B-2016-2572CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:. CONTRACTOR: PERMIT NO: B-2016-2572
7425 HEATHERWOdD DR CUPERTINO, CA 95014-5823 (359 26 045) HOMEOWNER
BUILDER
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OWNER'S NAME: KWAN TERENCE NANG CHONG TRUSTEE & ET AL DATE ISSUED: 08/23/2016
OWNER'S PHONE:
License Class Lic. #
Contractor HOMEOWNER BUILDER 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:
1. 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.
z. 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.
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 upon the above mentioned property for
inspection purposes. i (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 8/23/2016
hereby affirm that I am exempt from the Contractor's License Law for one of the
allowing two reasons:',
1. 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)
I, as owner of the property am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
1. I have and w'ill maintain a Certificate of Consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
perfolmauce''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
permit is issued.
3. 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 California. If, after making this certificate of
exemption, I 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 revoked. F
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 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 re ulations per the Cupertino Municipal
Code, Section 99.1188
Date 8/23/2016
PHONE NO:
BUILDING PERMIT INFO:
BLDG X ELECT _ PLUMB
MECH X RESIDENTIAL _ COMMERCIAL
3 DESCRIPTION:
TEMPORARY POWER POLE (100 AMP); POLE
Sq. Ft Floor Area:
Valuation: $200.00
"N Number: Occupancy Type:
359 26 045
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date: 08/2
RE -ROOFS -
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without fust obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant:
Date: 8123/201
"An
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
a_.I the Health & Safety Code, Sections 25505, 25533, and 25534.
Ow er or authorized agent:
Datd: 8/23/2016
CONSTRUCTION LENDING AGENCY
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.)
Lender's Name
Address
ARCH[TECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
DocuSign Envelope ID 247FB927-A80A-43FA-B32B-238A78DD6430 UPP
GENERAL PERMIT APPLICATIONoil
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COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, GA 95014-3255
idPi RTT IO(408) 777-3228 • FAX (408) 777-3333 e building(c Cupertino orclM isc
CIPLUMBING ❑ MECHANICAL ❑ELECTRICAL ®MISC
ELLANEOUS
PROJECTADDREss. 74.25 Heatherwood Drive - APN4 359-26-045 - - -
OWNER NAME Sar"jah Chart
PHONE 408-421-1080
E-MAIL sarahc@etechfocus.com
STREET ADDRESS 20832 Greenleaf Drive CITY, STATE:ZIP Cupertino, CA 95014 FAX
CONTACT NAME Tracy Hsu PHONE 408-4645030 E-MAIL tracy-hsu@yahoo.com
STREET ADDRESS 22; 30 Santa Paula Ave.
CITY,STATE, ZIP Cupertino, CA 95014
FAX 408-6245425
❑ OWNER OWNER -BUILDER ❑ OWNER AGE'N'T ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ® ENGINEER ❑ DEVELOPER 11 TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC 4
COMPANY NAME
E-MAIL FAX
i
STREET ADDRESS
CITY, STATE, ZIP PHONE
ARCHITECTIENGWEER Nf AME
LICENSE NUMBER BUS. LIC 9
COMPANY NAME
E-MAIL FAX
STREET ADDRESS
CITY, STATE, ZIP PHONE
USE OF ❑ SFD or DUPLEX ❑ MULTI -FAMILY
BUILDING; ❑ COMMERCIAL
PROJECT IN WILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ®YES
URBAN INTERFACE AREA ®NO FLOOD ZONE ❑ NO EICHLER HOME. ❑ NO
DESCRIPTION OF WORK - Temp Power Pole 100 amps
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TOTAL VALUATION: $200
RECEIVED BY;
By my signature below. Y certify to each of the following:. I am the property owner or authorized agent to act on the property owner's beh f. 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 InilC3is@atnsjeuction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
8/22/2016
Signature of Applicant/A, gent: Date:
W_ .INFORM[ATION REQUIRED
O«TCK LSE 01-IV
Q OVER-THE-COUNTER
s'r-MNs
0 LARGE
0 MAJOR
_WEPMiscApp_701 Ldoe revised 06/21/1]
DocuSign Envelope' ID: 7389FI 4B-6072-49B7-AF8D-387281 F30034
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO. CA 95014-3255
(408) 777-3228 - FAX (408) 777-3333 - bu ildiniQiia
CUPERTINO cupertino.oM
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
SITEADDREss 7425 Heatherwood Drive
AFF 359-26-045
BP*
OWNER NAMi Sarah Chan
i ...
01%VNERADDR -
ESS 20832 Greenleaf Drive, Cupertino, CA 9501z
I
DESCRIPTION OF WORK: temp power pole
We are prox?iding 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 iss ue a building permit until you have read, initialed your , understanding of each provision, signed, and
returned thils 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.
?ECTIONS: Please read and initial each statement below to sign, �you understand or verify this information)
DS
,t_ 1. 1: understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Silder",'building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. 1, 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 horneowner's insurance may not
provide coverage for those injuries- I am willfully acting as an Owner -Builder and am aware of ft limits of my
insurance coverage for injuries to workers on my property.
__ 2- 11 understand building permits are not required to be signed by property owners unless they are responsible for
�con$� truction and are not hiring a licensed Contractor to assume this responsibility.
DS
Y 11 understand as an "Owner -Builder" I am the responsible party of record on the permit I understand that 1 may
L
pmlect r,'nyself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
DS
.A. 4. 1. understand Contractors are required by law to be licensed and bonded in California and to list their license
5M,iiberon permits and contracts.
S. 1, understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
idered an "employer under state and federal law.
_(3, I,i understand if I am considered an "employer" under state an
d federal law, 1 must register with the state and
�ral government, withhold payroll taxes, provide workers` compensation disability Iinsurance, and contribute to
mployment compensation for each 'employee.' I also understand my failure to abide by these laws may subject
to serious financial risk.
7. 1 junderstand under California Contractors' State License Law, an Owner -Builder who builds single-family
ental structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
3ed� subcontractors and the number off structures does not exceed four within any calendar year, or all of the work
,formed under contract with a licensed general building Contractor.
C,t.8. JWriderstand 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
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defects in the workmanship or materials.
0vrnerEui1derFonn_2010.doc revised 04/14/10
DocuSign Envelopq ID: 7389FI 4B-6072-49B7-AF8D-387281 F30034
-DS
,t 9. Funderstand I may obtain more information regarding my obligations as an 'employer" from the Intemal
R -venue 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
Licenseboard (CSLB) at 1-800-321 -CSLB (2752) or www.osib.ca.gov for more information about licensed
10 `I am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I
party legally and financially responsible for proposed construction activity at the site address listed above.
1'I 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
-Agy.all applicable laws and requirements that govern Owner -Builders as well as employers.,
c,,� 12.'l agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
-44ormation 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 Contiaclors' Siaie 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
Contraciors 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 C bintractors; are properly licensed and the status of their workers' compensation insurance coverage.
(DIRECTIONS: Please complete the following construction lending agency information.)
1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(See 3097 C,iv.)
Lender Nam�e'. 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 verity the property owner'sDocuSigned by: V22�tfit6
Property Ov4ner's Signature: !n— -11 b - 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).
r_xcluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, 1 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. temp power pole
Scope of Construction Project (or Description of Work):
7425 Heatherwood Drive, Cupertino, CA 95014
Project Location or Address;
Tracy Hsu
Name of Authorized Agent:
408-4645030
Tel No
Address of Authorized Agent:
22330 Santa Paula Ave., Cupertino, CA 95014
I declare under penalty of perjury that I am the property owner for the address listed above and 1 personally filled out the
above inforr6tion 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.
DocuSigned by:
8/22/2016
Property Owner's Signature: A Date: -
D3E6EBE8898B420
at-nerBzd1derF6Pn-2010.dbr revised 04/14110