15090129 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1575 JAMES TOWN DR CONTRACTOR:SHAW JENG-REN AND PERMIT NO: 15090129
TAY SIOK HUANG ET
OWNER'S NAME: SHAW JENG-REN AND TAY SIOK HUANG ET 1575 JAMESTOWN DR DATE ISSUED:09/21/2015
OAVNER'S PHONE: 4089738697 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
DEMO(E)SWIMMING POOL&BACKFILL(FOR LANDSCAPE
License Class Lic.# PURPOSES ONLY)
Contractor Date
I 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.
I hereby affirm under penalty of perjury one of the following two declarations: Sq.Ft Floor Area: aluation:$5500
t 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 APN Number:36610095.00 Occupancy Type:
performance of the work for which this permit is issued.
z 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
permit is issued. PERMIT EXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR
I certify that I have read this application and state that the above information is 180 D FROM LAST CALLED INSPECTION.
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 1 i v"� qLol
I i�
upon the above mentioned property for inspection purposes. (We)agree to save Issued by: LvO JI[l� Date: 1
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 with RE-ROOFS:
all non-point source regulations per the Cupertino Municipal Code,Section 9.18.
All roofs shall be inspected prior to any roofing material being installed. 11'a roof is
Sianature Date installed without first obtaining an inspection,1 agree to remove all new materials for
Sianature
inspection.
OWNER-BUILDER DECLARATION Signature of Applicant: Date:
I hereby affirm that 1 am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
the following two reasons:
t. 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 HAZARDOUS MATERIALS DISCLOSURE
/�sale(Sec.7044,Business&Professions Code) 1 have read the hazardous materials requirements under Chapter 6.95 of the
2.11,as owner of the property,am exclusively contracting with licensed contractors to California Ilealth&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
construct the project(Sec.7044,Business&Professions Code). compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(x)should 1 store or handle hazardous material.
I hereby affirm under penalty of perjury one of the following three declarations: Additionally,should I use equipment or devices which emit hazardous air
1 1 have and will maintain a Certificate of Consent to self-insure for Worker's contaminants as defined by the Bay Area Air Quality Management District I will
Compensation,as provided for by Section 3700 of the Labor Code,for the maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
performance of the work for which this permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
z 1 have and will maintain Worker's Compensation Insurance,as provided for by Owner or aur orized 7t;�J
Section 3700 of the Labor Code,for the performance of the work for which this Date:
permit is issued.
iio3. 1 certify that in the performance of the work for which this permit is issued,I shall CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued(Sec.3097,Civ C.)
become subject to the Worker's Compensation provisions of the Labor Code,I
Lender's Name
must forthwith comply with such provisions or this permit shall be deemed
revoked. Lender's Address
APPLICANT CERTIFICATION ARCHITECT'S DECLARATION
I certify that I have read this application and state that the above information is I understand my plans shall be used as public records.
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 Licensed Professional
upon the above mentioned property for inspection purposes.(We)agree to save
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 with
all non-point source regulations/per the Cupertino Municipal Code,Section 9.18.
Date � /
SWIMMING POOL I SPA PERMIT APPLICATION
C COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 51159M 1 5C)l0 la l
(408)777-3228• FAX (408)777-3333•building(a cupertino.orq
CUPERTINO
PROJECT ADDRESS APN 4
-Y /
tLdin V.
ON'NERNAME "A PHONECL 4617 EMAILsiokhuan �' �na�t�•
STREET ADDRESS CITY, STATE,ZIPtJ 14 FAX
115V3 5AWS _e Q
corrrAcr NAME
E PHONE '� Sf�tL
STREET ADDRESS CITY STATE, ZIP L) ^� ' r F•`
515 JOM h �/T 4-
OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSETYPE BUS.LIC k
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
i , M ECIiENcANEER NAME LICENSE NUMBER BUS LIC#
)N1PANY NAME
E-MAIL FAX
>TREET ADDRESS
CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK
USE OF ❑ SFD or Duplex ❑ Multi-Family TYPE MATERIAL TYPE(CODE) AREA (SQ.FT.) VALUATION (5)
STRUCTURE: ❑ Commercial POOL
POOUSPA MATERIAL TYPE CODES: SPA
V - VINYL-LINED - -
F - FIBERGLASS DEMO
G - GUNITE
P - PREFABRICATED RECEIVED Bl' sl Y TOTAL VALUATION.
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property o\mer's behalf. I have read this
application and the information I have provided is 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 relating to building construction. I authorize tatives of Cupertino to enter the above-identified property for inspection purposes
Signature of Applicant/Agent L - ___ Date
SUPPLEMENTAL INFORMATION REQUIRED OFFICEUSEONLY
PLANCHECKIN"PE
_Commercial or Multi-Family Buildings with Public Swimming Pools:
Department of Environmental Health approval required. <I\'I:It-TnF-c'cn]rER -1 131 n DING nrPl
❑ EXPRESS ❑ 1'I.\>\Itis;UFI'I
❑ STANDARD ❑ 1'1111II A�ORKS DITI
❑ LARGE ❑ L\\IRONNIENTALHGV.-III
❑ NIA,IOR SANITARY SEIVER DISTRICI
SwimPoolApp_2011.doc revised 03/16/11
CITY OF CUPERTINO 150611)19 I D
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 1575 JAMESTOWN DR DATE: 09/21/2015 REVIEWED BY: PAUL
APN: 366 10 095 BP#: `VALUATION: $5,500
°PERMIT TYPE: Demolition Permit AA (•1 -:'Cll 1 ))
PRIMARY Swimming Pool, Res. PENTAMATION 1SFP00LDEM
USE: PERMIT TYPE:
WORK Demo E swimming pool & backfill For Landscape Purposes Only)
SCOPE
FEE ID #POOLS
1 DEMOPRES 1
;ilech. Man Che-
Fr
her
,,
Other , Lj Lj
NOTE: This estimate does not include fees due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the preliminarl information available and are onh,an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-033 EfL' 71 "13) FEE QTY/FEE MISC ITEMS
�'lutr ( '11(-ck I•C L
`'ullhl. PC Fee
I'lunth. 1lc'ch
Permit Fee: $329.00
Suppl. Insp. Fee:Q Reg. Q OT 0.0 hrs $0.00
Phunb. .Vlerh. L•lc
Plumb. : fech./Elee Perm
oustructilm 1(L1.
.1(hnini•slrulivr Fre:
Work 66ithoul Pernul?
Aelvcrnced Planning Fees:
lrclvcl I.)o('tltnrn (Il on /'Ce,S:
Strong Motion Fee: IBSEISAIICR $0.72 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $330.72 $0.00 TOTAL FEE: 1 $330.72
Revised: 07/02/2015
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
\ 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228 • FAX(408)777-3333 • buildino(Qcuoertino.org —
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 / ^ fq�o APN /o�� BP# ) O
OWNER NAM O 7 OWNER ADDRESS
DESCRIPTION OF WORK: 1/►'
Intl n c - < v " colu
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.)
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.
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.
4�k_L3. 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.
t, 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.
b. 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.
6. I understand if I am considered an "employer" under state and federal law, I must register with the state and
ederal 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.
J�W_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 alt 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.
6A8. 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.doe revised 04/14/10
e-19. 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.cslb.ca.gov for more information about licensed
contractors.
0-IS-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 proposed construction activity at the site address listed above.
6)�111. 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.
112. 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 si nature.
Property Owner's Signature: Date:
- -------------------------------------------------------------------------------------------------------------
e The following Authorization Form is required to be completed by the property owner only when designating all
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 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:
OwnerBuilderForm_1010.doc revised 04114/10
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SMOKE / CARBON MONOXIDE ALARMS
2-NI
OWNER CERT0CATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT^ BUILDING DIVISION
Cd.9P'E9TTkNO 10300 TORRE AVENUE o CUPERTINO, CA 95014-3255
(408)777-3228 a FAX(408)777-3333• building(a)-cupertino.org
fiN &N-1At K504
` c�ess �S �Pri+/t �o�� �Q �yl I #�� ��R� n � i o��:
PERMIT CANNOT BE FINALED AND COMPLETED UNTIL THIS CERTIFICATE
HAS BEEN 819N—M, ANT RETiTRNED TO THE BUILDING DIVISION
PURPOSE
This affidavit is a self-certification for the installation of all required Smoke and Carbon Monoxide Alarms for
compliance with 2013 CRC Section R314, 2013 CBC Sections 420.6 and 907.2.11.2 where no interior access for
inspections are required.
GENERAL INFORMATION
Existing single-family and multi-family dwellings shall be provided with Smoke Alarms and Carbon
Monoxide alarms. When the valuation of additions, alterations, or repairs to existing dwelling units exceeds
$1000.00, CRC Section R314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon
Monoxide Alarms be installed in the following locations:
AREA SMOKE ALARM CO ALARM
Outside of each separate sleeping area in the immediate vicinity of the X X
bedroom(s)
On every level of a dwelling unit including basements X X
Within each sleeping room X
Carbon Monoxide alarms are not required in dwellings which do not contain fuel-burning appliances and that
do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with
CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal.
Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated.
In existing dwellu-ig units, alarms are permitted to be solely battery operated where repairs or alterations do
not result in the removal of wall and ceiling finishes or there is no access by means of attic,basement or crawl
space.Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electricaAabove
e,; ed for
alarms which must be connected to the building wiring. �-
-
As owner of the above-referenced property, I hereby certify that the alarm(s) reference /have been
installed in accordance with the manufacturer's instructions and in compliance with the California Buildung
and California Residential Codes. The alarms have been tested and are operational, as of the date signed
below.
I have read and agree to coaly with the terms and conditions of this statement
�QeNneiv(or_O.wner,4gent`s)=Name "_-�
-IM
...
Dafe.
Contractor Name:
Smoke and CO form.doc remised 03/18/14
WATER-CONSERVING PLUMBING FIXTURES
OWNER CERTIFICATE OF COMPLIANCE
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
CUPERTINO 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333• building(a)cupertino.org
Owner Name a1 C—N4- KC-� 5HAW Permit No. I ��
Address 15��� 5_/0A-5 It9UJA1 Piz . CO Ato. GA q;v I
1. Is your real property a registered historical site?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
X No Go to Question 2.
2. Does your real property have a licensed plumber certifying that, due to the age or configuration of the property or its
plumbing,installation of water-conserving plumbing fixtures is not technically feasible?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply.
❑ The licensed plumber's certification has been provided to the Building Division.
Skip the rest of the form and sign bottom of form.
K No Go to Question 3.
3. Is water service permanently disconnected for your building?
❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
N No Go to Question 4.
4. Is your real property built and available for use or occupancy on or before January 1, 1994?
❑ No My real property is built and available for use or occupancy after January 1, 1994.
Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form.
l Yes My real property is built and available for use or occupancy on or before January 1, 1994,
Civil Code Sections 1101.1 through 1101.8 apply. Check one of the three following statements and sign
bottom of form..
5. Please check ONE of the following:
My property is a single-family residential real property. See Civil Code Section 1101.4.
On and after January 1, 2014, building alterations or improvements shall require all non-compliant plumbing fixtures
to be replaced with water-conserving plumbing fixtures throughout the building. On or before January 1,2017, all non-
compliant plumbing fixtures shall be replaced with water-conserving plumbing fixtures (regardless of whether
property undergoes alterations or improvements).
❑ My property is a multifamily residential real property. See Civil Code Section 1101.5.
On and after January 1, 2014, specified building alterations or improvements shall require non-compliant
plumbing fixtures to be replaced with water-conserving plumbing fixtures.
On or before January 1,2019, all non-compliant plumbing fixtures shall be replaced with water-
conserving plumbing fixtures throughout the building(regardless of whether property undergoes altprati,.-
improvements).
❑ My property is a corr777iercial real property. See Civil Code Section 1101.5. 9 ��-
On and after January 1, 2014, specified building alterations or improvements shall require non- c
plumbing fixtures to be replaced with water-conserving plumbing fixtures.
On or before January 1, 2019, all non-compliant plumbing fixtures shall be replaced with water- conserving
plumbing fixtures throughout the building(regardless of whether property undergoes alterations or improvements).
I,as the owner or owner's agent of this property, certify under penalty of perjury that non-compliant plurnbing fixtures will be
replaced prior to date specified above with water-:conserving plumbing fixtures in accordance with Civil Code Sections 1101.1
through 1101.8,the current California Plumbing Code and California Green Building Standards Code, and manufacturer's
installation requirements, and that the water-conserving plumbing fixtures comply with the requirements as indicated in the
table on the following page.
Owner or Owner Agent's Signature: Date:
Upon completing and signing this Certi icate,please return it to the Building Division in order to final your building permit.
SB4072015.doc revised 08126/15