10100192 CITY OF CUPER TINO BUILDING PERMIT
BUILDING ADDRESS: 874 BETTE AVE CONTRACTOR:MIU CHEUNG&HOK PERMIT NO: 10100192
LEUNG
_'NER'S NAME: MIU CHEUNG&HOK LEUNG 874 BETTE AVE DATE ISSUED: 10/27/2010
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OWNER'S PHONE: 4082344264 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG F_ ELECT r PLUMB�
License Class Lic.#
MECH f- RESIDENTIAL F COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: SERVICE UPGRADE TO 200AMP
(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 declaratio is:
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. Sq.Ft Floor Area: Valuation:$2000
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. APN Number:36924045.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 18O DAYS FROM LAST CALLED INSPECTION.
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 Issued by: Date'
9.18.
nature Date
RE-ROOFS:
OWNER-BUILDER DECLARATION 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
I hereby affirm that I am exempt from the Contractor's License Law for om of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licenM
ntractors i o ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shal l Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's Owner or sin ed agent:
Compensation laws of California. If,after making this certificate of exemption,I �y ` Date: l �/ i v
become subject to the Worker's Compensation provisions of the Labor Code,I m ist
forthwith comply with such provisions or this permit shall be deemed rev
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
correct.I agree to comply with all city and county ordinances and state laws relat ng
to building construction,and hereby authorize representatives of this cityto enter Lender's Address
the above mentioned property for inspection purposes.(We)agree to save
,inify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point so r regulations per the Cupertino Municipal Code,Section
9.18. / Licensed Professional
Signatures 1`� Date
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEFARTMENT•BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255
(408)777-3228- FAX(408)777-3333- buildina(a-)cuortino.or
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CUPERTINO
Dear Property Owner(s):
An application for a building permit has been submittec in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS APN BP# 2�
OWNER NAME ++ l I I WNE�ADDRESS {7 q y f`
1 1 Le(J11c t /� i s •? r
DESCRIPTION OF WORK: ( I. `
We are providing you with an Owner-Builder Acknowle dgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur b 1 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 tt a permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statemen`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-
j Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally:,1, as an Owner-Builder, may be held Ii able and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees H hile working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully z.cting 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.
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 hirir g a licensed Contractor and having the permit filed in his or her
name instead of my own.---
. --. _ _
r �_4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
5. 1 understand if I employ or otherwise eng-age 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 federz l law.
6. I understand if I am considered an "employer" under state and federal law, I must register with the state and
f eral government,withhold payroll taxes, provide workers' compensation disability insurance, and contribute o
unemployment compensation for each"employe a." I also understand my failure to abide by these laws may subject
me to serious financial risk.
r �; 7. 1 understand under California Contractor;' 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 genoral building Contractor.
(X_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.
OivnerBuilderFonm_2010.doc revised 04/14/10
FnPoor Ir ua rty and Finishes
1.Use Low/No-VOC Paint 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y--yes 0
3.Use Low/No VOC Adhesives 3 IAQ/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes 0
0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y--yes
7.Seal all EWosed 1PartioolebaW or MDF 4 IAQ/Health.pts y=yes D
8.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y--yes 0
1 1 1
N.Flooring
1.Select FSC Certified Wood Flooring B Resource pts y=yes 0
2.Use Rapidly Renewable,Flooring Materials 4 Resource pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y--yes 0
4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y--yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
60
1 1 1
Total Points Available 1 1401 1301 571 11
Total Points Project Received] 0 0 0
Mdatalprol slgreenbuildngguidelineslremodelerslgreenpointsfina12.12.D4protected.xls
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CITY OF CUPERTINO
CUPEKTINO GENERAL BUILDING
PERNUT APPLICATION FORM
APN # Date:
Building Address:
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of tl.is project? Yes No
HOA: (Exterior work only) mea-$- No If yes, provide letter from HOA
Owner's Name: Phone #:
Contractor: Phone: Z3 - Z-
' U, L CL Q- f�/ �— Fax:
Contractor License#: 6.5_I(9Z-2—
Cupertino
-ZCu ertino Business License#: j O
Contact: _Oz / Phone:
Fax:
.Kesidential Commercial ❑
Job Description: /
S-grill �' - vo r^"lam- / Z c):P A-
Building Permit Info:
Bldg ❑ Elect 11 Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type: P--9
1-A, 1-B ❑ U/HI/V-A ❑ II/III B, IV-HT, V-B ❑�
Valuation: Square Footage:
Project Size: Express [g--Standard ❑ Largs; ❑ Major ❑
Green Building: Please complete relevant portioji of the Green Building/LEED Checklist & attach it
to the application or if applicat le, include in plan set & the sheet index.
)ints Achieved: "
for help, contact Build it Green at www.builditQreen.or
Revised 07/14/09
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