-point source regulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
ill1i
SignatureDate / Licensed Professional
_ f
DEMOLITION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
'is, (408)777-3228• FAX(408)777-3333•building(cDcupertino.ora
CUPERTINO
PROJECT ADDRESS / APN# Jy 4007
OWNER NAME /_ /J� I /� PHONE 1 E-MAIL //n C Ca,07 C0
STREET ADDRESS �f CITY, STATE,ZIP FAX
APPLICANT NAME j_ PHONE E-MAIL
STREET ADDRESS OL CITY,STATE, ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ 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
DESCRIPTION OF WORK
m ak +(e-ev' Of
RESIDENTIAL #DWELLING OFFICE USE ONLY
FLOOR AREA UMTS USE C. 'rYPE, SOFT. VAL ATION
COMMERCIAL
FLOOR AREA
TYPE OF CONSTRUCTION #STORIES
AQMD JOB NUMBER RECEIVED BYr, TOTAL VALUATION:
J #: I -§_ oi�
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 bu 'n construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: 143� Z12 2Z
Date: /
SUPPLEMENTAL INFORMATION REQUIRE PRIOR TO ISSUANCE OF DEMOLITION PERMIT OFFICE USE ONLY
_Provide Job Number from Bay Area Air Quality Management District www.baaqmd.org @ 415-749-4762. PLAN CHECK` TPF,
_Provide three copies of a site plan showing protection for any trees 10"in diameter or more at 3'above grade. EXPRESS'.
_Provide letter from P.G.&E.(408-725-3325)stating all gas and electric has been disconnected. ❑ STANDARD
LA
_Provide a current preliminary title report issued within 30 days prior to issuance of demolition permit showing RCE
ownership,open deeds of trust,liens,taxes and legal description. All taxes must be current and paid in full. ❑ MAJOR
Complete a Demolition Request Form. Allow for 15 business days for interested parties to respond back.
_Provide a letter of inspection,tests,and abatement of any Hazardous Materials.Letter to be initiated by person(s)
certified in asbestos,mercury and/or hazardous material examination.
Planning Dept clearance to verify building is not considered an historical landmark.Allow 10 business days.
Provide letter of clearance of all vermin from a licensed pest control contractor.
Applicant shall call the Public Works Department at 408-777-3104 and schedule a"habitable dwelling"inspection.
Provide signed Debris Bin and Recyclable Materials form.
_Commercial Buildings Only: Provide Fire Dept clearance for fire suppression/alarm system review.
DemoApp_2011.doc revised 03/02/11
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36933017. 00
DATE ISSUED. . . . . . . : 03/11/2011
RECEIPT # . . . . . . . . . : BS000012885
REFERENCE ID # . . . : 11030059
SITE ADDRESS . . . . . : 10618 LA RODA DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : SHIN-CHYI HSIEH
ADDRESS . 10618 LA RODA DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : SHIN C HSIEH
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : SHIN-CHYI HSIEH
ADDRESS 10618 LA RODA DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 600 .00 1 . 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 600 . 00 0 . 50 0 . 00 0 . 50 0. 00
1INSPMIS HOURS 1 . 00 126 . 00 0 . 00 126 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 127 . 50 0 . 00 127 . 50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 127. 50 VISA
---------------
TOTAL RECEIPT 127 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
704 DEMO
DEMOLITION
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10618 la rhoda DATE: 03/11/2011 REVIEWED BY: bobs.
APN: BP#: "VALUATION: $600
y°PERMIT TYPE: Demolition Permit
PRIMARY SFD or Duplex7 PENTAMATION 1SFDWL-DEM
USE: PERMIT TYPE:
WORK code enforcement case: Remove illegal structure attached to the rear of sfd.
SCOPE
FEE ID FLR AREA
s.f.
1DEMORES 0
Li I
NOTE. Thesefees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn7 info.
FEE ITEMS 0 ee Resolution 09-051 /: .. 7/1 10) FEE QTY/FEE MISC ITEMS
Permit Fee: $0.00
Suppl. Insp.Fee-E) Reg. 0 OT 0.0 hrs $0.00
Strong Motion Fee: /BSEISMICR $0.50 1.0 hrs Inspections
Bldg Stds Commission Fee: 1BCBSC $1.00 $126.00 11NSPMIS Standard Inspections
SUBTOTALS: $1.50 $126.00 TOTAL FEE: 1 $127.50
Revised: 01/15/2011
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333• buildinala)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 ADDRESSrI6-
7P14 BP#
OWNER NAMEl / 1 OWNER A RESS /1
f �1
DESCRIPTION OF WORK: c
s __0 fS
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.)
1 1. 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.
C 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.
5iL3. 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.
�9� 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.
�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 "employe" under state and federal law.
StoL6. 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.
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.
OovnerBuilderForm 2010.doc revised 04/14/10