10090044 CITY OF CUPERTIN O BUILDING PERMIT
BUILDING ADDRESS: 10708 JOHANSEN DR CONTRACTOR:TAO XIONG PERMIT NO: 10090044
OWNER'S NAME: TAO XIONG 10708 JOHANSEN DR DATE ISSUED:09/08/2010
-4ER'S PHONE: 6513295165 CUPERTINO,CA 95014 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.# MECH r RESIDENTIAL r COMMERCIAL r
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACING THE SEWER LINE FOR 40 FEET&REPLACING
THE MAIN WATER LINE
(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 Sq.Ft Floor Area: V luau •$1200
permit is issued. 'a.
APPLICANT CERTIFICATION APN Number:37536003.00 ? Occupancy Type:
I certify that I have read this application and state that the above information is .w
correct.I agree to comply with all city and county ordinances and state laws relating
to building constriction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERM E WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments, W YS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply 1 M LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued b - - -------- Date:
Signature Date
OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
constrict the project(Sec.7044,Business&Professions Code). _VK ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety 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 Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner or authorized agent:
Date:�/p
forthwith comply with such provisions or this permit shall be deemed revoked.
T X CONS UCTION LENDING AGENCY
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
t—n the above mentioned property for inspection purposes.(We)agree to save
mify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
_.s,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
� I understand my plans shall be used as public records.
9.18.
Signature
Date /�( V Licensed Professional
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT' RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: B1}:: Lot:
APN 37536003 .00
DATE ISSUED. . . . . . . : 09,08/2010
RECEIPT #. . . . . . . . . BS000011398
REFERENCE ID # . . . : 10090044
SITE ADDRESS 10708 JOHANSEN DR
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER TAD XIONG
ADDRESS 10708 JOHANSEN DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : TAD XIONG
CONTRACTOR TBD - TO BE DETERMINED LIC # 00096
COMPANY TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . .
CITY/STATE/ZIP
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ---------- ---
1BCBSC VALUATION 1, 200 . 00 2 .00 0 .00 2 . 00 0 .00
1BUSLIC FLAT RATE 1. 00 114 . 00 0. 00 114 .00 0 .00
1PPERMITFE FLAT RATE 1. 00 84 .00 0 .00 84 . 00 0 .00
1PRSEWER UNITS 1. 00 42 .00 0 .00 42 . 00 0 . 00
1TRAVDOC FLAT RATE 1. 00 84 . 00 0 . 00 84 . 00 0 .00
- ---------- ---------- ---------- ----------
TOTAL PERMIT 326 . 00 0. 00 326 .00 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- -------------------
CREDIT CARD 326 . 00 MC
---------------
TOTAL RECEIPT 326 .00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- ------ -----
106 SEWER & WATER 202 UNDERFLOOR PLUMBING
301 ROUGH PLUMBING 400 SEWER/LATERAL
507 FINAL PLUMBING
CITY OF CUPERTINO
FEE ESTIMATOR--BUILDING DIVISION
ADDRESS: I DATE: REVIEWED BY:
APN: BP#: *VALUATION: $1,200
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY '[01111: PENTAMATION 1RPSS
USE: SFD or Duplex /-'1 00P, i1,1,,: PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Sewer, Building 1PRSEWER 1 # $21
TOTALS: $21.00
Pian Ch", 11 Plumb.Plan Check
Plumb.Permit Fee: IPPERMIT
�)rlr :1t�<1t 1rt ,> Other Plumb Insp. 0.0 �hrs $42.00 1"7c( lwq"
a! :i, Jr�sj� 1'cc Plrnrtb_ la �r;. I:.,t 1;Iec.Itzsf. /.•e-
NOTE. These ftes are based on the preliminary in ormation available and are only an estimate. Contact the Dept for addn'1 info,
FEE ITEMS (Fee Resolution 09-051 Eff. 7;'1/10) FEE QTY/FEE MISC ITEMS
suppl. PC Fee
PME Plan Check: $0.00
Pt=F-mlP f"('e.
PME Unit Fee: $22 1.00
PME Permit Fee: $42.00
��(I}ISlt'itt`EtOt1 1 C£1
(C011stit"ell 1it:'vict t°
Work Without Permit? 0 Yes E) No 90.00
I'Ir.rrtttitr,�7 1''cr�'i.
Travel Documentation Fee: ITRAVDOC $12.00 =]A
S`trr>r� �fatu��r 1'ee�: Select an Administrative Item
Bldy,Stds Commission Fee: IBCBSC :51.00
SUBTOTALS:; $106.00 $0.00 TOTAL FEE: $106.00
Revised: 9/01/2010
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333• buildingaCUoertino.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 ADDRESS /070ST06 V?n APN BP#
OWNER NAME ' �` OW R A D
Aci � 72h Z117
o arC� i Cl QS)/
DESCRIPTION OF WORK:
�P ACi� C QY 6vt
We are providing you with an Owner-Builder Acknowledg rent 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, it itialed 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 F ermitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement be low to signify you understand or verify this information.)
7K1. I understand a frequent practice of unlicensec persons is to have the property owner obtain an "Owner-
Builder" building permit that erroneously implies that-he property owner is providing his or her own labor and.material
personally. I, as an Owner-Builder, may be held IiablO 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 actir g as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
Tx 2. I understand building permits are not requirec to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contrai;tor to assume this responsibility.
1:IX3. 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.
'71��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. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
t to 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.
1 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.
' �7. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with t ie intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structure:;does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
K8. 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 SL bsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderFonn 2010.doc revised 04/14110
inc my
as an "employer"
rom the Internal
(� 9. I understand I may obtain more informatioAdministration,obligations eCaifornia Department fof Benefit Payments,
Revenue Service, the United States Small Business
and the California Division of Industrial Accidents.
loals�W d,Ib cangov for mored information on about licensed
rs' State
License Board (CSLB)at 1 800 321-CS ( )
contractors.
10. I am aware of and consent to an Owner-Builder bui ding permit applied for in my name, and understand that I
am the party legally and financially responsible for proposec construction activity at the site address listed above.
x11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
tions, deletions, or changes to any of the
12. I agree to notify the issuer formLicensed contractors��s are regf any ullated by laws designed o protect the public. If
of !
information I have provided on this
le to
you contract with someone who does not
sustainlicense,
resh t of atractors' State complaint. Your onlyer emedy against st unlicbensed
assist you with any financial loss you Y
Contractors may be in civil court. It is also important for yoL. to understand that if an
u li held tlab Coforntractor
damages. If
or
employee of that individual or firm is injured while working on your property,y Y
you obtain a permit as Owner-Builder and wish compe s u will be tonSlbsurance verifyingle for e ageether or not
those Contractors are properly licensed and the status of their workers'
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction len ding agency information.)
ing agency for the performance of the work for which this permit is issued
I hereby affirm that there is a construction lend
(Sec 3097 Civ.)
Lender Name: Lender Aldress:
rtoc
efore a building permit can be issued,this form must be completed and signed by the property owner and
turned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
rm notarization, or other verification acceptable to the city m9y be required to be presented when the permit is issued
veri the roe owner's si nature. Date:
Property Owner's Signature: -
-- - - -------- -- riz--- ------------------------------------------------------------------------------------------------------
(NOTE: The following Authoation Form is required to be completed by the property 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 PROPERTYOWNER'S BEHALF
hreby
Excluding the Notice to Property Owner,
the
tt to apply for, lresponsibility,
'
understandis
he document necessaryltoe
eobtain an
authorize the following person(s)to act as y gen (s)
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:
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
or other
above information and certify its accuracy. Note:Abe°y of t e property
when the permit s issued to verify the propterty owner's
verification acceptable to the city maybe required t pre
signature.
Date:
Property Owner's Signature:
DwnerBuilderForns_2010.doc revised 04/14/10
M.Indoor Air Quality and FbIshes
1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3IAQ/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
6.Use Exterior Grade Plywood.for Interior Uses 1 IAQ/Health pts y=-yes 0
1. _ .' _.. 4IAQ/Health pts y=yes 0
B.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
N.Flaoring
1.Select FSC Certified Wood Flooring B Resource pts y--yes 0
L 111,1111 �Joor y 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
1 1 1
Total Points Available: 1 1401 1301 57
Total Points Project Received: r 01 Or----0
G;data/prog&1jre 3nbuilclngguiderines/remodelers/greenpointsfina121204protected.xis
CITY OF C'UPERTINO
REPIPE/SEWEPJMAIN SERVICE
CUPCM OF
EkT1NO PERMIT APPLICATION FORM
AFN # / Date:
Building Address: /.70 S Cv Hi n 0 CA g50/ 4
Owner's Name: TAo Phone#: /5/_ 3 2 9-:�-/ 6S
Contractor: Phone#: 40 q8/ 1
G 9 A int Vm bin co Fax #:
Phone #:
Contact:
Len
Fax #:
Contractor License#: 6-06— 77 0
Cupertino Business License#:
Job Description: yeelpc n 9J Ae SPWeY l J
i'lP �-r 40 Opts,
-
yqoacin she main vJa+eY tine .ine .
Residential Commercial ❑
Valuation: 00. 00
Project Size: Express Standard Large ] Major
LJ
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
IPCSEER Commercial building P 1CPSS
W
sewer/sanitary Newer .�
1BPREPIPE Commercial re-pipe per fixtureP 1CPRP
1PGASC6M Commercial G-,Ls Piping System P
1-4 Outlets
1BCBSC Cal Bldg Standards COmmlSSlon. B ALL PERMIT
Fee TYPES
1BSEISMICOM Seismic Comrr.ercial P
Revised 01/07/09