15060115CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20336 NORTHBROOK SQ
CONTRACTOR: FANG -YIN WENDY KUO
PERMIT NO: 15060115
OWNER'S NAME: FANG -YIN WENDY KUO
20336 NORTHBROOK SQ
DATE ISSUED: 06/17/2015
OWNER'S PHONE: 4087506160
CUPERTINO, CA 95014
PHONE NO:
13 LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
ADD MASTER BATHROOM (24.5 S.F.)
License Class Lic.#
REV#I - REMOVE LVL BEAM FROM SCOPE OF WORK IN
Contractor Date
(E) MASTER BEDROOM
I hereby affirm that 1 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
Sq. Ft Floor Area:
Valuation: $10000
performance of the work for which this permit is issued.
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: 31639013.00
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. 1 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 FROM LAST CALLED INSPEC IO .
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:
Signature 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.
Z OWNER -BUILDER DECLARATION
Signature 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
I, 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)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I 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:
Health & 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 1 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 Health & Safety Code, Sections 255 5, 25533, aid 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
p
Owner or authorized agent:
1 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, 1
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby 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
upon the above mentioned property for inspection purposes. (We) agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand 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
Licensed Professional
9.18.
Signature
CONSTRUCTION PERMIT APPLICAT
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building (c cuDertino.o
❑ NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/T1 REVISION / DFLLLJED
ORIGINAL PERMIT m
PROJECfADDRESSGU Z -RT / a C'1,
2.933.E A10 -5,Q,
APN4
3i'61'a-?9- o/
OWNER NAME'I fi N4 ^ \ I V /� / PHONE E-MAIL
AI D l V v 21
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STREET ADDRESS CITY, STATE, ZIP
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FAX
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CONTACT NAME D N �D PHONE �d O
11,j4(ATL
STREET ADDRESS
,Z9� �1 �rr� sr tills
CITY, STATE, ZIP
�uNIV I VALE c,9 01
FAX
OWNER OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME a / ^
LICENSENIUMBER N/ n
LICENSETYPn
BUS. LIC k %4
///rJ
/ JN
�7
COMPANY NAME
E-MAIL
FAX xi//,CI
STREET ADDRESS /V
CITY, STATE, ZIP . / % Q
!/N/ / /
PHONE 'X1 4
ARCHITECT,ENGLNEER NAME LICENSE NWBER
BUS. LIC f/
COMPANY NAME V / n
E-MAIL / n
FAX
STREET ADDRESS /I
I
CITY, STATE, ZIP All
PHONE/ % q
✓� / ,I
DESCRIPTION OF WORK
_ kEf'LJ6V& ✓L iAl NAA E,< e��A,"6011 ,4-1 o
W�Rk ,
EXISTNG USE
PROPOSED USE CONSTR TYPE
9 STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION (S)
FXLSTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
-
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK ARE
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
❑ ATTACH
DWELLII.G UNrrS:
ISASECOND UNIT El YES
SECOND STORY ❑YES
BEINC AD DED? El NO
ADDITION? El NO
PRE -.APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
- U 7 E'J" kY" ij v ry
"', � II�k b
is;
TOTAL VALUATION:
PLANNING APPLE ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
uta t��d
t v, a
By my signature below, I certify to each of the following: I am the property owner or authoriz d agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to bui i nstru authorize representatives of Cupertino to enter the above -id ntified property fer inspection purposes.
Signature of Applicant/Agent Date: 6��
SUPPLEMEN AL INFORMATION REQUIRED
mfg <a� di TLA (`HiCICd'1 F� ly ha i
d t: raf � .,vROT17-IAC-SI,LP�s��a onCa�if� r'`4
New SFD or Nju[tifamily ciNvellings: Apply for demolition Permit for
" i
��-
'+Kd;�
T>✓�y;I
7NrCy Cl 1
O��PIP;gg�I��r,,?�RRI^
��l��^
`Yx�r„1
C[S° C+'"2L, 4NeWXFI
iFii�^+"r I,1h+'S�ra
existingo building(s). De.molition permit is required prior to Issuance of buildln�
k'9ir,p l1
tr 'i
rFTt?wHk l2'"i
t
kI,3L'"T'IL'I'D �2`EV��
for new building
.�""4ar
d Fpermit 5� uh �r`t `
Y�
tr
Pi 417sIz.r�ri�n x V[Dw I���
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
,y, f rt rI,IJmIT gry Til ry7ary1
❑ S DARI7b
❑ T)BtTC'R OE S,�P n`x �, yy4�' i Vf lex.
tx,
form if any Hazardous Materials are being used as part of this project.
LARC,L4 e.r �r i'f � ±�"�'� I k a !✓
❑r ;RII2N pE1 Tli � � spa rr 'nri � k
� � �
_ Co of Planning, Approval Letter or Meeting with Plasmin prior to`n�d
PY � PP � P
6 rIF���
Q §ANTT�ri] 5L 1 CRDIS CItIGi
submittal of Building Permit application.
,?s ,,i,�1 l rry� rr'* � (,,����,l�,�r�"',�wr�,�rt��
�t�'�i ��r,�?;� '�+,�ts�ir��,��F`",���,^� s2�IV
Clr`Lo\niEt` IAs rrE aurrl, ,-]s
BldgApp_2011.doc revised 06/21/11
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 `��� j
(408) 777-3228 - FAX (408) 777-3333 • buildingna,cupertino.org
❑ NEW CONSTRUCTION ❑ ADDITION C■i ALTERATION / Ti ❑ REVISION / DEFERRED ORIGINAL PERMIT #
PROJECTADDRESS20336 Northbrook Sq, Cupertino, CA
APN"316-39-013
OWNERNAME Fang -Yin Wendy Kuo
PHONE 408)750-6160
E-MAIL wkuo@hotmail.com
STREET ADDRESS 966 Aster Ct
CITY, STATE, ZIP Sunnyvale, CA 94086 FAX n/a
CONTACT NAME Rudy Tanoto
PHONE 408)598-0789
E-MAIL rudytanoto@hotmail.com
STREET ADDRESS 1298 Heatherstone Way
CITY, STATE, ZIP Sunnyvale, CA 94087
FAX n/a
❑ OWNER IN OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME n/a
LICENSE NUMBER n/a
LICENSE TYPE n/a
BUS. LIC # n/a
COMPANYNAME n/a
E-MAIL n/a
FAX n/a
STREET ADDRESS n/a
CITY, STATE, ZIP n/a
PHONE n/a
ARCHITECT/ENGINEER NAME n/a
LICENSE NUMBER n/a
BUS. LIC # n/a
COMPANY NAME n/a
E-MAIL n/a
FAX n/a
STREET ADDRESS n/a
CITY, STATE, ZIP n/a
PHONE n/a
DESCRIPTION OF WORK
Alteration of townhome to add master bedroom with no changes to total square footage
and no changes to exterior
EXISTING USE
PROPOSED USE
CONSTR. TYPE
d STORIES
2
USE
TYPE
OCC.
SQ.FT.
VALUATION ($)
residential
residential conventional
EXISTG
AREA 1062 sf
NEW FLOOR
AREA 1062 sf
DEMO
AREA 0
TOTAL
NET AREA 1 062 S
BATHROOM
REMODF-L AREA 24.5 sf
KITCHEN
RC fODFI., AREA 0
OTHER
REMODEL AREA 0
PORCH AREA DECK AREA TOTAL DECKTORCH AREA I GARAGE AREA: LJ DETACH
0 0 0 462 sf NA"ACH
t
#_6 1NdUNITS: ISA SECOND UNIT ❑ WS I SECOND STORY ❑YES
1 BEING ADDED? ONO ADDITION? ONO
PRE -APPLICATION ❑YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
IVED BY.
TOTAL VALUATION:
PLANNING APPL # ONO PLANNING APPROVAL LEITER
EICHLF,R HOME,? ENO
z
23LU,6
a/ 1000
By my signature below, I certify to each Qfthe following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information, Wave provi&N correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws rela fn to b ng cons cNn. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Appl icant/Agent: �'s? ' — µ~ — Date: 6/15/2015
SUPPLEMENTAL INF NATION REQU[RED
PLAN CHECK TYPC
ROUTING SLIP
oVER.TH&COUNTER
❑ BIVILDINGPLANREVIEW
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ EXPRESS
❑ PLANNING PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
❑
❑
LARGE
FIRE DEPT
Copy of Planning Approval Letter or Meeting with Planning prior to
❑
11
submittal of Building Permit application.
MAJOR
SANITARY SEW$RDTSTRICT
❑ ENVIRONMENTAL HEALTH
BldgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20336 NORTHBROOK SQ
CONTRACTOR: TtV— 0-11rt
PERMIT NO: 15060115
DET- nip44
OWNER'S NAME: FANG -YM WENDY KUO
r
DATE ISSUED: 06/17/2015
OWNER'S PHONE: 4087506160
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
ADD MASTER BATHROOM (24.5 S.F.)
License Class Lie.tl
Contractor Date
1 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.
1 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
Sq. Ft Floor Area:
Valuation: $10000
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
APN Number: 31639013.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 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
ISO DZ FROM LAST CALLED INSP TI?N.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
L r
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:
Signature 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
Signature of Applicant: Date:
1 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
I, 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)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
1 hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & 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 Cu ert'no Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Section's 553 d 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agin . Date:
permit is issued.
----7 -
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 Califomia. If, after making this certificate of exemption, l
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby 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
upon the above mentioned property for inspection purposes. (We) agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
non- ions per the Cupertino Municipal Code, Section
ip
all non�m r
Licensed Professional
9 ltg
w
Sig �natur�"" Date 6 17
.,
PA-M
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc). These fees are based on the preliminary information available and are only an estimate Contact the Dept jor addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/13)
ADDRESS: 20336 Northbrook Sq. DATE: 06/17/2015
APN: 316 39 013 BP#:ly)w 1151:
REVIEWED BY: Paul
*VALUATION: j$10,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex
USE: p
PENTAMATION
PERMIT TYPE: 1 R3SFDRE
WORK
Add Master Bathroom 24.5 S.f.
SCOPE
Suppl. PC Fee: C) Reg. Q OT
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc). These fees are based on the preliminary information available and are only an estimate Contact the Dept jor addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 7/1/13)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
=s.f.
$645.00
Remodel, Bath (<=300 sf)
IREMRESBAT
Suppl. PC Fee: C) Reg. Q OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee -.0 Reg. Q OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Work Without Permit? Yes Q No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
0
i
1r,rtcl (;�c��.�r�.�ri����lrzr(r:�x d°�,r�,..
Strong Motion Fee: IBSEISMICR
$1.30
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
bit TALS:
$2.30
$645.00 TOTAL FEE; '
$647.30
Revised: 0510712015
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildinq[>)cupertino.orq
Dear Property Owner(s):
An application for a building permit ha`s'bee
improvements specified at:
F" listing yourself as the builder of the property
Building Upirtment
SITE ADDRESS BP#
OWNER NAME /1 OWNER ADDRESS r �)r,'�x }
�CPhy-yip 2n � D FOR C ,_ C046At �„<, f �U/7� �%�
DESCRIPTION OF WORK:
A'Le� 12L -'D a,V /i9a5y5 7— hedrogen /7r0 -�o -D-ta f �
We are providing you with an Owner -Builder Acknowledgment and Information Vri c ` ion Form to m/ �' `a
akeC you warr
e of -����,,,,,,m
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.)
�41. 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.
V '2. 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 responsible party of record on the permit. I understand that I may
rotect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
'L4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
� 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
t tal 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�
,J�/u 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 also understand my failure to abide by these laws may subject
me to serious financial risk.
1�7. 1 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.
. 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.
OwnerBuilderForm 2010.doc revised 04/14/10
9. I 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.Gslb.ca.gov for more information about licensed
contractors.
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.
_�C11. 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.
r
�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 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 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 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-sigrtWure.
Property Owner's Signatur'. Date:
(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).
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. t � wll of --� v G dd f, A_� �-er-
Scope of Construction Project (or Description of Work): ��"1�� �.
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,� t' 6`6d� iif;� C,. P $,dk,���� '",�
Project Location or Address: Jam;76 /Vo �kbroe2k S
Name of Authorized Agent: (,{�� Vf�) f D Tel No�c
Address of Authorized Agent: ) 2 � � �"� ewG 464< y 7`m e o ) atj ri ��� ,,V 7
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 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: 0
OwnerBuilderForm 2010.doc revised 04/14/10
Northpoint Homeowner's Association
10880 Northpoint Way
Cupertino, CA 95014
Off. (408) 996-3734 Fax: (408) 996-0226
nianamkt r norlln2gi nt hoa. con i
/E L.OF'ME N 7' M ENT
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I L D �
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APPROVED CUPERTINO
MU".Jte kept at t,��e Building department
ctlorl. It i�
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June, ny N
ns ()rl JUN 17 2015
to cjov,�3te
'OM 13Lj!c!i11g offj(j,11.
S
arid HAL1 REVIEWED FOR CODE COMPLIANCE NOT
To)yhY�A �Pficbro.
.9rpJ _,a of the mlatlorl Reviewed By:
Ondl7,srrce or Stale
On TW,,�da Lee resented the board with plans of re -modification
��untube.
h- �e i , -ft om adiMg-a-big edro
to t y c1
We have no objection to his plans — they have been approved Mr. Yau-Shing Lee his re -
modification plans.
Interim GMC C-CKED BY
Northpoint HOA ,
DATE L .- i 7, 2-0
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IN�, `N� I N1 G D E PT
PE"�Fl T I N