10080049 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7925 FALL CT CONTRACTOR:BEN CHIA PERMIT NO: 10080049
VNER'S NAME: BEN CHIA 7925 FALL CT DATE ISSUED:08/06/2010
u WNER'S PHONE: 4084316339 CUP?RTINO CA, 95014-5931 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL C1 COMMERCIAL
CI
License Class Lic.# CHANGE 10 WINDOWS LIKE FOR LIKE NON-
STRUCTURAL
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.I t Floor Area: Valuation:$1400
1 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:36213002.00 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
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
(' RE-ROOFS:
nature 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.
OWNER-BUILDER DECLARATION
Sigm.ture of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) L(�
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 ha%a read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 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: Heal:h&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 I:ealth&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this i
�„
Own!r or authorized agenG; �4�-. _ 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
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I herf by 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
n the above mentioned property for inspection purposes.(We)agree to save
mnify 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 I und;rstand 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 Licer sed Professional
9.18.
Signaturex Date
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: LX rT PERMIT#
OWNER'S NAME. °G �ti PHONE# <-
I
GENERAL CONTRACTOR: BUSINESS LICENSE#
i
ADDRESS: C CITY/ZIPCODE:
i
*Our municipal code requires all businesses working in the c ty to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRAYCTO)RS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. )
I am not using any subcontractors:
Signatul•e Date �
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # �
Cabinets & Millwork
Cement Finishing
Electrical
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
Owner/Contractor Signature Date
M.lndDDr Air Quality and Finishes
1.Use LOw/No-VOC.Patnt 1 IAOJF ealth pts yeses 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/F ealth pts y--yes0
3.Use Low/No TOC Adhesives 3 IAQ/E ealth pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resoirce pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 6 IAQ/f lealth pts y--yes0
6.Use Exterior Grade Plywood for Interior Uses 1 lAQ/f i"th pts y=yes 0
7 Seal e l oseel nor OF _._. . _ _ 4 IAQA iealth. is y:-:yes
B.Use FSC Certified Materials for Interior Finish 4 Rescurce pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resc urce pts y=yes 0
10.Install Whole House Vacuum System 3 IMQ,Health pts y--yes, =77t0
1 1 D
N.Flooring
1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0
2.Use Rapidly Renekahle Flooring Materials 4 Resot irce pts y=yes 0
3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0
4.Install Natural Linoleum In Place of Vinyl 5 IAQA iealth pts yeses 0
5.Use Exposed Concrete as Finished Floor 4 Reso,irce pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Reso irce pts y--yes 0
1 1 1
Total Points Available: 1470 130 57
Total Points Project Received: 1 01 0 0
G:data/progslgreenbuilcRn iguidelinesiremodelerslgreenpointsfina1212D4proteetedxls
OWNER-BUILDER DISCLOSL RE FORM
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO,CA 95C 14-3255
(408)777-3228-FAX(408)777-3333-buiidinoi12u2e2110.0rc
CUPERTINO
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:
APN BP#
FSITEDRESS2 r GT— OWNER ADDRES o p C'T' Sa NAME ? e k C i^� r-r_ `
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 having tt is 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. Ar, 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 OF INFORMATION
(DIRE CTI NS:Please read and initial each statement below to signify you understand or verify this information.)
1. ( understand a frequen practice ractice of unlicensed perso is is to have the property owner obtain an"Owner-
Builder"building permit that erroneously implies that the properly owner Is providing his or her own labor and materia
personally. I, as an Owner-Builder, may be held liable and subject to serious fin M cihomeowneral risk ffor an insuries a may notby
an unlicensed person and his or her employees while working on my property. y
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
theconstruction and are not hiring a licensed Contractor to assume this responsibility.
V/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 licens ad Contractor and having the permit filed in his or her
name instead of my own.
V 4.1 understand Contractors are required by law to be icensed and bonded in California and to list their license
numbers on permits and contracts.
5. 1 understand if I employ or otherwise engage any p.;rsons,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.
�6. 1 understand if I am considered an"employer"un&r 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 Li:ense Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the int ant to offer them for sale,unless all work is performed by
licensed subcontractors and the number of structures doe 3 not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
1,/ 8. 1 understand as an Owner-Builder if I sell the prop,;rty for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subset uent owner(s)that result from any latent construction
defects in the workmanship or materials. NnerBuilderForn:_1010.doc revised 04/14/10
�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 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 www cslb.ca.gov for more information about licensed
contractors.
X10. 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 propose d construction activity at the site address listed above.
V/11. 1 agree that, as the party legally and financially re;;ponsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner-Builders as well as employers.
`/12. 1 agree to notify the issuer of this form immediatehr 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 working on your property,you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Con-ractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of tI'eir 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: Lender Ad Jress:
Before a building permit can be issued, this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. vote:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city ma;1 be required to be presented when thepermit is issued
to verifythe roe owner's signature.
Property Owner's Signature: Date:
-
------------------------------------------------ -i------------------------------------------------------------------------------------------
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit fo-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,or, 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 fcr the address listed above and I personally filled out the
above information and certify its accuracy. Note:A copy of the pi operty 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: — f L
Date:
a4we BuilderForm_2010.doc revised 04/14/10
CITY OF CUPEPTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lo'. .
APN . . . . . . . . : 36213002 . 00
DATE ISSUED. . . . . . . : 08/06/2 )10
RECEIPT #. . . . . . . . . BS000011105
REFERENCE ID # 1008004 )
SITE ADDRESS 7925 FALL CT
SUBDIVISION . . . . . . .
CITY CUPERTIvO
IMPACT AREA . . . . . .
OWNER BEN CHIA
ADDRESS . . . . . . . . . . : 7925 FALL CT
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5931
RECEIVED FROM BEN CHIA
CONTRACTOR LIC # *OWNER*
COMPANY BEN CHIA
ADDRESS 7925 FALL CT
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5931
TELEPHONE
FEE ID UNIT QUANTITY AMOUIST PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ------ ---- ----------
1BCBSC VALUATION 1,400 . 00 1. 00 0 . 00 1. 00 0 . 00
1BSEISMICR VALUATION 1,400 . 00 0 .50 0 . 00 0 .50 0 . 00
1WINREP EACH 8 10 .00 5( 6 . 00 0 .00 506 . 00 0. 00
------ ---- ---------- ---------- ----------
TOTAL PERMIT 507.50 0 . 00 507 .50 0 . 00
METHOD OF PAYMENT AMOUNT DEFERENCE NUMBER
----------------- --------------- --- -----------------
CREDIT CARD 507. 50 visa
---------------
TOTAL RECEIPT 507 . 50
Offiffiii
;aCITY OF CUP ERTINO
CITY OF
CUPEkTINO GENERAL BUILDING
PERMIT A.PPLICA.TION FORM
APN # Date: 16
(1-2-0
1 0
Building Address: /y S C� CP �S-o
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this projt ct? Yes No
HOA: (Exterior work only) Yes ❑ No If yes, provide letter from HOA
Owner's Name: - C J ,� Phone ,3
T e✓> vi
Contractor: Phone:
�e �' C � � � Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone:
Fax:
Residential Commercial El
Job Description: Ind a c S c N
Building Permit Info:
' Bldg. Elect ❑ Plumt ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type: 13
1-A, 1-B ❑ IUIII/V-A ❑ II/III B, IV-HT,V-B [ ;-•► -
Valuation: Square Footage:
Project Size: Express D9Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Bu' ding/LEED Checklist& attach it
to the application or if applicable, include in plan set & the sheet index.
oints Achieved: "
For help, contact Build it Green at www.builditgreen.or cy
Revised 07/14/09
i
CITY OF CUP ERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: DiLTE: REVIEWED BY:
tA PN: BP#: 'VALUATION:: $1,400
;'PERMITTYPE: Building Permit PLAN CH ECK TYPE: Alteration /Addition/ Repair
PRIMARY SFD or Duplex APPLICATION 1GENRES
USE: � L.i)�_?/�' l;"�i:,l. TYPE:
XW
� a
cc
3U
F1
FT-1 I T
NOTE: Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS(Fee Resolution 2I-051 Elf %;'1i09) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 10 # Window/Sliding Glass Door
Suppl. PC Fee: E) Reg. O OT 0.0 hrs $0.00 $506.00 1 WINREP Replacement
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Feer Reg. 0 OT ro.0 hrs $0.00
PNIE Unit Fee: $0.00
PME Permit Fee: $0.00
Acoustical Fee: Q Yes Q No $0.00 0
Work Without Permit? Q Yes Q No $0.00 E)
Planning Fee: $0.00 Select a Non-Residential Q
�'t;.lY('%l�n�'1.7N2?1lrN-k7ll 1'Ce'c:
Building or Structure
Strong,Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bids Stds Commission Fee: IBCBSC $1.00
_ fere'. .;.. '. r, _ •:•
SUBTOTALS: $1.50 $506.00 TOTAL FEE• $507.50
Revised: 7/28/2010