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10080130 CITY OF CUPERTINO BUILDING PERMIT UILDING ADDRESS: 11456 LINDY PL CONTRACTOR:ISHAN WU PERMIT NO: 10080130 WNER'S NAME: ISHAN WU 11456 LIN DY PL DATE ISSUED:08/19/2010 4ER'S PHONE: 4082558890 CUPERTI VO,CA 95014 PHONE NO: LICENSED CONTRACTOR'S DECLARATION F [- r BUILDIr G PERMIT INFO: BLDG ELECT PLUMB cense Class Lic.# MECH r RESIDENTIAL I— COMMERCIAL ontractor Date hereby affirm that I am licensed under the provisions of Chapter 9JOB DES CRIPTION:PATIO DOOR&WINDOW REPLACEMENT SINGLE PANE :ommencing with Section 7000)of Division 3 of the Business&Professions TO ode and that my license is in full force and effect. DOUBLE P ANE hereby affirm under penalty of perjury one of the following two declarations: have and will maintain a certificate of consent to self-insure for Worker's ompensation,as provided for by Section 3700 of the Labor Code,for the -rformance of the work for which this permit is issued. have and will maintain Worker's Compensation Insurance,as provided for by motion 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Flo(.r Area: Valuation:$26500 ermit is issued. APPLICANT CERTIFICATION APN Num ger:35624009.00 Occupancy Type: certify that I have read this application and state that the above information is )rrect.I agree to comply with all city and county ordinances and state laws relating ►building construction,and hereby authorize representatives of this city to enter pon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED ►demnify and keep harmless the City of Cupertino against liabilities,judgments, )sts,and expenses which may accrue against said City in consequence of the WTI,HIN 180 DAYS OF PERMIT ISSUANCE OR ranting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. pith all non-point source regulations per the Cupertino Municipal Code,Section .18. Issued by: Date: %��(Q ignature Date ) OWNER-BUILDER DECLARATION f'� RE-ROOFS: hereby affirm that I am exempt from the Contractor's License Law for one of All roofs s►all be inspected prior to any roofing material being installed.If a roof is he following two reasons: installed w ithout first obtaining an inspection,I agree to remove all new materials for as owner of the property,or my employees with wages as their sole compensation, inspection. +ill do the work,and the structure is not intended or offered for sale(Sec.7044, tusiness&Professions Code) Signature of Applicant: Date: as owner of the property,am exclusively contracting with licensed contractors to onstruct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER hereby affirm under penalty of perjury one of the following three(-) eclarations: HAZARDOUS MATERIALS DISCLOSURE have and will maintain a Certificate of Consent to self-insure for Worker's ;ompensation,as provided for by Section 3700 of the Labor Code,for the I have rea d the hazardous materials requirements under Chapter 6.95 of the erformance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& ection 3700 of the Labor Code,for the performance of the work for which this Safety Cole,Section 25532(a)should I store or handle hazardous material. Additiona Hy,should I use equipment or devices which emit hazardous air ermit is issued. contamins.nts as defined by the Bay Area Air Quality Management District I will 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 of employ any person in any manner so as to become subject to the Worker's Health& Safety Code,Sections 25505,25533,and 25534. 'ompensation laws of California. If,after making this certificate of exemption,I ecome subject to the Worker's Compensation provisions of the Labor Code,I must Owner aborized agent: mthwith comply with such provisions or this permit shall be deemed revoked. �.�� Date: 7 v APPLICANT CERTIFICATION 60 CONSTRUCTION LENDING AGENCY certify that I have read this application and state that the above information is I hereby a1 firm that there is a construction lending agency for the performance of work's orrect.I agree to comply with all city and county ordinances and state laws relating for which his permit is issued(Sec.3097,Civ C.) :)building construction,and hereby authorize representatives of this city to enter Lender's'.Jame ipon the above mentioned property for inspection purposes.(We)agree to save nnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's.lddress and expenses which may accrue against said City in consequence of the ,ranting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION vith all non-point so e r gulations per the Cupertino Municipal Code,Section A8. 1 understa►id my plans shall be used as public records. signature Date (P' ��I� Licensed 'rofessional CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35624009 . 00 DATE ISSUED. . . . . . . : 08/19/2010 RECEIPT #. . . . . . . . . : BS000011221 REFERENCE ID # . . . : 10080130 SITE ADDRESS . . . . . : 11456 LINDY PL SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . . ISHAN WU ADDRESS . . . . . . . . . . : 11456 LINDY PL CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : ISHAN WU CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . . ISHAN WU ADDRESS . . . . . . . . . . : 11456 LINDY PL CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 26, 500 . 00 2 .00 0. 00 2 . 00 0 .00 1BSEISMICR VALUATION 26, 500 . 00 2 .70 0 . 00 2 . 70 0 .00 1WINREP EACH 8 31 . 00 758 . 00 0 .00 758. 00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 762 .70 0 .00 762 .70 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 762 .70 #1257 --------------- TOTAL RECEIPT 762 .70 i .at .. CITY OF CUPERTINO CUPEkTINO GENERAL BUILDING PERMIT APPLICArHON FORM APN # 2 - 00q - U Date: `T �JO f Building Address: l 6 / i tiD r Fz,jLF, e �,���QT/�l1�', C'� • 9�0 `f' Mailing Address (if different from building address): Are Hazardous Materials being used as part of this project? Yes No HOA: (Exterior work on Yes ❑ No If yes, pr vide letter from HOA Owner's Name: Phone#: Contractor: Phone: Ila& - 3 7 7 -D/9-/ CTT 3 ut i-P&AS Fax: 7 -D Contractor License#: ff�L 3 q5-9 Cupertino Business License#: Contact: D Phone: 06 - 377- / �l f}POE-4l� ,(C I D Fax: Residential Commercial ?,A -r(o DooR Job Description: W I u tDD w R EPGgc F M S1144Z& /0A1\1e 0 1ou84& 40AME Building Permit Info: Bldg 2::-- Elect ❑ Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: 1-A, 1-B ❑ IV-HT II/III/V-A II/III B, V-B_a— Valuation: —Valuation: �. r`D� Square Footage: Project Size: Ex ress St dard ❑ Lar e ❑ r✓Iajor ❑ Green Building: Please complete relevant portion of the green Building/LEED Checklist& attach it to the application or if applicable, include in plan set& the sheet index. Points Achieved: �- For help, contact Build it Green at www.builditareen.or : Revised 07/14/09 CITY OF CUPI,-',RTINO FEE ESTIMATOR— BUILDING DIVISION ADDRESS: DATE: REVIEWED BY: APN: BP#: 'VALUATION: 1$26,500 -PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Addition/Repair PRIMARY SFD or Duplex OVER THE PENTAMATION USE: COUNTER. 0 Yes (D No PERMIT TYPE: WORK L SCOPE OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. s1 R-3(Custom) II-B,111-B,IV,V-B 0 $0.00 $0.00 TOTALS: 0ff$ $0.00Rk"v $0.00 E,- V*Y�LUH� � Q Ties FrO b fl ,o firm "Ir,n('h,rh_ 1.'r`t,;. I/an Cirrxi< f own!Fc,,. ;i/i; r 19`crr/r. fns I' Otiwi.f'/imil.; lrarrFIFL_ (Jlhi•r 1'1(ct Gnq, F-1 L Ih'ch In,., I cc NOTE: Thesefees are based on the preliminary information available-and are only an estimate. Contact the De t or addh7 info. FEE ITEMS(Fee Resolution 09-051 E(f. 7/1./10) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 L31 1 # Window/Sliding Glass Door Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 $758.00 I 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 turr�r,rr,'ti,lt 1"(0, T7 Acoustical Fee: © Yes 0 No $0.00 0 Work Without Permit? 0 Yes 0 No $0.00 0 Planning Fee. $0.00 Select a Non-Residential 0 Building or Structure 0 i Strom?Motion Fee: IBSEISMICR $2.65 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $2.00 SUBTQTAI:S: $4.65 $758.00 TOTAIFI•;E ` $762.65 _ Revised: 8/17/2010 co4 r� l �. �l �✓� V ., � �c��n �wr,r,�[t�• 1• _ r OD 7To 7tI Ln A O 5•ao A C c �c rn n Ell CL "•.,fes' �, 7 O to � o � -, k 4 k_ l 'r roc:~ A. rp cv w sz o � t ~I Y / •tib .O iw ox Z 4th r', ptv fli CYT 0 ID �-v OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333• buildin ;uoertino.orq 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: SITE ADDRESS Al / D p L APN 6 ► Z�.v Jg r p0 BP# OWNER NAME � �� OWNER AD OJ 14 � ES ��ND L/I /�, G CT�AA9 DESCRIPTION OF WORK: O !7 tlb ��'��� �`�` L#eJFA4 5f.4 J6 f 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 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 OF INFO 2MATION (DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.) /A21. 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 prope ty owner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable and sub.ect to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working :)n 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. ,004�. 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. 3. 1 understand as an"Owner-Builder" I am the responsib e 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. AaA. I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. `V5. 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. - �. I understand if I am considered an "employer" under slate 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 und,3rstand my failure to abide by these laws may subject me to serious financial risk. . I understand under California Contractors' State Licen 3e 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 does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 8. I 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 subsequert owner(s)that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 4ev 9. I understand I may obtain more information regarding my obl'gations as an "employer"from the Internal enue Service,the United States Small Business Administration, :he 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.g(iv for more information about licensed contractors. am aware of and consent to an Owner-Builder building pe-mit applied for in my name, and understand that I a the party legally and financially responsible for proposed constriction activity'at the site address listed above. /w11. 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. �12. 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 r:gulated by laws designed to protect the public. If you contract with someone who does not have a license, the Contactors' 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 unde rstand 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.) I hereby affirm that there is a construction lending agency for the pert)rmance 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 must 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. Date: Property Owner's Signature: NOTE: The following Authorization Form is required to be complee(�wne�Builder (_ _ ry_ owner only when designating an agent of the property owner to apply for a construction permit for the ):. AUTHORIZATION OF AGENT TO ACT ON INROPERTY 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, si 3n, 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 listedabove 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 w ien the permit is issued to verify the property owner's signature. Property Owner's Signature: Date' - ownerBuilderForm_2010.doc revised 04/14/10