11020060I CITY OF CUPERTINO BUILDING PERMIT I
IBUILDING ADDRESS: 7592 KIRWIN LN I CONSTRUCTION INC ILD I PERMIT NO: 11020060 I
OWNER'S NAME: HANG CHEN
INER'S PHONE:
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor
Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(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.
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.
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
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
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
9.18.
Signatar Date
LI OWNE UI_LDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
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, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
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
upon the above mentioned property for inspection purposes. (We) agree to save
mnify and keep harmless the City of Cupertino against liabilities, judgments,
.s, 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
9.18.
Signature
Date
1732 143RD AVE 1 DATE ISSUED: 02/15/2011
SAN LEANDRO, CA 94578 ( PHONE NO: (510) 388-5099
I— r I—
BUILDING PERMIT INFO: BLDG ELECT PLUMB
MECH RESIDENTIAL COMMERCIAL
JOB DESCRIPTION: SERVICE UPGRADE
Sq. Ft Floor Area: I Valuation: $2000
APN Number: 35922022.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 D OF PERMIT ISSUANCE OR
180 DAYS F AST CALLED INSSPECTIO%N.
Issued by: I Date:
RE -ROOFS:
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
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(x) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District 1
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 2553,, and 25534.
Owner or authorized age pt; - ., — Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Add
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 35922022.00
DATE ISSUED.......: 02/15/2011
RECEIPT #.........: BS000012721
REFERENCE ID # ...: 11020060
SITE ADDRESS .....: 7592 KIRWIN LN
SUBDIVISION ......
CITY .............. CUPERTINO
IMPACT AREA ......
OWNER ............. HANG CHEN
ADDRESS ..........: 7592 KIRWIN LN
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
OPERATOR: bethe
COPY # : 1
RECEIVED FROM ....: ZHONG MING MA
CONTRACTOR .......: ZHONG MING MA LIC # 31451
COMPANY ..........: BESTBUILD CONSTRUCTION INC
ADDRESS ..........: 1732 143RD AVE
CITY/STATE/ZIP ...: SAN LEANDRO, CA 94578
TELEPHONE ........: (510) 388-5099
FEE ID
UNIT
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
NEW BAL
----------
1BCBSC
-------------
VALUATION
----------
2,000.00
----------
1.00
----------
0.00
----------
1.00
----------
0.00
1BELEC200
METERS
1.00
42.00
0.00
42.00
0.00
1BSEISMICR
VALUATION
2,000.00
0.50
0.00
0.50
0.00
1EPERMITFE
FLAT RATE
1.00
42.00
0.00
42.00
0.00
1TRAVDOC
FLAT RATE
1.00
42.00
0.00
42.00
0.00
TOTAL PERMIT
----------
127.50
----------
0.00
----------
127.50
----------
0.00
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT :
AMOUNT
---------------
127.50
---------------
127.50
VOICE ID DESCRIPTION
-------- ----------------------------
103 UFER
505 FINAL ELECTRICAL
REFERENCE NUMBER
--------------------
visa
VOICE ID DESCRIPTION
-------- ----------------------------
304 ROUGH ELECTRICAL
CITY OF CUPERTINO
ro-m-N FF.F. ESTIMATOR - BUILDING DIVISION
APPLIANCE / EQUIP TYPE
ADDRESS: 7592 kirwin
--7DATE:
02/15/2011
REVIEWED BY: gs
BP FEES
APN: 359-22-022
BP#: I0,�, 00 (00
*VALUATION: 1$2,000
*PERMIT TYPE: Electrical Permit
100
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
/'ol-Inil Fi't'
PENTAMATION 1 REAP2
PERMIT TYPE: 19
WORK
SCOPE
PME Unit Fee:
APPLIANCE / EQUIP TYPE
FEE ID
ter 1'. r1�r %,� ..
QTY
UNITS
BP FEES
Elec. Permit Fee: IEPERMIT
Services
1 ERT<200
Other Elec. Insp. 0.0 hrs $42.00
100
Amps
$42
/'ol-Inil Fi't'
.old/)/)/. 1116 } 1 cc
PME Unit Fee:
$42.00
PME Permit Fee:
$42.00
Consit"iwiion Z'ax
�u�ldslilxll /�';+�°ic�iT IE>:
Work Without Permit? 0 Yes No
$0.00
TOTALS:
Travel Documentation Fee: ITRA VDOC
$42.00
Strong Motion Fee: IBSEISMICR
Nf)TF• Thoco foot aro hacod nn tho nrolirninary information availahle and are only an estimate. Contact the DeDt for addn 7 info.
FEEITEMS ,(ee Resolution 09-051 E('. 7%7./10)
FEE
ter 1'. r1�r %,� ..
Elec. Plan Check 0.0 hrs $0.00
'l -'c",
Elec. Permit Fee: IEPERMIT
.Srl/)Ir/. PC F e
Lj
Other Elec. Insp. 0.0 hrs $42.00
PME Plan Check:
$0.00
Nf)TF• Thoco foot aro hacod nn tho nrolirninary information availahle and are only an estimate. Contact the DeDt for addn 7 info.
FEEITEMS ,(ee Resolution 09-051 E('. 7%7./10)
FEE
QTY/FEE
MISC ITEMS
[//
Man 1..../Icc))I'-"v.
.Srl/)Ir/. PC F e
PME Plan Check:
$0.00
/'ol-Inil Fi't'
.old/)/)/. 1116 } 1 cc
PME Unit Fee:
$42.00
PME Permit Fee:
$42.00
Consit"iwiion Z'ax
�u�ldslilxll /�';+�°ic�iT IE>:
Work Without Permit? 0 Yes No
$0.00
Travel Documentation Fee: ITRA VDOC
$42.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
B1d�4Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$127.50
$0.00 TOTAL FEE:
$127.50
Revised: 01/15/2011
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buiidina(a-� 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 r� ^ 1 J
BP#
OW( ER NAME
OWNER AD SS
b /
DESCRIPTION OF WORK:
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 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.
\ 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.
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.
I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
;XL_�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.
�. 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.
IA -S_ -t, 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.
f k 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.
OwnerBuilderForn: 2010.doc revised 04/14/10
9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal
R�nue 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.
1 0. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
dm the party legally and financially responsible for proposed construction activity at the site address listed above.
AP
-LI 1. 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.
LX12. I 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 signa
ILA.
Property Owner's Signature: Date: `2
---------------------------------------------------------------------------------------------------------------------------------------------
(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:
Address of Authorized Agent:
Tel No
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:
OwnerBUilderFo n1 2010.docrevised04114/10
t
CM OF
CUPEkTINO
CITY OF CUPERTINO
TEMP POWER
PERMIT APPLICATION FORM
APN #
Date:
Building Address:
Fee Group
Permit Type
Owner's Name:
Phone #:
E
IREAP14
Contractor:
Phone #:-
Res. Temp Power <200
Amps
Fax #:
Contact:
Phone #:
Contractor License #: �'3 �j V
Res. Temp Power 200-1K
Amps
Cupertino Business License
Job Description:
1 EPERMITFE
/t/l ef <_r
E
Residential Commercial
Valuation (cost of project):
Type of Construction: N/A
Electric Plan Check
E
Quantity
Fee ID
Fee Description
Fee Group
Permit Type
IERT>lK
Res. Temp Power >lK
Amps
E
IREAP14
1 ERT<200
Res. Temp Power <200
Amps
E
IERT2001K
Res. Temp Power 200-1K
Amps
E
1 EPERMITFE
Electric Permit Issuance
E
1 ELCPLNCK
Electric Plan Check
E
IBCBSC
Cal Bldg Standards
Commission Fee
B
ALL PERMIT _
TYPES
1BSEISMICR
Seismic Residential
B
1TRAVDOC
Travel & Documentation
Fee
B
Revised 01/07/09