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10090267 CITY OF CUPERTI140 BUILDING PERMIT BUILDING ADDRESS: 1117 STEEPLECHASE LN CONTRACTOR:MIAO-HUI JOANNE YEH PERMIT NO: 10090267 OWNER'S NAME: MIAO-HUI JOANNE YEH 1117 STEEPLECHASE LN DATE ISSUED:09/29/2010 NER'S PHONE: 4085952910 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATIONF '47, r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class '3 f' Loc.# �lY"[ r (! MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:NEW CLEAN-OUT (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: lua n: 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:35931047.00X �*."� �u ncy 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 I R S�F WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save WITH 1 Q �;YS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 6A'YS 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 9.18. Signature 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). 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 permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the p Health&Safety 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 9"uth4 rize ent• p 2� 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 must forthwith comply with such provisions or this permit shall be deemed revoked dCONSTRUCTION LENDING AGENCY 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 unman the above mentioned property for inspection purposes.(We)agree to save mify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION L, and expenses which may accrue against said City in consequence of the granting of this permit.Additionall the applicant understands and will comply I understand my plans shall be used as public records. with all non-point source egulatio per the Cupertino Municipal Code,Section 9.18. Licensed Professional Signature Date CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Bl:c: Lot: APN . . . . . . . . : 35331047.00 DATE ISSUED. . . . . . . : 09/29/2010 RECEIPT #. . . . . . . . . : BS)00011593 REFERENCE ID # . . . : 1OD90267 SITE ADDRESS . . . . . : 1117 STEEPLECHASE LN SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : MIAO-HUI JOANNE YEH ADDRESS . . . . . . . . . . : 1117 STEEPLECHASE LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : MIAO-HUI JOANNE YEH CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : MIAO-HUI JOANNE YEH ADDRESS . . . . . . . . . . : 1117 STEEPLECHASE LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ------- 1BCBSC VALUATION 499. 00 1. 00 0. 00 1 . 00 0 .00 1BSEISMICR VALUATION 499. 00 0 .50 0 .00 0 .50 0 . 00 1PPERMITFE FLAT RATE 1. 00 42 .00 0 .00 42 . 00 0 .00 1PRSEWER UNITS 1. 00 21 .00 0 .00 21. 00 0 .00 1TRAVDOC FLAT RATE 1. 00 42 . 00 0 .00 42 . 00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 106 .50 0 .00 106 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 106 .50 AMEX --------------- TOTAL RECEIPT 106 .50 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 ILADDL,RESS: DATE: REVIEWED BY: : BP#: *VALUATION: $499 —� *PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY SFD or Du lex ��' PENTAMATION USE: p _711.C)<)fi i i�_�-: PERMIT TYPE: 1 RPSS WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Sewer, Sanitary 1PRSEWER 1 # $21 TOTALS: $21.00 Plumb.Plan Chec< 0.0 hrs $0.00 Ch",k Plumb.Permit Fee: IPPERMIT tr , Other Plumb Insp 0.0 hrsL$42.00 NOTE: Thesefees are based on the preliminary in ormation c vailable and are only an estimate. Contact the De t or addn'l info. FEE ITEMS (Fee Resolution 09-051 Eff. 7%1.10) FEE QTY/FEE MISC ITEMS ST pp/. I'C.'t t PME Plan Check: $C.00 Pel-Init Fcc_ Supp/. F PME Unit Fee: $21.00 PME Permit Fee: $42.00 Collstrtrction Zax Work Without Permit? 0 Yes 0 No $(1.00 1'Iczrtrttn,�>1=c'e'.i: Travel Documentation Fee: ITRAVDOC $4':.00 A Strong:Motion Fee: $0.50 Select an Administrative Item Bldg:Stds Commission Fee: IBCBSC $1 .00 SUBTOTALS: $106.50 $0.00 TOTAL FEE: $106.50 Revised: 9/29/2010 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333• :wiidingacupertino.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 APN BP ��2 OWNERNAME OWNER ADDRESS s DESCRIPTION OF WORK: We are providing you with an Owner-Builder Acknowledgrient 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 indicatod. An agent of the owner cannot execute this notice unless you,the property owner, obtain the prior approval of the po:rmitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS:Please read and initial each statement bei ow to signify you understand or verify this information.) 21� I 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 property. )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. �AL 3. 1 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. L 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 total value of my construction is at least five hundred lollars ($500), including labor and materials, I may be considered an"employer' under state and federal law. �. )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. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with tt a 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 bjilding Contractor. " 8. 1 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 su)sequent owner(s)that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 f. J 9. I understand I may obtain more information retarding my obligations as an"employer"from the Internal ve `Renue Service,the United States Small Business AJministration,the California 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 vww.cslb.ca.gov for more information about licensed contractors. i�)10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that am the party legally and financially responsible for pro)osed construction activity at the site address listed above. ,111. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide y all applicable laws and requirements that govern Owner-Builders as well as employers. 7),_.,12. 1 agree to notify the issuer of this form immed ately of any additions, deletions, or changes to any of the Mformation I have provided on this form. Licensed cortractors are regulated by laws designed to protect the public. If you contract with someone who does not have a licen:;e, the Contractors' State License Board may be unable to assist you with any financial loss you may sustain as E result of a complaint.Your only remedy against unlicensed Contractors may be in civil court. It is also important fc 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.) 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: l� � Lend'r Address: Before a building permit can be issued,this form ust be completed and signed by the property owner and returned to the agency responsible for issuing th , permit. Note:A copy of the property owner's driver's license, form notarization, or other verification accep le to cis y may be required to be presented when the permit is issued to verify the property owner's ure.--.7, PropertyOwner's Signature: J� Date:--------------------------------------------------------------------------------------------------------------------------------------------- (NOTE: The following Authorization Form is required to b.- 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. 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 cf the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be p,-esented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnelBuilderForn1 2010.doc revised 04/14/10 Z CITY OF C.UPERTINO Dog 02-0-1 REPIPE/SEWEI.VMAINT SERVICE CM OF CUPEkTINO PERMIT APPLICATION FORM A.PN 4 GLI-7 Date. Building Address: Owner's Name: Phone#: J L 4 Contr tor: Phone Lj_-ZL_�.v Fax Y 4 72" C C Phone 9: ntact: Fax #: Contractor License zi, Cupertino Business License#: Job Description: Residential Commercial ❑ Valuation: Project Size: Express Standard Large LJ 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 Descripi.-ion Fee Permit Type Group IPCSEVYrER Commercial b-L-ilding P ICPSS sewer/sanitary sewer IBPREPiP_E Commercial re-pipe per fixture P 1CPR-P IPGASCOM Commercial Gis Piping System P 1-4 Outlets IBCBSC Cal Bldg Stancards Commission. B ALL PERTNUT Fee TYPES IBSEISMICOM Seismic Commercial P Revised 01/07/09