10090276 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10262 TERRY WAY CONTRACTOR:ANDREW KANG PERMIT NO: 10090276
OWNER'S NAME: ANDREW KANG 10262 TERRY WAY DATE ISSUED:09/30/2010
BIER'S PHONE: 4089961069 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATIONr
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH r— RESIDENTIAL[_ COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:APTS 1,2&3-NON-STRUCTURAL;REPLACE EXISTING
(commencing with Section 7000)of Division 3 of the Business&Professions SINGLE PANE SECOND FLOOR HALLWAY/BATHROOM WINDOWS
Code and that my license is in full force and effect. WITH RETROFIT/FLUSH FIN WINDOW COSNTRUCTION.NEW
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: Valuation:$628
permit is issued.
APPLICANT CERTIFICATION APN Number:35917016.00 Occupancy Type:
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
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by 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,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). 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. I 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&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
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 aut orized a t
Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION 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
upon the above mentioned property for inspection purposes.(We)agree to save
it'-mnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
and expenses which may accrue against said City in consequence of the
gi,..,ting 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
9.18. I understand my plans shall be used as public records.
Signature �- Date « Licensed Professional
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35917016 . 00
DATE ISSUED. . . . . . . : 09/30/2010
RECEIPT #. . . . . . . . . BE000011603
REFERENCE ID # . . . : 1C090276
SITE ADDRESS . . . . . : 1C262 TERRY WAY
SUBDIVISION . . . . . .
CITY CL PERTINO
IMPACT AREA . . . . . .
OWNER AISDREW KANG
ADDRESS 1C262 TERRY WAY
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : AT-DREW BONG KANG
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY AYDREW KANG
ADDRESS 1C262 TERRY WAY
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . .
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- - --------- ---------- ---------- ----------
1BCBSC VALUATION 628 . 00 1. 00 0 .00 1. 00 0 .00
1BSEISMICR VALUATION 628 . 00 0 .50 0 .00 0.50 0 . 00
1WINREP EACH 8 6 . 00 380 .00 0. 00 380. 00 0 . 00
- --------- ---------- ---------- ----------
TOTAL PERMIT 381.50 0 .00 381.50 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 381.50 #1047
---------------
TOTAL RECEIPT 381 .50
CITY OF CUPERTINO
FEE ESTIMATOR -BUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: *VALUATION: $628
x ERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition
PRIMARY I t>7,;1. PENTAMATION 1 GENRES
USE: SFD or Duplex J I 00H,1 t/ ,1, PERMIT TYPE:
WORK
SCOPE
NOTE: Thesefees are based on the preliminatUy in ormation available and are only an estimate. Contact the Dept-for addn'1 info,
FEE ITEMS free Resolution 09-051 Elf 7/l.-'101 FETE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 EE # Window/Sliding Glass Door
Suppl. PC Fee: (F) Reg. 0 OT 0.0 hrs $0.00 $380.00 1 WINREP Replacement
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee10 Reg. 0 OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
�'U11.�I1't�t`Fti)yt I cZ�"
Acoustical Fee: 0 Yes (E) No $0.00 0
Work Without Permit? 0 Yes E) No $0.00 E)
Planning Fee: $0.00 Select a Non-Residential 0
Building or Structure 0
Trrrf�� 1?ociF>=t7��trfEx7ir�n F�r�'s: �
Strong;Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00 7
SUBTOTALS: $1.50 $380.00 TOTAL FEE: $381.50
Revised: 9/29/2010
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OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPAFTMENT-BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333- building cupertino.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 ADDR S APN BP# 01
2?
OW ER NAME OWNER ADDRESS
Dc�
DESCRIPTION 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 hiving 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 permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION DF 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 t-ie 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 pror erty.
�2. I 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.
"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.
4. 1 understand Contractors are required by law I 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 Dollars($500), including labor and materials, I may be
considered an"employer" under state and federal lm%. y
6. 1 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' Ste to License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with tI•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 building Contractor.
�8. 1 understand as an Owner-Builder if I sell the 1)roperty 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 04/14110
�3. 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 California Department of Benefit Payments,
and the California Division of Industrial Accidents. I a'so understand I may contact the California Contractors'State
License Board (CSLB)at 1-800-321-CSLB (2752)or Nww.cslb.ca.gov for more information about licensed
contractors.
-"'1/0. 1 am aware of and consent to an Owner-Builjer building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
11. 1 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.
X12. 1 agree to notify the issuer of this form imme Jiately 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 license, 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 wo-king 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 stats 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:;t 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 city 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 ire 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)tc 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 )f 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:
OwnerBuilderForm 2010.doc revised 04/14/10
C(Do� 7
CITY OF C-UPERTINO
cu CITY Of GENERAL BUILDING
PERMIT APPLICATION FORM
Date:
BuildinEAddress-
7,a) GtI
Mailing Address (if different fromMdin6o address):
Are Hazardous Materials being used as part o is project? Yes No
,yes rovide letter from SOA
HOA: (Exterior work only) Yes ❑ N° � J
Owner's Name: phone#: oto
Phone:
Contractor. ,�u(L n C— Fax:
Contractor License#: A
Cu ertino Business License#: 7phone:
Contact: Fax:
Residential Commercial
Job Description: t 1F_- 'P j0.I
PA
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Building Permit Info:
Elect ❑ Plumb ❑ Mech ❑
Bld C�-� 70cancy Type' 3
Type of Construction (Usage Class):
II/VI B, IV-HT, <-
1-A, 1-B ❑ -A ❑ Square Footage:
tjaluaton.
Project Size: Express �tandard ❑
Larg: ❑ Major ❑ ���--
een Building: Please complete relevant portio a of the Green Building the sheehind Checklist & attach it
Gr b
to the application or if applicable, include in plan set
Points Achieved:
For hel , contact Build it Green at www•builditf een.or
Revised 07/14/09
3