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10040128 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 883 S TANTAU AVE CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO: 10040128 OWNER'S NAME: LIN PAN&LIHUI WANG DATE ISSUED:04/20/2010 PHONE NO: QER'S PHONE: 4089311339 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG f— ELECT PLUMB License Class Lic.# MECH I- RESIDENTIAL r- COMMERCIAL Contractor Date JOB DESCRIPTION:KITCHEN CABINETS REMODEL(200SQ)&CHANGE 5 I hereby affirm that I am licensed under the provisions of Chapter 9 WINDOWS (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. I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$2000 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:37538043.00 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 to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DA OM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Z_/, v _f 9.18. Issued by. Date: Sienature Date OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to any roofing material being installed.If a roof is I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for the following two reasons: inspection. 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, Signature of Applicant: Date: Business&Professions Code) 1,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). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(x)should I store or handle hazardous material. 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 I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. 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 Owner or authorized a nt: O become subject to the Worker's Compensation provisions of the Labor Code,I must Imo, _ Date: forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter u-^-the above mentioned property for inspection purposes.(We)agree to save Lender's Address .nify 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 g—ting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Signature_t'-, �� P, Date / Licensed Professional W `T!.fid��0�0 s 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: S83 c5 Tan k Ave , C BERMIT# 0 0 OWNER'S NAME: '11111111`n n PHONE# 40tg , 31 — 3 3 GENERAL CONTRACTOR: OwvW r bui def' BUSINESS LICENSE# ADDRESS: CITY/ZIPCODE: *Our municipal code requires all businesses working in the city 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 SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature 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 i CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 37538043 . 00 DATE ISSUED. . . . . . . : 04/20/2010 RECEIPT # . . . . . . . . . BS000010227 REFERENCE ID # 10040128 SITE ADDRESS 883 S TANTAU AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER LIN PAN & LIHUI WANG ADDRESS 883 S TANTAU AVE CITY/STATE/ZIP CUPERTINO, CA 95014 RECEIVED FROM . . . . : LIN PAN CONTRACTOR TBD - TO BE DETERMINED LIC # 00096 COMPANY TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . CITY/STATE/ZIP TELEPHONE . . . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- - 1BCBSC VALUATION 2, 000 . 00 1. 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 2, 000 . 00 0 . 50 0 .00 0 . 50 0 . 00 1REMRESKIT SQ FEET 200 .00 570 . 00 0 .00 570 . 00 0 . 00 1WINREP EACH 8 1.00 380 . 00 0 . 00 380 . 00 0 . 00 ---------- ---------- ---------- ------ TOTAL PERMIT 951.50 0 . 00 951 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- - CASH 951.50 --------------- TOTAL RECEIPT 951. 50 O � A CD qI �� C \ /' ov 4 7 � Q � r, � D N 0 t W 4 � A 4Z900 N w N + -4- o L� LZBaLZ9 f+C#1"HSIf:' '; �4Z8 Z1706M Zb0£M b605 NF` '1Zb I zm NakN r- k. ,LZ LZ -- ..E£ 4 Z- ,+,' -..bZ-------.I 00 _ w f t . :--� � - I `� � ��'� � ��\\� ® � � �\���� �\\ �; �\�� , �, it _ li I� i I I IIII i/� \`C �/ _I I _ i � 7 _ 4 .- r` r� �..; -� � i r-, � � ,,, � i o-- CITY OF CUPERTINO -` ADDITION/REMODEL CUPCITY Of EkTINO PERMIT APPLICATION FORM Date: to Is a 2" unit being added? Yes ❑ No 0 If yes, please fill out the permit application for 2" unit. Building Address: 393 S. TaKfAI,, A m �•'t-i�n o Mailing Address (if different from building address): Owner's Name: �, p h A / Phone# n r n l �,�,�, A n Contractor: Phone#: /A Fax #: Contractor License#: Cu ertino Business License#: Contact: Phone#: Lan PAYS Fax#: `T l Building Permit Info: e Bldg. Elect. El plumb. ❑ Mech. ❑ Hillside Job Description: Addition-What is being added?(Be Specific): U Cy,,d,'qei re n ogel C.i.ro s f vie, wi nd�s What is being remodeled (not including addition)? Remodel Includes Re-Roof. Yes ❑ No If yes list number of squares Remodel Includes Structural: Yes ❑ No 9 Do you have the pre-application planning approval? Yes ❑ No V If yes, please provide a -.opy of your plannin approval letter. Planners name: Square Footage: Addition: Porch: Deck: Garage: Detached Attached Remodel: Kitchen 2©O Bath Other Type of Construction(Usage Class): Occupancy Type: 1-A, I-B ❑ II/III/V-A ❑ II/III B, IV-HT,V-B Valuatio Please check this box if the project is a OI 8 0 + �-On = a2�-v o second-story addition ❑ Project Size: Express ❑ Standard El Large ❑ Ma'or❑ 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. ***For Office Use Only*** Revised 07/06/09 Over-the-Counter ❑ CITY OF CUPERTINO ADDITON/REMODEL FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type S Ft DECKS 1R3SFDADD OR 1R3SFDREM I DECKWOOD Deck (Wood)-Each B (Each) 1 DECKRAIL Deck Railing-Each B (Each) GARAGES 1R3SFDADD OR DETACHED 1R3SFDREM 1GARDTW<=1K Wood Frame up to B 1,000 SF (each) 1 GARDTM<=1 K Masonry up to 1,000 SF B (each) 1BCONSTAXR Construction Tax Res (new detached garage) PATIO'S OPEN 1R3SFDADD OR 1R3SFDREM 1PATIOWOOD Wood Frame up to 300 B SF IPATIOMETAL Metal Frame up to 300 B SF 1PATIOOTHER Other Frame up to 300 SF B PATIO'S CLOSED 1R3SFDADD OR & SUN ROOMS 1R3SFDREM IPATIOENCLW Enclosed Wood up to 300 B SF 1PATIOENCLM Enclosed Metal up to 300 B SF 1PATIOENCLO Other Enclosed Patio up B to 300 SF 1 COVPORCH Porch Covered-Each B (Each) REMODELS 1R3SFDREM IREMRESKIT Kitchen Remodel up to B (Deduct "$"for ea plan 'L Q o 300 SF check IREMRESBAT Bath Remodel up to 300 B " SF 1 REMREOTH Other Remodel up to 300 B " SF CITY OF CUPERTINO ADDITON/REMODEL FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type Sq Ft 1 REMRES2 Remodel Residential B Greater than 1000 sq ft 1REMRES3 Remodel Residential B Greater than 2500 sq ft. 1REROOFRES Residential Re-roof Each B 100 SF REMODEL PLNCK 1 STPLNCK(1-3 for Standard Plan Check B NOT FOR OVER THE remodel) COUNTER PLAN CKS. WINDOW/SLIDING 1R3SFDREM GLASS DOOR 1 WINREP Replacement windows B (ea 8 windows) 1 WINNEWNSTR New Window (non- B structural 1 WINMEWSTR New Window (Structural B Shear Wall/Masonry) 1 WINBAYSTR Bay Window (Structural) B SKYLIGHTS 1R3SFDREM 1 SKYL<10 SF Skylight less than 10 sf B 1 SKYL>1 OSF Skylight greater than 10 B sf or structural 1STAIRS Stairs-first flight/ea addt'1 B IEPERMITFEE Electrical Permit Fee E 1 MPERMITFEE Mechanical Permit Fes M 1 PPERMITFEE Plumbing Permit Fee P 1 ELCPLNCK Stand Alone Electric Pln E Ck (hourly) CITY OF CUPERTINO ADDITON/REMODEL FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type Sq Ft 1 MECPLNCK Stand Alone Mechanical M Pln Ck (hourly 1 PLMPLNCK Stand Alone Plumbing P Pln Ck (hourly) 1BCBSC Cal Bldg Standards B ALL PERMIT TYPES Commission Fee 1 BSEISMICRE Seismic Residential B 1 TRAVDOC Travel &Documentation B 1BUSLIC Business License B OVMER-BUILDER DISCLOSURE FORM / =AX 7717-K-32- 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 ADDRESSG11taLc A VQ APN 3 7� 3�U3 BP# OWNER NAME ,1 rad I` , L ��Q. OWNER ADDRESS Q \� �an-�0.�{ Av"e . DESCRIPTION OF WORK: G-{ ra 'S VV'njowS 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 INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) L•P "'�. 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 property. I 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. L•P��. I 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. L,f�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. L.P . 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 ($500), including labor and materials, I may be considered an "employer" under state and federal law. L I��� I understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. L P 1.•'''17. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. L0'8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. Ovia7erBuilderForm_2010.doc revised 04/12/10 L• 4$�I understand I may obtain more information regarding my obligations as an "employer"from the Internal F�evenue 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.csib.ca.gov for more information about licensed contractors. � L 0. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that Ahe part legally and financially responsible for proposed construction activity at the following address: $3 5 Tanta Ay-e G -Ern o LT.lPti. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide y all applicable laws and requirements that govern Owner-Builders as well as employers. I •t A-42. 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 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 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 fending 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 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 agency is required to be presented when the permit is issued to verify the p2eerty owner's signature. Signature of property owner: - 4 Date: /2, AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF (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 for the Owner-Builder). 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 of the owner's driver's license, form notarization, or other verification acceptable to the agency is required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderFonn_2010.doc revised 04/12/10