10090113 CITY OF CUPERTIN O BUILDING PERMIT
BUILDING ADDRESS: 1199 STAFFORD DR CONTRACTOR:' _ PERMIT NO: 10090113
NER'S NAME: JACK TSAI DATE ISSUED:09/15/2010
OWNER'S PHONE: 4089228202 w PHONE NO:(408)786-8120
LICENSED CONTRACTOR'S DECLARATIONr F
BUILDING PERMIT INFO: BLDG r ELECT PLUMB
License Class Lic.# r r
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLACE FURNACE,SAME LOCATION
(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
permit is issued. APN Number:36211028.00 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, 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
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by:. - '.�`-� �._ Date P-:1t6
9.18.
' cure G= ` f 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 one 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 licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code). M c,7
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
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 Owngr or authorized agent:
Compensation laws of California. If,after making this certificate of exemption,I Date: l
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 revoked. CONSTRUCTION LENDING AGENCY
MC,T 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 relating
to building construction,and hereby authorize representatives of this city to enter Lender's Address
`he above mentioned property for inspection purposes.(We)agree to save
.mify 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 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_--.c' _ Date
CITY OF ,CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: I DATE: REVIEWED BY:
APN: BP#: "VALUATION: $3,000
*PERMIT TYPE: Mechanical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY 70I l 1. PENTAMATION 1 RM61
USE: SFD or Duplex f-l_CXM VVI'11: PERMIT TYPE:
WORK
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Furnace, Floor 1 # $63
TOTALS: $63.00
T-1-
Mech.Plan CheckFO-01hrs $0.00 t'ow, I m,('1I�'�
[Mech.Permit Fee: IMPERMIT F"!Ii Pc,&!w/'c1:7c c hr rnir I';E
Other Mech.Insp. 0.0 hrs $42.00 On c�r M!!y,1,In'!" Urh�f�1,`__�c t np,
L1
NOTE: Theseees are based on the preliminaryin ormation available and are onlyan estimate. Contact the De t or addn'l info,
FEE ITEMS (Fee Resolution 09-051 Ef. 7,7/10) FE1E, QTY/FEE MISC ITEMS
Moll Check Vcc:
suppL PC Fc'e
PME Plan Check: $0.00
suppl. /Ttsp P'Cc
PME Unit Fee: $63.00
PME Permit Fee: $42.00
C0;7Sl7'llt'ti0l7 TON
,Icollslic al lcr+rit�iti°I ec>:
Work Without Permit? 0 Yes 0 No $10.00
Plr.rrrrtt� �7 f�c�i'>:
Travel Documentation Fee: ITRA VDOC $42.00
Strong Motion Fee: $3.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $143.50 $0.00 TOTAL FEE: $148.50
Revised: 9/14/2010
CITY OF CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: B1}:. Lot:
APN . . . . . . . . . 36211028 .00
DATE ISSUED. . . . . . . : 09/15/2010
RECEIPT #. . . . . . . . . BS000011467
REFERENCE ID # . . . : 10090113
SITE ADDRESS . . . . . : 1199 STAFFORD DR
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER JACK TSAI
ADDRESS . . . . . . . . . . : 1109 STAFFORD DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : MIlTG-CHIEH TSAI
CONTRACTOR . . . . . . . : TOITY FERREIRA LIC # 31778
COMPANY . . . . . . . . . . : TFF HEATING AND AIR CONDITIONI
ADDRESS . . . . . . . . . . : 291.) CORNING AVE
CITY/STATE/ZIP . . . : MILPITAS, CA 95035
TELEPHONE . . . . . . . . : (408) 786-8120
FEE ID UNIT QUANTITY AMOUNT 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
1MPERMITFE FLAT RATE 1.00 42 .00 0 .00 42 . 00 0 .00
1MRRAA UNITS 1. 00 63 .00 0 . 00 63 . 00 0 .00
1TRAVDOC FLAT RATE 1. 00 42 .00 0. 00 42 .00 0 .00
- --------- ---------- ---------- ----------
TOTAL PERMIT 148 .50 0.00 148 .50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 148 .50 DISCVR
---------------
TOTAL RECEIPT 148 .50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
------ ---------------------------- -------- ----------------------------
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO CA 95014-3255
CUPERTINO (408)777-3228-FAX(408)777-3333-;wilding(aDcupertino.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 ADDRESSS7�� DFL ,VFL APN � �I I - �2 BP#
OWNER NAME h. 1 NGC H I�� S�Z OWNER AC DRESS ] (� S r/}� pp DR� (t4pER7�Alo c q�v�
DESCRIPTION OF WORK: l ( [
1EFLAcEOrNT o� -FURNACE _ 'AM e Loci4 T i&V
We are providing you with an Owner-Builder Acknowledgrr ent 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, inil ialed 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 permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION C F 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-
B liu der" building permit that erroneously implies that th a 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 propE rty.
_�L2. I understand building permits are not required t)be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
X 3. 1 understand as an"Owner-Builder' I am the re:;ponsible 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.
)� 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.
A 5. 1 understand if I employ or otherwise engage 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 federal law.
X 6. 1 understand if I am considered an "employer"c nder state and federal law, I must register with the state and
federal government,withhold payroll taxes, provide wo-kers'compensation disability insurance, and contribute to
unemployment compensation for each "employee." I al 3o understand my failure to abide by these laws may subject
me to serious financial risk.
X 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 c oes not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
X 8. 1 understand as an Owner-Builder if I sell the prz)perty for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any sub:;equent owner(s)that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderFo»n 2010.doc revised 04/14/10
X-9. 1 understand I may obtain more information regarding my obligations as an"employer"from the Internal
Revenue Service,the United States Small Business Administration,the Califdrnia Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board(CSLB)at 1-800-321-CSLB (2752)or%&ww.csib.ca.gov for more information about licensed
contractors.
k- 10. 1 am aware of and consent to an Owner-Buildar building permit applied for in my name, and understand that I
am the party legally and financially responsible for pro)osed 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 ONner-Builders as well as employers.
/V12. 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 licen3e,the 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 statu 3 of their workers'compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following constructicn 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!;t be completed and signed by the property owner and
returned to the agency responsible for issuing the pe rmit. 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 propety owner's si natur b
Date:
Property Owner's Signature: /
--------------------------------------------------------------- -----------------------------------------------------------------------------
(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 permit 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. RFP(AC; FGtRNpCr. S,40
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:
ON'nerBuilderFonn_2010.doc revised 04/14110
T"' R
CITY OF +�UPERTINO
FURNYWE/AC
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CUPER `MO PERMIT APPLI[CATION FORM
APN 14 3 � Z — � 1 _• o 2 8 Date: /? / to/ I ()
Building Address: � 9 L � b r.
Owner's Nanie: Phone n:1408 -122 -8.20Z
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Contractor: Phone,-. L4D$ ., Z
To n Fe-r rte. Fax W: 4og -- q 3,4f,9 aL1g
Contractor License -t: Cupertino Business License ':
q X50 f3 1 7-7 -4- S
Contact: _ Phone 9:
Fax 4:
Building Permit Info:
Elect ff�--- Plumb Mech
Residential Commercial El
Job Description:
Repla-ce -�v rha� � , Sammi f oc-a:+i o
For Residential Installations:
Attic F-1I" floor ® 2"d floor ❑
Adhere to minimum sotbacic req uiremeat
For Commercial Installations:
ad
Replacement same weight El additional weight (structural talcs) ❑
Structural Calculation,, required for new. installation ❑
New installation Planning Approval Required ❑
Cost of Project: Type of Corstruction (Usage Class):
OOo .
Strapped ElOn Platform ❑ Bonded ❑ New Location L] Replacement
Project Size: Express ❑ Standard Large ❑ Major ❑
Valuation:
Green I3t-"ilding: Plon,;e complete relevant portion (f the Green Building Checklist & attach it to the
application or if applicable,ineluc a in plan set & the sheet index.
i
Revised 0110?/09
Z-d 6V069£680ti OVAH JJl eaieaae�Auol d£9:£0 0 L 60 deS