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10090208 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10385 NORWICH AVE CONTRACTOR:RAYMOND HO PERMIT NO: 10090208 OWNER'S NAME: RAYMOND HO 10385 NORWICH AVE DATE ISSUED:09/22/2010 ER'S PHONE: 4089960087 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r PLUMB License Class Lic.# MECH r RESIDENTIAL r COMMERCIAL r Contractor Date JOB DESCRIPTION:TEMP POWER POLE 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:$220 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 anc Type:Occu APN Number:31629079.00 P Y 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 relatin€ PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 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 �2 2,—t XI- with all non-point source regulations per the Cupertino Municipal Code,Section Issued bi�� '----- Date: , 9.18. Signature Date RE-ROOFS: i V 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 heresy affirm that I am exempt from the Contractor's License Law for one c f inspection. the following two reasons: 1,as owner of the property,or my employees with wages as their sole compensatioir, Signature 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 contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). 1, HAZARDOUS MATERIALS DISCLOSURE I hereby affirm under penalty of perjury one of the following three 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& Safety Code,Section 25532(a)should I store or handle hazardous material. performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will Section 3700 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the permit is issued. Health&Safety Code,Sections 25505,25533,and 25534. 1 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 authorized agent: Compensation laws of California. If,after making this certificate of exemption,I Date: become subject to the Worker's Compensation provisions of the Labor Code,I mu st forthwith comply with such provisions or this permit shall be deemed revoked. I CONSTRUCTION LENDING AGENCY `S• 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 relati sg to building construction,and hereby authorize representatives of this city to enter Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save hmify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION i and expenses which may accrue against said City in consequence of the 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 source regulations per the Cupertino Municipal Code,Section 9.18. --�� Licensed Professional Signature Date y� � v OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPAR"-MENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228-FAX(408)777-3333- building(a)cupertino.orp CUPERTINO Dear Property Owner(s): An application for a building permit has been submitted in,four name listing yourself as the builder of the property improvements specified at: SITE ADDRESS APN BP# " / PDESCRI NAME OWNER ADDRESSP ON 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 pormitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS:Please read and initial each statement 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- Builder" 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 proFerty. t,i y2. 1 understand building permits are not required to be signed by property owners unless they are responsible for be construction and are not hiring a licensed Contractor to assume this responsibility. VI 3. I understand as an "Owner-Builder" I am the r:sponsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a icensed Contractor and having the permit filed in his or her name instead of my own. r„ 4. 1 understand Contractors are required by law :o be licensed and bonded in California and to list their license numbers on permits and contracts. 4 1�-5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the tal 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 lavf. .. 6. I understand if I am considered an "employer' under state and federal law, I must register with the state and deral 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 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. l8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for ny 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 04/14/10 li�9. I understand I may obtain more information regarding my obligations as an"employer"from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I al:;o understand I may contact the California Contractors' State License Board (CSLB)at 1-800-321-CSLB (2752)or vNm.cslb.ca.gov for more information about licensed contractors. �10. 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 prc posed construction activity at the site address listed above. 11. 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 Cwner-Builders as well 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 licer se, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as 3 result of a complaint.Your only remedy against unlicensed Contractors may be in civil court. It is also important f)r 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 mu st 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 c ity 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 5e completed by the property owner only when designating an agent of the property owner to apply for a construction p?rmit 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, 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: Name of Authorized Agent: Tel No 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: OwnelBuilderForm_2010.doc revised 04/14/10 CITY OF CUPERTINO 5 ITEMS OF 5 PERMI'C RECEIPT OPERATOR: patg COPY # : 1 Sec: Twp: Rng: Sub: B1:{: Lot: APN 31529079 .00 DATE ISSUED. . . . . . . : 09/22/2010 RECEIPT #. . . . . . . . . BS000011529 REFERENCE ID # 10090208 SITE ADDRESS 10385 NORWICH AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : RPYMOND HO ADDRESS : 1C385 NORWICH AVE CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM RLYMOND HE CONTRACTOR LIC # *OWNER* COMPANY . . . . . . . . . . : RliYMOND HO ADDRESS . 10385 NORWICH AVE CITY/STATE/ZIP CUPERTINO, CA 95014 TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC --NEW-BAL- ---------- ------------- ---------- ---------- ----- 1BCBSC VALUATION 220. 00 1. 00 0 . 00 1. 00 0 .0 1BSEISMICR VALUATION 220. 00 0 . 50 0 .00 0 .50 0 .00 1EPERMITFE FLAT RATE 1. 00 42 .00 0 .00 42 . 00 0 .00 1ERT<200 UNITS 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 127 .50 0. 00 127 .50 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- -- --------------- ----- CREDIT CARD 127 .5C VISA --------------- TOTAL RECEIPT 127 .5C VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ------------------------ -------- ----------------------- 402 TEMPORARY POWER Y CITY OF CUPERTINO FEE ESTIMATOR--BUILDING DIVISION ADDRESS: IDATE: REVIEWED BY: APN: BP#: *VALUATION: $220 xPERMIT TYPE: Electrical Permit PLA N CHECK TYPE: Alteration/Addition / Repair PRIMARY --[PENTAMATION SFD or Duplex 1REAP14 USE: p ��' I1 ��I, PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1 ERT<200 100 Amps $42 TOTALS: $42.00 Elec.Plan Check 0.0 hrs $0.00 -r,clt_ l7c t'lJcrlt Elec.Permit Fee: IEPERMIT )) J( }} Other Elec.Insp. EJ�rs $42-00 Li ,'.h ;rt= .1; P�r�rztb F�'r i€ec �•riP_1�� NOTE: These fees are based on the preliminary in ormatior available and are only an estimate. Contact the Dept for addn'l info, 1/10) FEE Q MISC ITEMS FEE ITEMS (Fee Resolution 09-O51 Eff. i/ TY/FEE Non C't1C'C� /'�cc sZpp/. P r i'c'y:' PME Plan Check: $0.00 I't�r'trtal /'e'c'• PME Unit Fee: $42.00 PME Permit Fee: $42.00 C`ollswIlf°tial, Ta, Work Without Permit? 0 Yes No $0.00 Travel Documentation Fee: ITRAVDOC 942.00 Select an Administrative Item Strong Motion Fee: $0.50 Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS27.50 $0.00 TOTAL FEE: $127.50 Revised: 9/14/2010 Building Department City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 CUPERTINO CONTRACTOR/ SL BCONTRACTOR LIST PERMIT# JOB ADDRESS:�63�J 'c� -� �a OWNER'S NAME: �'c PHONE# GENERAL CONTRACTO BUSINESS LICE SE# ADDRESS: ,flf' C CITY/ZIPCODE: �� l *Our municipal code r uires all businesses working it the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S)NANE OBTAINED AHCITY OF CU ERTINO UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTF:ACTORS BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please check applicable subcontractors and comp'ete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electricalt� 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 Date Owner%Contractor Signature CITY OF CUPERTINO TEMP POWER CUPEk iNO PERMIT APPLICATION FORM APN # ��In/� � Date: Building Address: Owner's�Ne. Phone #: C ontractor- 0/�' Pone#: �� v ��-Z�—,�2 Fax #: Phone #: Contact: Contract( cense #: Cuerf' Business License#: Job E _option: Residentia Commercial Valuation (cost of project): Type of Constructio :N/ Quantity Fee ID Fee Description Fee Group Permit Type IERT>1K Res. Temp Power>1K E 1REAP14 Amps IERT<200 Res. Temp.P ewer<200 E Am s 1 ERT2001 K Res. Temp P awer 200-1 K E Amps I EPERMITFE Electric Permit Issuance E 1 ELCPLNCK Electric Plan Check E 1BCBSC Cal Bldg Standards B ALL PERMIT _ Commission Fee TYPES 1BSEISMICR Seismic Res.dential B ITRAVDOC Travel & Documentation B Fee Revised 01/07/09