10110118 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1141 S STELLING RD CONTRACTOR:MR&MRS MARK CHU PERMIT NO: 10110118
OWNER'S NAME: MR&MRS MARK CHU 1141 S STELLING RD DATE ISSUED: 11/17/2010
OWNER'S PHONE: 4082213589 CUPERTINO CA,CA 95014-5020 PHONE NO:
L LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
RELOCATE NEW GAS METER 3FT FROM SAME LOCATION.
License Class Lie.#
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.
Sq.Ft Floor Area: Valuation:$100
I hereby affirm under penalty of perjury one of the following two declarations:
t. I have and will maintain a certificate of consent to self-insure for Worker's APN Number:36222014.00 Occupancy Type:
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
2. 1 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 EXPIRES IF WORK IS NOT STARTED
permit is issued. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
APPLICANT CERTIFICATION 180 DAYS FROM LAST CALLED INSPECTION.
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 Issued by r Date:
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 ROOFS:
all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 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
Signature Date inspection.
Signature of Applicant: Date:
OWNER-BUILDER DECLARATION ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
tI,as owner of the property,or my employees with wages as their sole HAZARDOUS MATERIALS DISCLOSURE
compensation,will do the work,and the structure is not intended or offered for I have read the hazardous materials requirements under Chapter 6.95 of the
sale(Sec.7044,Business&Professions Code) California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
2. I,as owner of the property,am exclusively contracting with licensed contractors to compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
construct the project(Sec.7044,Business&Professions Code). Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
I hereby affirm under penalty of perjury one of the following three declarations: contaminants as defined by the Bay Area Air Quality Management District I will
1. I have and will maintain a Certificate of Consent to self-insure for Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation,as provided for by Section 3700 of the Labor Code,for the Health&Safety Code,Sections 25505,25533,and 25534.
performance of the work for which this permit is issued. Own r �}hori d a e
2. I have and will maintain Worker's Compensation Insurance,as provided for by �,wn22r �r—'--Date: 7 7i�)/L7
Section 3700 of the Labor Code,for the performance of the work for which this �—'
permit is issued. CONSTRUCTION LENDING AGENCY
3. I certify that in the performance of the work for which this permit is issued,I shall
I hereby affirm that there is a construction lending agency for the performance of work's
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 for which this permit is issued(Sec.3097,Civ C.)
become subject to the Worker's Compensation provisions of the Labor Code,I Lender's Name
must forthwith comply with such provisions or this permit shall be deemed Lender's Address
revoked.
ARCHITECT'S DECLARATION
APPLICANT CERTIFICATION I understand my plans shall be used as public records.
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 Licensed Professional
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
ling of this permit.Additionally,the applicant understands and will comply with
.on-point source regulations per the Cuperti o Municipal Code,Section 9.18.
4712SI
Signatur — ��—Date
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 1141 s.stelling rd. DATE: 11/17/2010 REVIEWED BY: building
APN: BP#: *VALUATION: $100
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex ` PENTAMATION 1 RPGAS
USE: >,`t'- r`-_- PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Piping, Gas <=4 Outlets 1 PGASRES 1 # $63
TOTALS: 1 $63.00
Plumb.Plan Check 0.0 hrs $0.00 L/, /Vi,
Plumb.Permit Fee: IPPERMIT
fi Other Plumb Insp. 0.0 hrs $42.00 011;( '_1s=;,, Li
1.rt M"I" 1'.,_ f.rnt', I 1,,1,
NOTE. Thesefees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addh I info,
FEE ITEMS (Fee Resolution 09-051 Eft' L1101 FEE QTY/FEE MISC ITEMS
PME Plan Check: $0.00
Permit 1`cc.
PME Unit Fee: $63.00
PME Permit Fee: $42.00
C.,`o�r.5to��crrr,}tr Iir.�
,ft;att:stt'ra1 li�ttt�t1 I cc�:
Work Without Permit? 0 Yes E) No $0.00
Ylerruttrz�7 l'e<'j
Travel Documentation Fee: 1TRAVDOC $42.00
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $148.50 $0.00 TOTAL FEE: 1 $148.50
Revised: 11/08/2010
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: suew
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36222014 . 00
DATE ISSUED. . . . . . . : 11/17/2010
RECEIPT #. . . . . . . . • : BS000012033
REFERENCE ID # . . . : 10110118
SITE ADDRESS . . . . . : 1141 S STELLING RD
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : MR & MRS MARK CHU
ADDRESS . . . . . . . . . . : 1141 S STELLING RD
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5020
RECEIVED FROM . . . . : CHIENHUA CHU
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : MR & MRS MARK CHU
ADDRESS 1141 S STELLING RD
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5020
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ---
1BCBSC VALUATION 100 .00 1.00 0 .00 1 .00 0. 00
1BPGAS OULETS 1.00 63 . 00 0 .00 63 . 00 0. 00
1BSEISMICR VALUATION 100 . 00 0 . 50 0 . 00 0 .50 0 . 00
1PPERMITFE 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 148 .50 0 .00 148 .50 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 148 . 50 VISA
---------------
TOTAL RECEIPT 148.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ------------------
202 UNDERFLOOR PLUMBING 301 ROUGH PLUMBING
506 GAS TEST 507 FINAL PLUMBING
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 1
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 ' }
CUPERTINO (408)777-3228•FAX(408)777-3333- building(c�cuoertino.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 ADDRES APN B FW
OWNER NAME OWNER ADDRESS
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.)
61_ l understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
guilder' 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.
4�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.
`11&1�. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
�. 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
1/36"de—ral 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.
1!�Z7. 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.
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.
OwnerBuilderForm 2010.doc revised 04114110
�Z�. I understand I may obtain more information regarding my obligations as an"employer"from the Internal
evenue 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.
X10. 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.
Z�)Ucl 1. 1 agree that,as the party legally and financially responsible for thisproposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders as welfi as employers.
,/�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.)
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 si na re.
Property Owner's Signature: Date:
The following Authorization Form is required to be completed by the properly 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,app file,the documents cessary 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 0 Z
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: f 7/,2-&4)
OwnerBuilderForni 2010.doc revised 04/14/10
CITY OF CUPERTINO
} REPIPE/SEWER/MAIN SERVICE
CUPEi�T1NO PERMIT APPLICATION FORM /t/)//i
APN # O f Date:
Buildin Address: '� / /�
S h L t C,CJ _ /
Owner's Name: Pho
r
Contractor: Phone#: E4 k1,Y) 2 f Zl�
✓'� ,y, Fax #: tar
Co tact: r Phone#:
G'►'►J pc.w� Fax #:
Contractor License S, rS�'r
Cupertino Business License#: / C`
Job Description:
AdIVI/1-1�,+C-1/-
a",
Residential Commercial ❑
Valuation:
Project Size: Express Standard LJ 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
1PGASCOM Commercial Gas Piping System P
1-4 Outlets
1BCBSC Cal Bldg Standards Commission B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Commercial P
Revised 01/07/09