10100157 CITY OF CUPERTINO B UILDING PERMIT
BUILDING ADDRESS: 21835 LOMITA AVE CONCRACTOR:JERRY LIU PERMIT NO: 10100157
OWNER'S NAME: JERRY LIU 975 PLANETREE PL DATE ISSUED: 10/21/2010
4ER'S PHONE: 4083149909 SUNNYVALE,CA 94086 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F ELECT r PLUMB r
License Class Lic.# F
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE 4 WINDOWS,WATER HEATER,KITCHEN TRAP
(commencing with Section 7000)of Division 3 of the Business&Professions &INT 3RIOR REPIPING
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 Sq.F t Floor Area: Valuation:$6000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:35716063.00 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
to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
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 80 DAYS FROM LAST CALLED INSPECTION.
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. Issw:d by: (� Date:w v �
Signature Date
LI OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of insta led without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspe ction.
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, Sign,rture of Applicant: Date:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I ha��e read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the Cali ornia Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. com>liance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safe:y 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 Add tionally,should I use equipment or devices which emit hazardous air
cont iminants 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 shall Hea th&Safety Code,Sections 25505,25533,and 25534.
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 owl
become subject to the Worker's Compensation provisions of the Labor Code,I must V Date: 7i to
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I her eby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for-,ihich this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Len ler's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Len ier's Address
1nify and keep harmless the City of Cupertino against liabilities,judgments,
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
with all non-point source regulations per the Cupertino Municipal Code,Section I un ierstand my plans shall be used as public records.
9.18.
J2 t I` Lie(nsed Professional
Signature Date U
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: L 3�6 �� 4 DATE: ZI 10 REVIEWED BY:
APN: BP#: *VALUATION: 1$6,000
R*PERMITTYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex rr, PENTAMATION
USE: I°' (. ;'�'_t r ?_
PERMIT TYPE: PR EATR
WORK TZ,ChI,AC EN 0 F VV lly L)0 WS WA T 15r2 N EATER K I7GHCIy
SCOPE -TIZAF 61y 12 IZE�p l Pi I+6
Plumb.PlanHCheck (.0 hrs $0.00 ' ;t'hPermit Fee: IPPERMIT
Other Plumb Insp. (.0 hrs $42.00
b /"w.
NOTE. Thesefees are based on the preliminary information availaide and are only an estimate. Contact the De t or addn'1 info.
FEE ITEMS (P-ee Resolution 09-051 E(f T"I.,10) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 1 # Plumbing
Suppl. PC Fee: E) Reg. 0OT 0.0 hrs $0.00 $25-001 IPRWHEATR Water Heater
PME Plan Check: $0.00 '= # Plumbing
Permit Fee: $0.00 $8.00 IBPTRAP Kitchen Type Trap
Suppl. Insp. Fee Reg. 0 OT 0.0 hrs $0.00 4j # Window/Sliding Glass Door
PME Unit Fee: $0.00 $380.00 1 WINREP Replacement
PME Permit Fee: $42.00 1 # Plumbing
$42.00 1PREPPIPE Piping,Drainage
Acoustical Fee: 0 Yes 0 No $0.00 0
Work Without Permit? G Yes 0 No $497.00 E)
Planning Fee: $0.00 Select a Non-Residential Q
Travel Documentation Fee: ITRA VDOC $42.007 -1
Building or Structure
i
Strong,Motion Fee: 1BSEISMICR $0.60 Select an Administrative Item
Bldg;Stds Commission Fee: 1BCBSC $1.00
SUBTOTALS: $582.60 $455.00 TOTAL FEE: $1,037.60
Revised: 9/29/2010
CITY OF CUPERTINO
8 ITEMS OF 8 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: mot:
APN . . . . . . . . . 35716)63 .00
DATE ISSUED. . . . . . . : 10/21/2010
RECEIPT #. . . . . . . . . : BS000)11804
REFERENCE ID # . . . : 10100L57
SITE ADDRESS . . . . . : 21835 LOMITA AVE
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . . JERRY LIU
ADDRESS 975 P.-jANETREE PL
CITY/STATE/ZIP . . . : SUNNY'IALE, CA 94086
RECEIVED FROM . . . . : JERRY J LIU
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY JERRY LIU
ADDRESS 975 PhANETREE PL
CITY/STATE/ZIP . . . : SUNNYITALE, CA 94086
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ----- ----- ---------- ---------- ----------
1BCBSC VALUATION 6, 000 . 00 1.00 0 . 00 1. 00 0.00
1BPTRAP NO OF TRAPS 1. 00 16 . 00 0 .00 16. 00 0 . 00
1BSEISMICR VALUATION 6, 000 . 00 0 .60 0 . 00 0. 60 0 .00
1PPERMITFE FLAT RATE 1. 00 84 . 00 0 . 00 84 . 00 0 . 00
1PREPPIPE FLAT RATE 1. 00 84 . 00 0. 00 84 . 00 0 . 00
1PRWHEATR UNITS 1 . 00 50 . 00 0 . 00 50 . 00 0 .00
1TRAVDOC FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 0 . 00
1WINREP EACH 8 1 . 00 "60 .00 0. 00 760. 00 0 . 00
----- ----- ---------- ---------- ----------
TOTAL PERMIT 1( 37 .60 0.00 1037.60 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- -- ------------------
CHECK 1, 037 .60 #1019
---------------
TOTAL RECEIPT 1, 037 .60
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333• buildir 05cuoertino.org
CUPERTINO
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at: �7
APN TBP*
sl�R`b 3 S, LOHITA AVE CUPE1Z71 hlt7
OW ER NAME
OWNER ADDRE1iS 0140c$&
,NE NA LIU 1-15 PLA ?tzEE PL• SUNNY I.� C�1
rzG �1 G
DESCRIPTION OF WORK: �1 OF
rQF WATr_R
"
We are providing you with an Owner-Builder Acknowledgment
this permit assuedon en your Verification Form
as the Owner-Builder. We
your responsibilities and possible risk you may Y of each
will not issue a building permit until you h�ess indicatedve read, !en agent oyour f the ownergannot execute this nn notice uncle sd
returned this form to us at our official add
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 t)signify you understand or verify this information.)
ik1. I understand a frequent practice of unlicensed pen:ons is to have the property owner obtain an"Owner-
Builder" building permit that erroneously implies dthat liablee p-operty owner is subject t seriousrfinan cal's or risk for any injr own uries sustained or and lal
by
personally. I, as an Owner-Builder, may be M homeowner's insurance may not
an unlicensed person and his or her employees while wor<ing on my property. Y
provide coverage for those injuries.
. I am workers y property.an Owner-Builder and am aware of the limits of my
insurance coverage for injuries
J V2. I understand building permits are not required to re signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
that I
J L/3. I understand as an"Owner-Buis risk b1 hiring record
havi g the permit filed in sdor her may
protect myself from potential financial y 9 a licensed Contractor
name instead of my own.
J(/4. I understand Contractors are required by law to b a licensed and bonded in California and to list their license
numbers on permits and contracts. ge any
k5. I understand if I employ or otherwise
hundred dollars r($500),t including her than Clabo�andrnia materials,
Contractors, and the
als, I may be
jtotal value of my construction is at lea
considered an"employer" under state and federal law.
J L 6. 1 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.
J 1/7. 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.
JL/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 subs:quent owner(s)that result from any latent construction
defects in the workmanship or materials. 011,„erBuilderForm_2010.doc revised 04114/10
J L 9. 1 understand I may obtain more information regardir g my obligations as an"employer"from the Internal
Revenue Service, the United States Small Business Admin stration,the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also un Jerstand I may contact the California Contractors'State
,slb.ca.gov for more information about licensed
License Board (CSLB)at 1-800-321-CSLB (2752)or www..
contractors.
J V 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am the parry legally and financially responsible for proposed construction activity at the site address listed above.
J V 11. 1 agree that, as the party legally and financially responsible for this iproposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
J�/12. 1 agree to notify the issuer of this form immediatel/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, t-ie 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'heir 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 foi 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 br. 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 permi`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 ap)ly 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: 2 1b 3 5 LO h ITla A Vr GUMIZ71140 ► CA
Name of Authorized Agent: F'1
INtIZVA AY3AC) Tel No 00 -35 3 -0x73
Address of Authorized Agent: 1357 WMDL,A N V AVS ' we�'LO VA)z1C GA' 94025
1 declare under penalty of perjury that I am the property owr er 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 pre,;ented when the permit is issued to verify the property owner's
signature.
C',Property Owner's Signature:
/ Date:
Oh4,l7eTBuildei-Foi-i??_2010.doc revised 04/14/10
CITY OF CUPERTINO
CUPEKTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN# Date:
/ 0 3 10 -- Zo • �v
Building Address:
219 35 1,0 m v 15 GV pF-- t2 ,A .
Mailin Address (if different from building address):
7 g F L A N S[1zI✓F FL, 5 V N N VA L,t; ICA • 01�n��
Are Hazardous Materials being used as part of this project? Yes No
HOA: (Exterior work only) Yes ❑ No Q---I es, provide letter from HOA
Owner's Name: Phone#:
Contractor: Phone:
�� Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone:
Fax:
,�,esidential Commercial
Job Description:
le ��erneM'f q U)Ao d-zw-s
�� '►�vi'a'"` 0� ,
L Q�L r
1 _
Building Permit Info:
' Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ U/MN-A ❑ II/III B, IV-HT, V-B [ �.
Valuation: oG Square Footage:
p04 .
Project Size: Express ❑ Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of th,; Green B ' ding/LEED Checklist & attach it
to the application or if applicable, inc:.ude in plan set & the sheet index.
)ints Achieved:
L for help, contact Build it Green at www.builditgreen.o -gr
Revised 07/14/09