15120179CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: 15120179
11107 LINDA VISTA DR CUPERTINO CA 95014 (356 06 019)
OWNER/BUILDER
22129 RAE IN
OWNER'S NAME: XING MIN
DATE ISSUED: 03/11/2016
OWNER'S PHONE: 617 -659 -2262
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lic. #
Contractor OWNER /BUILDER Date 03/11/2016
—BLDG _ELECT _PLUMB
MECH RESIDENTIAL COMMERCIAL
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.
JOB DESCRIPTION:
INSTALL (N) DECD AT REAR (135 SF); REMODEL (2)
I hereby affirm under penalty of perjury one of the following two declarations:
BATHROOMS (99 SF); ADD (N) BATHROOM AND CLOSET ON
1. I have and will maintain a certificate of consent to self - insure for Worker's
2ND FLOOR (67 SF); ADD (N) LAUNDRY ROOM AND CLOSET
Compensation, as provided for by Section 3700 of the Labor Code, for the
(25 SF); CONVERT (E) UNDER STAIR CLOSET TO (N)
performance of the work for which this permit is issued.
POWDER ROOM (19 SF); CONVERT (E) LAUNDRY ROOM TO
2. I have and will maintain Worker's Compensation Insurance, as provided for
NEW ENTRY WAY (NEW DOOR)
by Section 3700 of the Labor Code, for the performance of the work for which
this permit is issued.
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above
Sq. Ft Floor Area:
Valuation: $100000.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and hereby
Number:
Occupancy Type:
authorize representatives of this city to enter upon the above mentioned
56
3 06 019
356
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
PERMIT EXPIRES IF WORK IS NOT STARTED
comply with all non -point source regulations per the Cupertino Municipal
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Code, Section 9.18.
180 DAYS FROM LAST CALLED NS T CTION.
Signature Date 03/11/2016
'
Issued by: ALEX VALLELUNGA
OWNER - BUILDER DECLARATION
Date: 03/11/2016 r
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE- ROOFS:
following two reasons:
r. I, as owner of the property, or my employees with wages as their sole
All roofs shall be inspected prior to any roofing material being installed. If a roof is
compensation, will do the work, and the structure is not intended or offered
installed without first obtaining an inspection, I agree to remove all new materials for
for sale (Sec.7044, Business & Professions Code)'
inspection.
I, as owner of the property, am exclusively contracting with licensed
'
contractors to construct the project (Sec.7044, Business & Professions Code).
Signature of Applicant
Date: 03/11/2016
I hereby affirm under penalty of perjury one of the following three declarations:
r. I have and will maintain a Certificate of Consent to self - insure for Worker's
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
2. 1 have and will maintain Worker's Compensation Insurance, as provided for
HAZARDOUS MATERIALS DISCLOSURE
by Section 3700 of the Labor Code, for the performance of the work for which
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
this pen-nit is issued.
Ja. , I certify that in the performance of the work for which this permit is issued, I
�,- `
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the
material. Additionally, should I use equipment or devices which emit hazardous
Worker's Compensation laws of California. If, after making this certificate of
air contaminants as 'defined by the Bay Area Air Quality Management District I
exemption, I become subject to the Worker's Compensation provisions of the
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Labor Code, I must forthwith comply with such provisions or this permit shall
the Health & Safety Code, Sections 25505 5533Aand4,,
be deemed revoked.
i'i
APPLICANT CERTIFICATION
owner or authorized agent:'/
1 certify that I have read this application and state that the above information is
Date: 03/11/2016
N R LENDING E
correct. I agree to comply with all city and county ordinances and state laws
I hereby affirm that there is c struction lending agency for the performance
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relating to building construction, and hereby authorize representatives of this city
for inspection (We) agree
of work's for which this pe is issued {Sec. 3097, Civ C.)
to enter upon the above mentioned property purposes.
Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
Lender's Address
consequence of the granting of this permit. Additionally, the applicant
understands and will comply with all non -point source regulations per the
ARCHITECT'S DECLARATION
Cupertino Municipal Code, Sectio :18.
I understand my plans shall be used as public records.
Signature1' Date 03/11/2016
Licensed
Professional
—
M
CCNSTRUCTION PERMIT APPLICATIasi
10300TORRE AVENUE - CUPERTINO, CA 95014-3255 ti
(408) 777-3228 • FAX (408) 777-3333 • bui1dino(a-=t)erCino.ora
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By my s;Enazure below, I certify to each or the following: I am the property o-v,-,)cr or autthori7ed aLtnt to act on the prop,., y ov,-ner's behalf I have YcFd this
application and the information I have provided is c=, tct. I age,.to -comply with P-11 applicable local
ordinances and state !a-vvs relpting to buildling Ccristru tio- [Authoriz'- /V tSe1nt--i'Vr;s -of Cupertino to enter the above-ide-riti-5-
L o- prop--T-,y ior Inspection purposes.
A Date: U7—
Si---nature of Ao-olicant/A.Rent:
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SUP PLEIA.-ERNITAL i SQL
IME 50,
2
'New SFD' orMuhif= ily d- I;n,-S: Apply for dcmolition -p=nit or
existing building s), De-molition pe,a-,nit is r--qu,r-.d prior toiSs"Ll-ancr--of bull ding
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permit for new building
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Co7-nIerc:al,Bldgs: Provide a comxplet5d Hazzard6us Materials Disclosure-
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if any I-,TazajjOu5 1�4 aleri a! s are being us --d as pan o f thi S proj -�ot.
Copy or Planning Approval Lefler or 2-Mlecting with Planning prior to.
subrninal ofBj_1iIdir-,a P---.,,-iit application.
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do c rev is ed 06121111
__ CITY OF CUPERTINO
FFF ESTIMATOR — BUILDING DIVISION
ADDRESS: 11107 Linda Vista
FEE
DATE: 1212112015
REVIEWED BY :''Phuong
APN: 356 06 019
BP #:
*VALUATION:
$100,OOD
} °PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY
SFD or Duplex
USE:
hrs
PENTAMATION
PEitMIT TYPE: 1GENRES
WORK
To Clear Code. Enforcement Case:
SCOPE
_
_
Fe,
-ch.
Li
NOTE: This estimate does not
fees due to other Departments (i.e. Planning,
the Works, Fire, Sanitary Sewer Disi
ool
—A ed on the relimina information available and are only an estimate. Contact the ue t or aaan c info -
zstrzct, a c..
FEE ITEMS (Fee I ?esolution .1.1 -013 Ef. 7!1113
FEE
QTY /FEE
MISC ITEMS
Plan Check Fee:
$0,00
1 #
$503.00
Deck / Deck Railing
IDECKWOOD Deck (wood)
Suppl. PC Fee: (D Reg. C) OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
1 1 85J s.f.
$645.00
Remodel, Bath (< =300 sfl
IxEMRESBAT
Permit Fee:
$0.00
Suppl. Insp. Fee: Reg. 0 OT
0,0
hrs
$0.00
# Window /Sliding Glass Door
$431.00 IWrnRn Replacement
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
{ c'? 0A,
Work Without Permit ?' Q Yes cQ, No
$1,579.00
Advanced. Plannin Fee:
$0.00
Select a Non- Residential
Building or Structure
Q
0
Strong Motion Fee: IBSEISMICR
$13.00
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$4.00
VBTQTALS;'
$1,596.00
$1,579.00 TOTAL FEE:
$3,175.00
nevisea: W/U uzv ru
CUPERTINO
OWNER- BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 • build inana cuoer lno.ora
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:
51 T E ADDRE55 ( /. /v / f In(� q . V fs ; ...iAPN.
��p 0 a� BPS / t..� 2 0 i 7
OWNER NAME \ .:...- .. \ _ ...
N r Nog
OWNER ADDRESS !
.....// ..: �3? /ZP Rae L� • � c�I �,ir1 Q , c�'
DESCRIPTION OF WORK: a 464 r- NAG✓
We are providing.you with an Owhe�- BuilderAckhowledgment 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.)
7fYM1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
Buii[, er" building permit that erroneously implies that the property owner is providing his or her own labor and material
pe ovally. I, as an Owner - Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an licensed person and his or her employees while working on my property. My homeowner's insurance may not
pr ;bride coverage for those injuries. I am willfully acting as an Owner - Builder and am aware of the limits of my
in ance coverage for inj'aries to workers on my property.
Jprtritl� 12. I understand. building permits are not required to be signed by property owners unless they are responsible for
onstruction 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
ct mys elf from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
n fibers on permits and contracts.
5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
' to al value of m construction is at least five hundred dollars $500 including labor and materials I may be
Y ( )� 9 Y
considered an "employer" under state and federal law.
6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and
feHral government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
u 11 e1 ployment compensation for each "employee." I also understand my failure to abide by these laws may subject
m - b serious financial risk.
I . 7. 1 understand under California Contractors' State License Law, an Owner - Builder who builds single - family
re rtlential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
Iioensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is rformed under contract with a licensed general building Contractor.
8. 1 understand as an Owner - Builder if I sell the property for which this permit is issued, I may be held liable for
a yfinancial 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 04114110
4,
9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal
nue Service, the United States Small Business Administration, the California Department of Benefit Payments,
ie California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
se Board (CSLB) at 1 -800- 321 -CSLB (2752) or v✓vnv.cslb.ca.gov for more information about licensed
actors.
10. 1 am aware of and consent to an Owner- Builder building permit applied for in my name, and understand that I
ie party legally and financially responsible for proposed construction activity at the site address fisted above.
11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
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
nation-) 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 maybe in-civil court. Ifis also important foryou-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 note
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 signature.
Property Owner's Signature: Date:
---------------------------------------------------------------------------------------------------------------------------------------------
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the properly 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: 1/107 1 11 d a �/ r 5 �( '� (mil � Pi N (� 7 1 f4
Name of Authorized Agent: �� !T� A �-f—v Tel No
Address of Authorized Agent: ` I
I declare under penalty of perjury that I am the property owner for the address listed above and I ersonally ouit(e
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: M ��� Date: 12"91
OwnerBuilderForm 2010.doc revised 04114110