10110153CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10192 PARK CIRCLE E CONTRACTOR: WILLIAM &PATRICIA PERMIT NO: 10110153
TSAI
C :R'S NAME: WILLIAM & PATRICIA TSAI
10192 PARK CIRCLE E I DATE ISSUED: 11/22/2010
OWNER'S PHONE: 6509689746 1 CUPERTINO, CA 95014 1 PHONE NO:
11
License Class
Contractor
LICENSED CONTRACTOR'S DECLARATION
Lic. #
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 harn Less 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.
Date
BUILDING PERMIT INFO: BLDG r— ELECT f— PLUMB I—
MECH I- RESIDENTIAL I- COMMERCIAL r—
JOB DESCRIPTION: STORE ROOM - 75 GALLON WATER HEATER
Sq. Ft Floor Area: I Valuation: $2386
APN Number: 32632007.EAST I Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:i �� Date:/ — z�
ROOFS:
OWNER -BUILDER DECLARATION All roofs shall be inspected prior to anyy 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
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
tr 'ding construction, and hereby authorize representatives of this city to enter
u, to 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- o t source regulatiotper the Cupertino Municipal Code, Section
9.18. ` rI -
Ci ... t,,TP I rA4 .i'A, � It� J,- Date
inspection.
Signature of
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(a) 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 I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
O norized ge t: O !D
ZI DateV
4a
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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
5 ITEMS OF 5
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 32632007.EAST
DATE ISSUED.......: 11/22/2010
RECEIPT #......... BS000012075
REFERENCE ID # ...: 10110153
SITE ADDRESS 10192 PARK CIRCLE E
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OWNER ............: WILLIAM & PATRICIA TSAI
ADDRESS 10192 PARK CIRCLE E
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM ....: PATRICIA & WM TSAI
CONTRACTOR LIC # *OWNER*
COMPANY WILLIAM & PATRICIA TSAI
ADDRESS 10192 PARK CIRCLE E
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
TELEPHONE .........
OPERATOR: patg
COPY # : 1
FEE ID
UNIT
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
----------
NEW BAL
----------
----------
1BCBSC
-------------
VALUATION
----------
2,386.00
----------
1.00
----------
0.00
1.00
0.00
1BSEISMICR
VALUATION
2,386.00
0.50
0.00
0.50
0.00
1PPERMITFE
FLAT RATE
1.00
42.00
0.00
42.00
0.00
1PRWHEATR
UNITS
1.00
25.00
0.00
25.00
0.00
1TRAVDOC
FLAT RATE
1.00
42.00
0.00
42.00
----------
0.00
----------
TOTAL PERMIT
----------
110.50
----------
0.00
110.50
0.00
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
110.50
---------------
110.50
REFERENCE NUMBER
--------------------
#990
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
� CITY OF CUPERTINO
FFM7 FEE ESTIMATOR -BUILDING DIVISION
iialADDRESS:
10192 park circle east.
DATE:
REVIEWED BY: bobs.
UNITS
APN:
BP#:
''VALUATION: 1$2,386
*PERMIT TYPE: Plumbing Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY SFD or Duplex
USE:
1't1TV,
� t )f}I, -�
PENTAMATION PRWHEATR
PERMIT TYPE:
WORK
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
Plumb. Plan Check 0.0 1 hrs $0.00
QTY
UNITS
BP FEES
Water Heater
1PRWHEATR
1
#
$25
PME Unit Fee:
$25.00
PME Permit Fee:
$42.00
C on.SIrtwfi on /CL
<Jcousli al1&,vicll [0(11:
Work Without Permit? Yes E) No
$0.00
TOTALS:
Travel Documentation Fee: ITRAVDOC
$25.00
Strong Motion Fee: IBSEISMICR
7VI)TF. - Thece fees are haled on the nreliminary information available and are onlv an estimate. Contact the Dept for addn'l info.
FEE ITEMS ("Fee Resolution 09-051 Et 7/1/11))
FEE
Plumb. Plan Check 0.0 1 hrs $0.00
MISC ITEMS
I'lou C-'Iw("A7 1� "c:
Plumb. Permit Fee: IPPERMIT
()"/ r ',A chi�
Other Plumb Insp. 0.0 hrs
PME Plan Check:
$0.00
7VI)TF. - Thece fees are haled on the nreliminary information available and are onlv an estimate. Contact the Dept for addn'l info.
FEE ITEMS ("Fee Resolution 09-051 Et 7/1/11))
FEE
QTY/FEE
MISC ITEMS
I'lou C-'Iw("A7 1� "c:
I'(1, FCC
. lipl.71. I'(1, CC
PME Plan Check:
$0.00
PME Unit Fee:
$25.00
PME Permit Fee:
$42.00
C on.SIrtwfi on /CL
<Jcousli al1&,vicll [0(11:
Work Without Permit? Yes E) No
$0.00
I'Icr>rrrr`tJ Y Fcc'):
Travel Documentation Fee: ITRAVDOC
$42.00
Strong Motion Fee: IBSEISMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
1 $110.50
$0.00 TOTAL FEE:
$110.50
Revised: 11/08/2010
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(cD_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 ADD SS` V{ APN BP#
p AMEN i�GiQ G�( OWNERAA, 141 lie/, L65S --
DESCRIPTION F WORK:
z
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.
PJ_ 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.
PT' 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 "employer" under state and federal law.
�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.
PI -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.
8.I 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.
OwnerBuilderFonn 2010.doc revised 04114/10
PJ -19. 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 1 may cpntact the California Contractors' State
License Board (CSLB) at 1-800-321-CSLB (2752) or www.csib.ca.gov for more information about licensed
contractors.
ej--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.
11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
y all applicable laws and requirements that govern Owner -Builders as well''as employers.
P12. 1 agree to notify the issuer of this form immediately of any additions
information I have provided on this form. Licensed contractors are regulated
you contract with someone who does not have a license, the Contractors' S
assist you with any financial loss you may sustain as a result of a complaint
Contractors may be in civil court. It is also important for you to understand 0
employee of that individual or firm is injured while working on your property,
you obtain a permit as Owner -Builder and wish to hire Contractors, you will
those Contractors are properly licensed and the status of their workers' corn
deletions, or changes to any of the
by laws designed to protect the public. If
ate License Board may be unable to
Your only remedy against unlicensed
at if an unlicensed Contractor or
you may be held liable for damages. If
)e responsible for verifying whether or not
sensation 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 igned 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 ac table to the c. ay be required to be presented when the permit is issued
to veri the roe owner's si nature
Property Owner's Signature: M144z& Date: i �y
------ ---- -- - --------g -- -- -:--:---- '---------D-re--d-
-:--- -- ------ -P ------- Y- -- -----------------------------------------------
(NOTE: The followin Authorization Form is re -Dred to be corn leted b the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner -Builder).
RIZATI
TO ACT ON PROPE
'S
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 properly owner's
signature.
Property Owner's Signature: ( 1 Date:
Owne)BuilderForm 2010.doc revised 04/14/10
N. Flooring
1. Select FSC Certified Wood Flooring
1 IAQ/Health pts
y=yes
2. Use Low VOC, Water -Based Wood Finishes
2 IAQ/Hsalth pts
y-yes
1ti1lst:�'lii�
31AQMealth pts
yeses
4. Use Salvaged Materials for Interior Finishes
3 Resource pts
y --yes
5. Use Engineered Sheet Goods with no added Urea
4 Resource pts
y --yes
Formaldehyde
B IAQ/Health pts
y --yes
B. Use Exterior Grade Plywoodfor• Interior Uses
1 IAQ/Health pts
y --yes;
4IMI-Iealth. pts
y --yes
B. Use FSC Certified Materials for Interior Finish
4 Resource pts
y --yes
B. Use Fnger-Jointed or Recycled -Content Trim
1 Resource pts
y --yes;
10. Install Whole House Vacuum System
3 IAOJHealth pts
y=yes
N. Flooring
1. Select FSC Certified Wood Flooring
B Resource pts
y --yes
_
4 Resource pts
y --yes
3. Use Recycled Content Ceramic Tiles
4 Resource pts
y --yes
4. Install Natural Linoleum in Place of Vinyl
.5 IAQMealth pts
y -yes
5. Use Exposed Concrete as Finished Floor
4 Resource pts
y --yes
B. Install Recycled Content Carpet with Low VOCs
4 Resource pts
y --yes
Total Points Availal?le.,
Total Points Project Deceived:
.1401. 1301 57
0 01 0
OvIt
B.data/piD*greenbiMcOnggWdelines/remodelersfgreenpoinMna1212D4proteDfedxls
CITY OF CUPERTINO
WATER HEATER
CUPEkTINO PERMIT APPLICATION FORM
APN # 0
Date: I
Building ddress: Pas
rc ie, f , CyeAmo, CA
%�O 14-
Owner's Name: t
► �am� a �� s�c01 l
`
P4one #:
(^�C� 97�
Contractor" -
Phone #: Zf fog _ZS
Fax#:
Cupertino Business License #:
Contractor State License #:
Contact: )W
Phone #:
m 16,M4 I ala 1 I
Fax #: �s� r 113
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Mech ❑
Residential ❑ Commercial
Job Descri tion:
cti� Dn wa f ere.,/1fVI-
Strapped ❑ On Platform ❑ Bonded ❑ New Location ❑ Replacement
Valuation (cost of project):
Project Size: Express ❑ Standard V 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.
15�—
Green Building Points achieved:
Revised 03/10/10