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10070018 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10265 VIRGINIA SWAN PL CONTRACTOR:PETER'S CONSTRUCTION PERMIT NO: 10070018 OWNER'S NAME: CHAI-FEN JAIN 100 CONCORD CIR DATE ISSUED:07/01/2010 N1ER'S PHONE: 4082559447 MOUNTAIN VIEW,CA 94040 PHONE NO:(650)906-8788 ❑ LICENSED CONTRACTOR'S DECLARATION 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:REMODEL BATHROOM(55SQFT) (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:$3500 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 permit is issued. APN Number:31646017.00 Occupancy Type: APPLICANT CERTIFICATION 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply l with all non-point source regulations per the Cupertino Municipal Code,Section Issued ��' �� Date 9.18. Signature Date RE-ROOFS: OWNER-BUILDER DECLARATION 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 I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). �T I hereby affirm under penalty of perjury one of the following three) HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safety Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&Safety Code,Sections 25505,25533,and 25534. 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 O r r dor Jani- Compensation laws of California. If,after making this certificate of exemption,I Date: become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoCONSTRUCTION LENDING AGENCY IT I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lender's Name 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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, ,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION ..ring of this permit.Additionally,the app' ant understands and will comply I understand my plans shall be used as public records. with all non-point sou regulations per upertino Municipal Code,Section 9.18. Licensed Professional k) Signature ,,._ Date CITY OF CUPERTINO FEE ESTIMATOR--BUILDING DIVISION ADDRESS: DATE: REVIEWED BY: APN: BP#: "VALUATION: Iso xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex OVER THE 1 APPLICATION 1 R3SFDADD/REM USE: p -7COUNTER. 0 Yes No TYPE: MECHANICAL Q Yes (F) No PLUMBING 0 Yes 0 No ELECTRICAL Q Yes 0 No xw � a cc 3 �d OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR. (S41A.) R-3 (Custom) II-B,111-B,IV,V-B 0 $0.00 $0.00 TOTALS: 0 $0.00 $0.00 1'Y7 I 0 ' U"'_, iW' 1J;fr i'turv`. Ing tsar NOTE. Thesefees are based on the preliminary in ormation available and are only an estimate. Contact the Dept-for addn'1 info. FEE ITEMS (Fee Resolution 09-051 Ef: T'l/091 FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 1 s.f. Remodel, Bath(<=300 sf) Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 $570.00 1REMRESBAT PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Feer Reg. 0 OT 0.0 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 0 No $0.00 0 Planning e: $0.00 Select a Non-Residential 0 Building or Structure Strong Motion Pee: $0.00 Select an Administrative Item Bldg Stds Commission Fee: $).00 SUBTOTALS: $0.00 $570.00 TOTAL FEE: 1 $570.00 Revised: 6/30/2010 CITY OF CUPERTINO ADDITIOw/REMODEL CUPERTINO FEE SCHEDULE APN# Date: Is a 2nd unit being added? Yes ❑ No ❑ If yes, please fill out the permit application for 2" unit. Building Address: Mailing Address (if difterent from building address): Owner's Named Phone# : C��G� � �-.�� 'j Contr tor, Phone#: Fax#: Cupertino Business Licens _ State Contractor License#: Contact: r— Phone#: C` v'�� i�L Fax#: Landscape Ordinance Compliance: Landscape area in sq. ft. (includes all irrigated ar gas): .,A,- If 2,500 sq. ft. or less, compliance with the Landscape Water-Efficiency Checklist is required. If more than 2,500 sq. ft., a complete Landscape Project Submittal is required. Compliance Method: ❑ Plant Type ] Water Budget Building Permit Info: Bldg. [2' Elect. Er Plumb. Mech. Hillside ❑ Job Description: Addition-What is being added?(Be Specific): What is being remodeled(not including addition;? b1 Y&&,;I,,, Remodel Includes Re-Roof. Yes ❑ No E] If yes list number of squares Remodel Includes Structural: Yes ❑ No 51 Do you have the pre-application planning apr roval? Yes ❑ No If yes, please provide a copy of your planning approval letter. Planners name: Square Footage: Addition: Porch: Deck: Garage: Detached Attached Remodel: Kitchen Bath Other Type of Construction(Usage Class): Occupancy Type: 1-A, 1-B ❑ II/III/V-A ❑ IUIII B, IV-HT, V-B Valuation: Please check this box if the project is a Project Size: Express ❑ Standard ❑ Large ❑ la'or ❑ second-story addition ❑ Please complete relevant portion of the Green Building Checklist& attach it to the application or if applicable, Green Building Points Achieved: include in plan set& the sheet index. Revised 05/18/10 CITY OF CUPERTINO 2 ITEMS OF 2 PERMI`C RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blit: Lot: APN 31546017. 00 DATE ISSUED. . . . . . . : 07 /01/2010 RECEIPT #. . . . . . . . . : BS)00010764 REFERENCE ID # . . . : 10 )70018 SITE ADDRESS . . . . . : 10265 VIRGINIA SWAN PL SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER CH%I-FEN JAIN ADDRESS 10265 VIRGINIA SWAN PL CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : GWD HANN JAIN CONTRACTOR . . . . . . . : PErER WANG LIC # 25511 COMPANY PET'ER' S CONSTRUCTION ADDRESS . . . . . . . . . . : 100 CONCORD CIR CITY/STATE/ZIP . . . : MOJNTAIN VIEW, CA 94040 TELEPHONE . . . . . . . . : (650) 906-8788 FEE ID UNIT QUANTITY kMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 3, 500 . 00 1. 00 0. 00 1 . 00 0 . 00 1REMRESBAT SQ FEET 1. 00 570 .00 0. 00 570 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 571 .00 0 .00 571. 00 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 571. 00 #2623 --------------- TOTAL RECEIPT 571 .00 RESIDENTIAL PROTECT COVER SHEET Assessor's Parcel Number: Name of owner. J a i & Project address. J V 1Cl/'✓� �a �' 17 r� Contact person. / i�' Vk hone. Fax. Net square footage of lot. Existing Proposed Square footage: First floor: �— Second floor: Garage: TOTAL: - Are there at least two 10 foot by 20 foot clear spaces ins'.de the garage? Is privacy protection planting required for the project? ry— —N— Build it Green Total Points On what floor(s) is work being done? _ Brief description of work. Code editions:2007 CBC -N)2007 CFC N)2007 CMC �N) 2007 CPC (Y ' N)2007 NEC N) Effective 1/1/08 I LJ� Plan Review Process Work Book Page-8-Revised 8/05/08 r� �� W N - \ -• N `J r � 4 T V � ----�. rz, PA-00 M OWNER-BUILDER DISC_OSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINC, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333• ��iia aim ?i�_ J 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, r1, j ` �rl� i�.1�1� APN BP# oD�h�l OWNER NA E V (J OWNER ADDRESS � U�. C DESCRIPTION OF WORK: 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 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 indicatod. An agent of the owner cannot execute this notice unless you,the property owner, obtain the prior approval of the pormitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS:Please read and initial each statement bel:)w to signify you understand or verify this information.) -Z1. 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 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 prop3rty. 2. 1 understand building permits are not required :o be signed by property owners unless they are responsible for Ithe coo truction and are not hiring a licensed Contrac-or to assume this responsibility. 7 3. 1 understand as an"Owner-Builder" I am the rE s onsible art of record on the permit. I understand that I may P party protect myself from potential financial risk by hiring a I censed Contractor and having the permit filed in his or her name instead of my own. __L1 I understand Contractors are required by law t) be licensed and bonded in California and to list their license numbers on permits and contracts. V5. I 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 _L,/6. I 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 a Iso understand my failure to abide by these laws may subject me to serious financial risk. . I understand under California Contractors' Sta a License 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. v. 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 sut Sequent owner(s)that result from any latent construction defects in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 -L—/9. I understand I may obtain more information regarding my obligations as an "employer"from the Internal Revenue Service,the United States Small Business Ac ministration,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 wrvw.cslb.ca.gov for more information about licensed contractors. V 10. 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 proposed construction activity at the site address listed above. _Z11. 1 agree that, as the party legally and financial)-i 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 con tractors are regulated by laws designed to protect the public. If you contract with someone who does not have a licen:e, 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 worth ing 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 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 mus: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 si nature. Property Owner's Signature: Date: 5 -- ---------------------------------------------------------------- ---------------------------------------------------------------------- (NOTE: The following Authorization Form is required to b)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)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 c 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. 7 L Mr, Property Owner's Signature: Date: OwnerBuilderFonn 2010.doc revised 04/14/10