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10100153 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21090 RAINBOW PL CONTI:ACTOR:ADVANCED PERMIT NO: 10100153 CONSTRUCTION AND "'"NER'S NAME: ROBERT&GRACE ANG PO BO:(474 DATE ISSUED: 10/22/2010 %,vJNER'S PHONE: 4085686728 CUPERTINO,CA 95014 PHONE NO:(408)932-4411 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r— PLUMB r License Class Lic.# MECH r— RESIDENTIAL r— COMMERCIAL Contractor Date JOB E ESCRIPTION:REPLACE OLD FURNACE 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. Sq.Ft floor Area: Valuation:$3000 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 APN Number:36626028.00 Occupancy Type: 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 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, 1110 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 Issuet by:, Date: e, 9.18. �':-nature Date RE-ROOFS: OWNER-BUILDER DECLARATION All roc fs shall be inspected prior to any roofing material being installed.If a roof is installe d 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 inspection. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Signat ire of Applicant: Date: 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 ontractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). -�q_ 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. 1 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 Addit onally,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 maint tin compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safkty Code,Sections 25505,25533,and 25534. 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 Owner or �izedla' en_t: a Compensation laws of California. If,after making this certificate of exemption,IDate: 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 r6k;�— CONSTRUCTION LENDING AGENCY lJI here iy affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for wl Lich this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lend pr's Name 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 Lend.-r's Address i the above mentioned property for inspection purposes.(We)agree to save unify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence of the granting of this permit.Additionally,the applicant understands and will comply I undo�rstand my plans shall be used as public records. with all non-point urce regulations per the Cupertino Municipal Code,Section 9.18. Licen sed Professional Date Signature r�/� — `C� CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 36626028 . 00 DATE ISSUED. . . . . . . : 10/22/2010 RECEIPT #. . . . . . . . . BS000011816 REFERENCE ID # . . . : 10100153 SITE ADDRESS . . . . . : 21090 RAINBOW PL SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER ROBERT & GRACE ANG ADDRESS . . . . . . . . . . : 21090 RAINBOW PL CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : GRACE Z ANG CONTRACTOR . . . . . . . : MIKE TAJVAR LIC # 31633 COMPANY . . . . . . . . . . : ADVANCED CONSTRUCTION AND ADDRESS . . . . . . . . . . : PO BCX 474 CITY/STATE/ZIP . . . : CUPEFTINO, CA 95014 TELEPHONE . . . . . . . . : (408) 932-4411 FEE ID UNIT QUANTITY AMCUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---- ------ ---------- ---------- ---------- 1BCBSC VALUATION 3, 000 . 00 1 . 00 0. 00 1. 00 0 .00 1BSEISMICR VALUATION 3, 000 . 00 0 .50 0 .00 0 .50 0 .00 1MFR=<100 UNITS 1 . 00 126 . 00 0 . 00 126 . 00 0 . 00 1MPERMITFE 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 211 .50 0 . 00 211.50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- - ------------------- CHECK 211. 50 # 337 --------------- TOTAL RECEIPT 211 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 505 FINAL ELECTRICAL 507 FINAL PLUMBING 508 FINAL MECHANICAL CITY OF CU PERTINO FEE ESTIMATOR- BIJILDING DIVISION ADDRESS: DATE: REVIEWED BY: APN: BP#: *VALUATION: 1$3,000 R*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Duplex jr�l."` PENTAMATION USE: 1't��r0,':1/if.��; PERMIT TYPE: FURN/AC WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Furnace, Forced-Air 1MFR=<100 1 # $126 TOTALS: $126.00 Mech.Plan Check 0.0 hrs $0.00F Mech.Permit Fee: 1MPERMIT Other Mech.Insp. Fo.0 hrs $42.00 ta; ,71 .', r� Lj I NOTE: Thesefees are based on the preliminary information availaole and are only an estimate. Contact the De t or addh 7 in o. FEE ITEMS (Fee Resolittion 09-051 E(f. 7%7;'70) FEE QTY/FEE MISC ITEMS 1'/O (71Ce i FCC. Suj pl, PC I t-v PME Plan Check: $0.00 f'cnni! FE.c: Sttj)j)l" It,sj Fc PME Unit Fee: $126.00 PME Permit Fee: $42.00 Con' r lwfion 7-ax �t:Otd�I'i't(h RI-i- -w[CC' Work Without Permit? Q Yes (F) No $0.00 Plctrtrritt< Fcc Travel Documentation Fee: ITIN VDOC $42.00 i Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $211.50 $0.00 TOTAL FEE: $211.50 Revised: 10/17/2010 M.lndDDr Air Gualfty and Fintshn - - . 1 IA(VHealth es 0 -. _ _ pts Y=Y 2.Use Low VOC,Water-Based Wood Finishes 2 IA(Mealth pts y--ye 0 3 IM YHealth pts y=yes 0 4.Use Salvaged Materials for Interior Finishes 3 Re Source pts y--yes D 5.Use Engineered Sheet Goods with no added Urea Formaldehyde 6I=Health pts y--yes 0 6.Use Exterior Grade Plywood.ior Interior Uses 1 IA(VHealth pts y--yes 0 - — - _ 4IMI'lealth.pts y--yes 0 B.Use FSC Certified Materials for Interior Finish 4 Re source pts yeses 0 9.Use Finger-Jointed or Recycled-Content Trim 1 Re source pts y=yes 0 10.Install Whole House Vacuum System 3 IA)JHealth pts -YE` 0 N.Ffaaring 1.Select FSC Certified Wood Flooring B Resource pts y--yes 0 ��ejsl oaa� edr�s 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 IA(IHealth pts y=yes D 5.Use Exposed Concrete as Finished Floor 4 Res ource pts y--yes 0 B.Install Recycled Content Carpet with Low VOCs 4 Res ource pts y--yes 0 Total Points Available: . 1401. 130 57 Total Points Project Received. 0 0 0 GdaWpmgslgreenbuild ngguiderines/remodelerslgreenpointsfina1212D4proteefedxis Building Department City Of Cupertino Is 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR / SUBC'ONTRACTOR LIST JOB ADDRESS: 'zo U l�A1N��= /�L dZ,( '`U PERMIT# OWNER'S NAME: X_A0d-A+ <WA-I PHONE# GENERAL CONTRACTOR: C) BUSINESS LICENSE # ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INIQ,PECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signal ure Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum /Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Painting/Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT -BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95(14-3255 (408)777-3228•FAX(408)777-3333• buildina,d�cupert_ina_arg CUPERTINO Dear Property Owner(s): An application for a building permit has been submitted in your ne me listing yourself as the builder of the property improvements specified at: BP# FSITEADDRESS �f/J (� �� c/ Z APNgER NAME oc�`, OWNER DDREFCE'� ,aCT DESCRIPTION OF WORK: rm to make you are We are providing you with an Owner-Builder Acknowledgment incur havng this pe�mitassuedon en your Verification oe as the Owner-Builder. We your responsibilities and possible risk you may Y of each will not issue a building permit until you have indicated! An agent of the owed your nergannot execute this nn notice unless you, returned this form to us at our official address 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.) e property owner ain an"Owner G '1. I understand a frequent practice im lies thatf unlicensetersc ns is to prc perry owner rishpro providing his or her own labor and material Builder" building permit that erroneously Pal risk es sustained personally. I, as an Owner-Builder, may be held liable and Ic ubject to serious fin M cihomE ofwner's insurance may not y an unlicensed person and his or her employees while worki-ig on my property. Y provide coverage for those injuries. I am willfully acting as e n Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. 64 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. 6'4 3. 1 understand as an"Owner-Builder" I am the respor sible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licenE ed Contractor and having the permit filed in his or her name instead of my own. �2 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. (;�I-5. I understand if I employ or otherwise ve hundred gdred dolls-s($500),persons, other including Clabo�andrnia lmateeals, I may beContractors, and the total value of my construction is at lea considered an"employer' under state and federal law. 6x46. I understand if I am considered an"employer" und,;r state and federal law, I must register with the state and federal government,withhold Payroll or each 11employee."provide INalsoe.inderstandcompensation my failuredisability to abinsurance, ide by these laws may subject unemployment compensation for me to serious financial risk. Ca -7. 1 understand under California Contractors' State L cense Law, an Owner-Builder who builds single-family residential structures cannot legally build them err of structth the inent to offer them for sa ,ures doE s not exceed four within anyless all work calendar yeah, or all of the prformed work licensed subcontractors and the numb work is performed under contract with a licensed general buildi-Ig Contractor. 6-7 4�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 subsequent owner(s)that result from any latent construction defects in the workmanship or materials. OivnerBuilderForm_1010.doc revised 04/14110 understand I may obtain more information regarding Adm Hit at onbltghe obligations Department of Benefit Payments, Revenue Service, the United States Small Business te and the California Division of Industrial Accidents. Ilalsso uunde- cad I ffa cO tact the California mation licensedrs' to e License Board (CSLB)at 1-800-321-CSLB (2752)or www.cs] contractors. E7Z4 10. 1 am aware of and consent to an Owner-Builder building permit ion activity ator lthe site addresn my name, s)listed above. 6, I am the party legally and financially responsible for propose C 11. I agree that, as the party legally and financially responsible for well asthis opos d construction activity, I will abide by all applicable laws and requirements that govern Owner-E s any of the 7l1 12. 1 agree to notify the issuer of this form immediately's are e uf any 'lated by laws designed o pro,Ideletions, or changesotect the public. If information I have provided on this form. Licensed contracto 9 you contract with someone who does not have a licenseesul:of a c dors'ntt Four'onlyr e edy ga nbst unlicensed assist you with any financial loss You may sustaina erstand that if an unlicens Contractors may be in civil court. It is alsoed whilfant for you to e working o i your property,you may be held able for damages. If employee of that individual or firm is incur you will tie responsible for verifying whether or not you obtain a permit as Owner-Builder and wish to hire Contractors, y ensation insurance coverage. those Contractors are properly licensed and the status of th,ir workers' comp CONSTRUCTION LENDING AGENCY (DIRECTIONS: Please complete the following construction lensing agency information.) eb affirm that there is a construction lending agency for the performance of the work for which this permit is issued 1 her y (Sec 3097 Civ.) Lender Address: Lender Name: leted and aigned=�ewnerner and Before a building permit can be issued,this form must be -omp of the pro 's license,returned to the agency responsible for issuingthe permit. Note:A copyform notarization, or other verification accepta to the city me y be required to be premit is issuedto veri the ro ert owner's si nature. - l� Property Owner's Signature: (N OTE: The following Authorization Form is required to be co-npleted by the pioperty owner only when designating an agent of the property owner to apply for a construction permit or the Owner-Builder). AUTHORIZATION OF AGENT TO AC'T ON PROPERTY OWNER'S BEHALF the execution of which I understand is my personal responsibility, I hereby Excluding the Notice to Property Owner, n, and file the documents necessary to obtain an for, sign,authorize the following person(s)to act as my agent(s)to appy Owner-Builder Permit for my project. Scope of Construction Project(or Description of Work): Project Location or Address: Tel No Name of Authorized Agent: Address of Authorized Agent: he I declare under penalty of perjury that I am the property of rile for the property owner's essdriver'sblicense,)form notal rizal tion, ored out other ove an above information and certify its accuracy. Note:A copy powner's verification acceptable to the city may be required to be presented when the permit is issued to verify the property signature. Date: Property Owner's Signature: ownerBuilderFonn_2010.doc revised 04114/10 CITY OF C UPERTIN O FURNACE/AC CUPS 000F PERMIT APPLICATION FORM APN# Date: _ /j Building Address: - � cc/ Owner's Name: Phone#: Contractor: , A l? i/AA) 0-C7 �cl ti S TR u C i/3�v J��Dom' Phone 74;o Fax#: Contractor License#: Cupertino Business License#: U Contact: Phone#: �o /u Fax #: Building Permit Info: Elect Plumb Mech l Commer Residentiacial ❑ Job Description: For Residential Installations: 1"floor � 2"d floor Attic ❑ .❑- Adhere to minimum setback requirement ❑ For Commercial Installations: IVIA . Additional weight(structural calcs) Replacement same weight F-1 ❑ Structural Calculations required for new installation ❑ New installation Planning Approval Required ❑ Cost of Project: Type of Cons truc ' n(Usage Class): Bonded [] New Location Replacement Strapped On Platform Project Size: Express Standard ❑ Large ❑ Major❑ Valuation: Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, includ( in plan set & the sheet index. Revised 01/07/09