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10090162 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10210 VICKSBURG CT CONTRACTOR:YUANDAN LOU PERMIT NO: 10090162 OWNER'S NAME: YUANDAN LOU 10210 VICKSBURG CT DATE ISSUED:09/17/2010 .NER'S PHONE: 4084461941 CUPERTINO CA, 95014-3331 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class Lie.# POOL REMOVAL 200 SQ FT Contractor Date 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:$5000 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 APN Number:36914015.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ( Date: granting of this permit. Additionally,the applicant understands and will comply Issued by: L G` G with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date 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 inspection. ❑��Q, OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one c f the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,as owner of the property,or my employees with wages as their sole compensatioi 1, 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 HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. / Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: � J,_ Date: permit is issued. 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 CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 -on the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION mnify and keep harmless the City of Cupertino against liabilities,judgments, _.s,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature �� �� Date otj�1l Lo to CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: B1}_. Lot: APN 36914015. 00 DATE ISSUED. . . . . . . : 09,17/2010 RECEIPT #. . . . . . . . . BS000011488 REFERENCE ID # . . . : 10090162 SITE ADDRESS 10:?10 VICKSBURG CT SUBDIVISION . . . . . . . CITY CU'.?ERTINO IMPACT AREA . . . . . . OWNER YUANDAN LOU ADDRESS 10.210 VICKSBURG CT CITY/STATE/ZIP . . . : CU:?ERTINO CA, 95014-3331 RECEIVED FROM YU.\NDAN LOU CONTRACTOR LIC # *OWNER* COMPANY YUWDAN LOU ADDRESS 10210 VICKSBURG CT CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3331 TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY kMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ------ 1BCBSC VALUATION 5, 000 . 00 1. 00 0 .00 1 . 00 0.00 1BSEISMICR VALUATION 5, 000 .00 0 .50 0 . 00 0 . 50 0 . 00 1DEMOPRE EACH 1 .00 291. 00 0 .00 291 . 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 292 . 50 0 . 00 292 .50 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 292 . 50 me --------------- TOTAL RECEIPT 292 . 50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ------------- 704 DEMO OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPART-HENT•BUILDING DIVISION its 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333.1wilding(alcupertino.org CUPERTINO Dear Property Owner(s): An application for a building permit has been submitted in,/our name listing yourself as the builder of the property improvements specified at: SITE ADDRESS W V9PKZ1 APN BP# Q Z O set.nC OWNER NAM OWNER ADDRESS Y ,J2A+� L_o v ( F S al t�� C-pu r, Cu(1 etc;w-- A � -t !:� DESCRIPTION OF WORK: o 0L^0 L- 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 heving 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 indicati:d. An agent of the owner cannot execute this notice unless you,the property owner, obtain the prior approval of the p:rmitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION )F INFORMATION (DIRECTIONS:Please read and initial each statement be ow to signify you understand or verify this information.) Y. L.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 tie 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. Y,�=_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. y-�. 3. I understand as an"Owner-Builder' I am the r3sponsible 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. YL C 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. .C5. 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 lav/. Y,1, 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. Y 117. 1 understand under California Contractors'State License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with tie intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structure 3 does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. Y.L. 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 subsequent owner(s)that result from any latent construction defects in the workmanship or materials. OwnerBuilderForn?_2010.doc revised 04/14/10 my ions 7< <.9. 1 understand I may obtain more information rega dnistrationblthe Californ a Department of Benefit Payments, Revenue Service,the United States Small Business and the California Division of Industrial Accidents.2Ioalso Nu'nd r cand I for con oreanformatolnoabout Ilicensedrs' Sta e License Board (CSLB)at 1-800-321 CSLB ( ) contractors. ermit applied for in my name, and understand that I Y, L,10. I am aware of and consent to an Owner-Builder building p 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 financi ll�responsible -Builders or this well proposed emploconstruction activity, 1 will abide by all applicable laws and requirements that govern deletions, or changes any of the Y 12. I agree tonotify the issuer this form Licensed cony ract�s are gulatedf any ,by laws des gned o prootect the public. If information I havea provided on this form. LBoard may be le to you contract with someone who does not have cenr as a eesult of aContractors' complaintt Your onlyeemedy against unli bensed if an aassist you with any financial loss you may s Contractors may be in civil court. It is also important for you to understand t,you may unlicensed Contractor be held liable damages. If employee of that individual or firm is injured while working on your prow illbe responsible for verifying whether or not you obtain a permit as Owner-Builder and wish to hire Contractors,y those Contractors are properly licensed and the statuE of their workers'compensation insurance coverage. CONSTRUCTION LENDINGAGENCY ctio,i lending agency information.) (DIRECTIONS:Please complete the following constru nt/for the performance of the work for which this permit is issued I hereby affirm that there is a construction lending age (Sec 3097 Civ.) Lender Name: Lenc er Address: permit can be issued,this form mu.-;t be completed and signe7r�Vn:he ty owner:an Before a building p g p of the rriver's lice,returned to the agency responsible for issuin the permit. Note:A co y pform notarization, or other verification acceptable to the city may be required to tae prepermit iuedto veri the ro ert owner's sin ure. ( �1 � Property Owner's Signature: owner only when designating an - -------------------------------- ------------------------------------------------------------------------------------- (NOTE: The following Authorization Form is required to 5e completed by the property Y agent of the property owner to apply for a construction p mmit for the Owner-Builder). AUTHORIZATION OF AGENT TCI ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner,the execution cf which I understand is my personal responsibility, I hereby authorize the following person(s)to act as my agent(s)t:)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: Tel No Name of Authorized Agent: Address of Authorized Agent: the address he I declare under penalty of perjury that I am the property owner f the for o erty owner's dridverb's license,ove and )form notarization, orpersonally filled out other above information and certify its accuracy. Note:A cop y o p p owners verification acceptable to the city may be required to be presented when the permit is issued to verify the property signature. Date: Property Owner's Signature: OwnerBuilderFonn_2010.doc revised 04/14/10 CITY OF CUPERTINO FEE ESTIMATOR--BUILDING DIVISICDEMOLITION ADDRESS: DATE: REVIEWED BY: APN: BP#: *VALUATION: $5,000 —� ;*PERMIT TYPE: Demolition Permit PI I ", C X11:{'K t)Pty PRIMARY Swimming Pool, Res. --T PENTAMATION 1 SFPOOLDEM USE: 9 PERMIT TYPE: WORK SCOPE FEE ID #POOLS 1DEMOPRES 7T—T A!c,h, f'Lo+ Moo Gl_°cit. P�rnt+.�<<' I'lr ., . P<• rtuf L`i'e I,icc Pt- rtzlf lc'c. NOTE: Thesefees are based on the preliminary in ormation+available and are only an estimate. Contact the Dept for addn'l info, FEE ITEMS (Fee Resolution 09-05I Elf ?il%IO) FEE QTY/FEE MISC ITEMS P/on Cltf'c A 1"c": slfpp/l N /'cc Permit Fee: $29'1.00 Suppl. Insp. Fee O Reg. 0 OT r 0.0 hrs $0.00 Pllnnlz;�,11cci1.:'I:fcc Unit F(T." P/tsrrth. 11�c/r.L1;1rc� Perfild �t)i1,ti1t7tL'i73)t1 1 e7:1 + 5 ,Ic°c�osFic c¢t 1t81'1e=�ti -Ec�: iL'cark 1titTrolrt 1'�zlr�rit' Irore=l l}qac rr�rter�ttrrlic�rr 1�`c't's: Strong Motion Fee: IBSEISMICR $).50 Select an Administrative Item Bldg_Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $292.501 $0.00 TOTAL FEE: $292.50 Revised: 9/14/2010 CITY OF C;UPERTINO I `vY. DEMO 'CUPE1�T]NO PERMIT APPLICATION FORM oy Date: Building Address: 102-10 VtcrsS cl Co10 CL4��R7�N� Mailing Address (if different from building addre 3s): Owner's Name: Phone: Y�A�,ri 0A,3 L© L 43T Contractor: Phone : ©5 Fax: Contractor License #: Cupertino Business License#: Phone: Contact: Fax: Residential f Sq Footage Commercial ❑ Sq Footage Job Description: e00 Valuation: S o Project Size: Express ❑ Standard ❑ Laige ❑ Major ❑ Please complete relevant portions of the Gree:1 Building Checklist & attach it to the application or if applicable, include on the plan set & the sheet index. Quantity Fee ID Fee Df scription Fee Group Permit Type 1DEMORES Demo-Residential B 1SFDWL-DEM j 1DEMOPRES Pool Dehio Residential B 1SFP00L-DEM7 1BCBSC Cal Bidg Standards B ALL PERMIT Commis:ion Fee TYPES 1BSEISMICRE Seismic Residential B Revised 01/07/09