10070040 CITY OF CUPERTIPIO BUILDING PERMIT
BUILDING ADDRESS: 10847 NORTHRIDGE SQ CONTRACTOR:AMERICAN HOME PERMIT NO: 10070040
RENEWAL INC
NER'S NAME: WENYUAN CHIEN 310 SHAW RD STE A DATE ISSUED:07/06/2010
OWNER'S PHONE: 4083090023 S SAN FRANCISCO,CA 94080 PHONE NO:(650)553-9054
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r— PLUMB
License Class Lic.#
MECH f- RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REPLC 3 EXSTNG PATIO DOOR&2 WINDOWS W/ENERGY
(commencing with Section 7000)of Division 3 of the Business&Professions EFFICIENT WINDOWS.THE PATIO DOORS WILL BE DONE AS
Code and that my license is in full force and effect. NEW CONST&THE WINDOWS WILL BE RETROFIT.ALL JOBS
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:$5200
permit is issued.
APPLICANT CERTIFICATION APN Number:31636032.00 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: G�
" 'iture 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). j• )`C- 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 O nerau rized
forthwith comply with such provisions or this permit shall be deemed revoked. Date: l
!J_C„
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
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
the above mentioned property for inspection purposes.(We)agree to save
_unify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source legulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signatur� Date L Licensed Professional
61 c.
CITY OF CUPERTINO
FEE ESTIMATOR-- BUILDING DIVISION
ADDRESS: DATE: REVIEWED BY:
APN: BP#: "VALUATION: Iso
YPERMIT TYPE: Building Permit PLA N CHECK TYPE: Alteration /Addition / Repair
PRIMARY SFD or Du lex OVER THE APPLICATION 1R3SFDADD/REM
USE: p COUNTER. Yes No TYPE:
MECHANICAL Q Yes 0 No PLUMBING Q Yes Q No ELECTRICAL o Yes Q No
xW
cc
3C-)
TYPE OF FLR AREA
OCCUPANCY TYPE: CONSTR. sq.ft. PC FEES PC FEE ID BP FEES BP FEE ID
R-3 (Custom) II-B,111-B,IV,V-B 0 $0.00 $0.00
TOTALS: 0 $0.00 $0.00
NOTE: Theseees are based on the preliminairTv in ormation available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 09-051 Ftp' 7,,-'l 09) FEF, QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 ET] # Window/Sliding Glass Door
Suppl. PC Fee: Reg. OT 0.0 hrs $0.00 $380.00 I WINREP Replacement
--1
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Feer Reg. 0 OT 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Acoustical Fee: 0 Yes Q No $0.00 0
Work Without Permit? Q Yes (E) No $0.00 E)
Planning Fee: $0.00 Select a Non-Residential E)
Building or Structure 0
Strom Motion Fee: $1100 Select an Administrative Item
Bld�_, Stds Commission Fee: $).00
SUBTOTALS: $0.00 $380.00 TOTAL FEE: $380.00
Revised: 6/30/2010
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIP RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blt: Lot:
APN . . . . . . . . : 31536032 . 00
DATE ISSUED. . . . . . . : 07/06/2010
RECEIPT #. . . . . . . . . : BSD00010781
REFERENCE ID # . . . : 1070040
SITE ADDRESS . . . . . : 10347 NORTHRIDGE SQ
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : WENTYUAN CHIEN
ADDRESS . . . . . . . . . . : 10347 NORTHRIDGE SQ
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : WEV-YUAN CHIEN
CONTRACTOR . . . . . . . : MARC STELZER LIC # 22705
COMPANY . . . . . . . . . . : AMERICAN HOME RENEWAL INC
ADDRESS . . . . . . . . . . : 310 SHAW RD STE A
CITY/STATE/ZIP . . . : S SAN FRANCISCO, CA 94080
TELEPHONE . . . . . . . . : (650) 553-9054
FEE ID UNIT QUANTITY kMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 5, 200 . 00 1 .00 0. 00 1. 00 0 . 00
1BSEISMICR VALUATION 5, 200 . 00 0 .60 0 . 00 0 . 60 0 .00
1WINREP EACH 8 1. 00 380 . 00 0 . 00 380 . 00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 381 .60 0 .00 381 .60 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 381 .60 MC
---------------
TOTAL RECEIPT 381.60
I,-S-N-Z, CITY OF .,UPERTINO
CM of
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # .� Date: Z
Buildin Address:
Mailing Address (if different frbuilAng address):
Are Hazardous Materials being used as part of this project? Yes No
HOA: (Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA
Owner's Name: Phone#:
Wen�ia Y? Che YI �f_ 2-> 4
Contractor: Phone: ' C 2, Z
h h1 � TOC L Fax: (� �' }
Contractor License#: 74_o_5-J� _777Cupertino Business License#:
Contact: Phone:
�_. Fax:
Residential Commercial El
Job Description:
#rxt,e fi�S 3 piXiS �s ! � ponr5 � Z (.Jz�lduCvS ✓..�� �,��
A� nes,,-- LeSt, O
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Building Permit Info:
Bldg fff Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A 1-B II/III/V-A II/III B, IV-HT, V-:3 0`
Valuation: Square Footage:
Project Size: Express Standard ❑ Large Major ❑
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.builditgrcen.or
Revised 07/14/09
INPUT Resources • 1ADIHeafth
M.Indoor Air Quality and Finishes
1.Use Low/No-VOC Paint 1 IAQ/Health pts y=yes 0
2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0
3.Use Low/No VOC Adhesives 3 IAQ/Health pts y=yes 0
4.Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0
5.Use Engineered Sheet Goods with no added Urea
Formaldehyde 61AQ/Health pts y=yes 0
0
6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes
7.Seal all Exposed Particleboard or MDF 4 IAQ/Health. pts y=yes 0
B.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0
9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0
10.Install Whole House Vacuum System 3 IAQ/Health pts y—yes 0
1 1 6
N.Flooring
1.Select FSC Certified Wood Flooring 3 Resource pts y=yes 0
2.Use Rapidly Renewable Flooring Materials 4 Resource 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 IAQ/Health pts y=yes 0
5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0
6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0
6 E �
Total Points Available: 1401 130 57
Total Points Project Received: 0 0 0
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OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPAR FMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333•,:�ii�i-i�u�a_ -ti�_.�-
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 Y �1 APN BP#
O r )'� Q svr
OWNER NAME OWNER ADDRESS
e t G /
o r >
DESCRIPTION OF WORK: - Y rkkl
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 ha✓ing 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 pE!rmitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
&)L0. I understand a frequent practice of unlicensed )ersons is to have the property owner obtain an "Owner-
Builder" building permit that erroneously implies that ti-a 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 actinc as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my prop":rty.
W,L,2. I understand building permits are not required+o be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
r)_C.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.
gL(:�4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
0,C,5. I understand if I employ or otherwise engage a-iy persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred c ollars($500), including labor and materials, I may be
considered an "employer"under state and federal law.
& ._L.6. I understand if I am considered an "employer" ender state and federal law, I must register with the state and
federal government, withhold payroll taxes, provide wc,rkers'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.
G�1,LJ. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with this intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures Joes not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general bL ilding Contractor.
dtJ L& 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 suCsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderForm 2010.doe revised 04/14/10
W.L.9. 1 understand I may obtain more information rE!garding my obligations as an "employer"from the Internal
Revenue Service, the United States Small Business,Ndministration,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 www.csib.ca.gov for more information about licensed
contractors.
/o1,(_,10. 1 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 pr)posed construction activity at the site address listed above.
x_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.
AJ_( 12. I 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 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 complaints Your only remedy against unlicensed
Contractors may be in civil court. It is also important fir you to understand tk�at 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 constructicn 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: Lenc er 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 pe-mit. 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: O o
(NOTE: The following Authorization Form is required to b9 completed by the property owner only when designating an
agent of the property owner to apply for a construction pe.mit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of,vhich 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 o`the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be pr9sented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
OH,rnerBuilderForm 2010.doc revised 04/14/10