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11010021 ` CITY OF CUPERTINO BUILDING PERMIT BUILDING ADbkESS: 739 STENDHAL LN CONTRACTOR:CHEN-WEI SHIH PERMIT NO: 11010021 OWNER'S NAME: CHEN-WEI SHIH 739 STENDHAL LN DATE ISSUED:01/03/2011 rP"INER'S PHONE: 4088324559 CUPERTINO,CA 95014 PHONE NO: V LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r— ELECT r PLUMB r License Class Lic.# MECH r— RESIDENTIAL F COMMERCIAL r Contractor Date JOB DESCRIPTION:REPLACE SEWER LATERAL APPROX 15Ff&ADD ON I hereby affirm that I am licensed under the provisions of Chapter 9 CITY& (commencing with Section 7000)of Division 3 of the Business&Professions BUILDING CLEAN OUT 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. r °' 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: p Valuation:$2400 permit is issued. APPLICANT CERTIFICATION APN Numkr: 41N. D 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 Y' " to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save PE T EXPIRES IF WORK IS NOT STARTED 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 granting of this permit. 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 4 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, 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). C .�N ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three W 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. I 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& 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 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 Owne Hty V K gen l l/ Date: forthwith comply with such provisions or this permit shall be deemed revok C CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION 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 and expenses which may accrue against said City in consequence of the ng of this permit.Addition)) ,the applicant understands and will comply ARCHITECT'S DECLARATION wnn all non-poi soE re;la' per the Cupertino Municipal Code,Section 9.18. 2 I understand my plans shall be used as public records. Signature E Date / Licensed Professional CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 37542034 .00 DATE ISSUED. . . . . . . : 01/03/2011 RECEIPT #. . . . . . . . . BS000012387 REFERENCE ID # 11010021 SITE ADDRESS . . . . . : 739 STENDHAL LN SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : CHEN-WEI SHIH ADDRESS . . . . . . . . . . : 739 STENDHAL LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : CHEN WEI CONTRACTOR LIC # *OWNER* COMPANY . . . . . . . . . . : CHEN-WEI SHIH ADDRESS 739 STENDHAL LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- --------- 1BCBSC VALUATION 2, 400. 00 1.00 0 .00 1. 00 0 .00 1BSEISMICR VALUATION 2, 400.00 0 .50 0 .00 0 .50 0 . 00 1PPERMITFE FLAT RATE 1.00 42 . 00 0 .00 42 . 00 0 .00 1PRSEWER UNITS 1. 00 21 .00 0 .00 21.00 0 .00 1TRAVDOC FLAT RATE 1. 00 42 .00 0 . 00 -----4200 ------0 00 ---------- ---------- TOTAL PERMIT 106 .50 0 . 00 106 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- ------- CREDIT CARD 106 .50 MC --------------- TOTAL RECEIPT 106 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION __ _ - -- ---------------------------- 106 SEWER & WATER 202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING 400 SEWER/LATERAL 507 FINAL PLUMBING CITY OF CUPERTINO FEE ESTIMATOR— BUILDING DIVISION ADDRESS: 739 stendhal lane I DATE: 01/03/2011 REVIEWED BY: bobs. APN: BP#: *VALUATION: $2,400 PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PENTAMATION SFD or Duplex It,�1`tt, 1RPSS PRIMARY USE: 117-0tJIz"iPERMIT TYPE: WORK replace sewer lateral add property line clean out SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1PRSEWER 1 # $21 TOTALS: $21.00 Lf«;r_ Plan t'hcrh Plumb.Plan Check 0.0 hrs $0.00 rl< I'tarr t_"racck L1<>zi,_ 1'ern�u 1 t>r Plumb.Permit Fee: 1PPERMIT t,l<:c f't rtnii I°et C)rlfr .tfec°tr. Irt_sp. Other Plumb Insp. 0.0 hrs $42.00 NOTE: These fees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn'l info. FFEEITEMIS(Fee Resolution 09-051 E f 7,'1%101 FEE QTY/FEEMISC ITEMS I e<Sapp . E e PME Plan Check: $0.00 Permit f ec: Supp1. Irrs p Fc-le PME Unit Fee: $21.00 PME Permit Fee: $42.00 C'onslrlfction Tax "Ic'Ouslic of 1?f,viciv Work Without Permit? 0 Yes No $0.00 I'latirl n",7 1`E'E's Travel Documentation Fee: ITRA VDOC $42.00 Strom Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bl_dy,Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $106.501 $0.001, TOTAL FEE. $106.50 Revised: 12/07/2010 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 (408)777-3228• FAX(408)777-3333- building(�cupertino.org CUPERTINO 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 921 S 7' ; APN BP# OWNERNAMEoafS � Cfj-/wOWNER ADDRESS W !;�10 L q_ DESCRIPTION OF WORK: (( S S i.G'� a-e-ArteK,6- q4J G 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 understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner- Buil e►"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. G 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. L,J 3. 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. C,41 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. C_A5. 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. G,.A�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. C, 7. 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. G, 8. 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. OwnerBuilderForns 2010.doc revised 04/14/10 �. 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 www.cslb.ca.gov for more information about licensed contractors. G..,&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. C- 11. I 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. G•-&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.) 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: - -------- --------------------------------------------------------------------------------------------------------------------------------- -(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: OwnerBuilderFonn 1010.doc revised 04114/10 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: � !;TPNA L L NZ- PERMIT2-- OWNER'S NAME: -5'H j CHIN W-C-- PHONE# 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 V Plumbing S p`Le Roofing Septic Tank Sheet Metal Sheet Rock Tile Date Owner/ ontractor Signature CITY OF CITY OF CUPERTINO REPIPE/SEWER/MAIN SERVICE CUPERTINO PERMIT APPLICATION FORM APN# � r n Date: _ 41- 11 Building Address: 19r � s-fM>HA L 44 , c UP6,�TzAIO , � Owner's Name: � / lA Phone#-�� Contractor: R - Phone #: Fax#: Contact: Phone#: _ Fax/e-mail: Contractor License#: A" Cupertino Business License #: ' Job Description: / 57 4�•vJ• '� � �-i �t� �►zv • Residential [ Commercial ❑ Valuation: Z L Project Size: Counter ❑ Express ❑ Standard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set& the sheet index. Green Building Points: Quantity Fee ID Fee Description Fee Permit Type Group 1PCSEWER Commercial building P 1CPSS sewer/sanitary sewer 1BPREPIPE Commercial re-pipe per fixture P 1CPRP 1 PGASCOM Commercial Gas Piping System P 1-4 Outlets 1BCBSC Cal Bldg Standards Commission B ALL PERMIT Fee TYPES 1BSEISMICOM Seismic Commercial P Revised 12/06/10