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B-2016-2210
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2210 22568 LAZY OAK CT CUPERTINO, CA 95014-5610 (342 32 006) OWNERMUILDE 22568 LAZY OAK CT CUPERTINO, CA 95014-5610 OWNER'S NAME: WANG XIAOGUANG AND YU PING DATE ISSUED: 02/01/2017 OWNER'S PHONE: 408-242-2292 PHONE NO: None LICENSED CONTRACTOR'S DECLARATION BUII.DING PEPAUT INFO: License Class Lic. # Contractor OWNER/BUILDER Date X BLDG —ELECT -PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing MECH X REEDENTIAL — —COMMERCIAL with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIP ION: REMODEL 1/2 E ATH INTO A FULL BATH (30 SQ FT). 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. 2. 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. Sq. Ft )Floor Area: Valuation: $3000.00 APPLICANT CERTIFICATION I certify that I have read this application and state that the above APN Number: Occupancy Type: information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize 342 32 006 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 PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non-point WITHIN 80 DAYS OF PERMIT ISSUANCE OR source regulations per the Cupertino Municipal Code, Section 9.18. 180 DAYS ROM LAST CALLED INSPECTION. Signature Date 02/01/2017 Issued by: Kim Dunbar Date: 02/01/2017 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: following two reasons: All roofs shall be ' aspected prior to any roofing material being installed. If a roof is 1. I, as owner of the property, or my employees with wages as their sole installed without first obtaining an inspection, I agree to remove all new materials for ompensation, will do the work, and the structure is not intended or offered for inspection. ale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed b Signature ofApplic t: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 02/01/2017 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER r. 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. . t[AZARDOUS MATERIALS DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code, for the performance of the work for which this California He th & Safety Code, Sections 25505, 25533, and 25534. I will permit is issued. maintain co mplia ce with the Cupertino Municipal Code, Chapter 9.12 and the s. I certify that in the performance of the work for which this permit is issued, I Health & Safe 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. Additio ally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If, after making this certificate of will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Heal h & Safety Code, Sections 25505, 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall r be deemed revoked. ( Owner or author! ed agent: APPLICANT CERTIFICATION Date: 02/01/2017 I certify that I have read this application and state that the above information is CONST-145_�_�___ LENDING AGENCY correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction, and hereby authorize representatives of this city of work's for which this permit is issued (Sec. 3097, Civ C.) to enter upon the above mentioned property for inspection purposes. (We) agree 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 Addres consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code, Section 9.18. e 1 understand my plans shall be used as public records. .Signature , Date 02/01/2017 Licensed professional 0 CUPERTINO CONSTRUCTION PERMIT APPLICA7 COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building akupertino.c ❑ NEW CONSTRUCTION n A T111TIrnv R A T TRA A TTn1T / 1 F-1 n BIdgApp_2011.doc revised 06/21/11 UrIUINALFhKM1T# PROJECT ADDRESS 2,� � L G APN # r I— _ 2' ® ® /Q G/`l7 OWNER NAME . i st g 6, 0 A� . WA PHONE D EMAIL _ � `�� y �� AP STREET ADDRESS �26�1 4A 4 oar 4 CITY, STATE, ZIP : 19 CONTACT NAME ! [ PHONE/E-MAIL i STREET ADDRESS ` - �7 CITY, STATE, ZIP p J FAX OWNER ❑ OWNER-BUILDEk ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME,, ,f} [ (1v iy (ae-Im LICENSE NUMBER LICENSE Ii TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECVENGINEER NAME '� �1n:Yt b LAS LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK EXISTING USE PROPOSED USE CONSTR. TYPE #STORIES USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODELAREA REMODELAREA REMODELAREA PORCH AREA DECK AREPISASECONDUNIT TOTAL DECK/PORCH AREA. GARAGE AREA: DETACH ❑ ATTACH # DWELLING UNITS: ❑YES SECOND STORY ❑YESGADDED? ❑NO ADDITION? ❑NO PRE -APPLICATION ❑ YES' IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES - R: C $- - -- - -_ - TOTAL VALUATION - PLANNING APPL # F1 NO PLANNING APPROVAL LETTER EICHLER HOME? []NO - __ - - a By my signature below, I certify to each of the following: I am the property owner or authorized agent to act n the property owner's behalf. hhave 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 buildin_VconStrUction. I,authorize representatives of Cupertino to enter the above -identified property for inspection purposes. T, Signature of Applicant/Agent: Date: SUPPLEMENTAJ�'FORMATION REQUIRED PLAIN cEn.cx TYPE ROt?'1'IlYG SI ii OVER-THEotNTER BuuDnvs PLAN tEv[EwQ _ 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 © PLANMNG PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑- STANDARD ❑ plrr3l Ic WORKS form if any Hazardous Materials are being used as part of this project. ❑` LARGE"-- ❑-FIRE.DEP1' Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. ❑ MAJOR - ❑ SANITARY SEWER DISTRICT -- ❑ ENVIRONMENTALHEALTH BIdgApp_2011.doc revised 06/21/11 OWNER -BUILDER DISCLOSURE FO COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING ' IVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildingCcb-cupertino.org Dear Property Owner(s): An application for a building permit has been submitted in your name listing improvements specified at: SITE ADDRESS a OWNER NAME 5 DESCRIPTION OF WORK: APN OWNER ADDRESSg� I� I� . q) as the builder of the property Q BP# O' al: T , -)_9D t;4;b , 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 ui understand a frequent practice of unlicensed persons is to have u der building permit that erroneously implies that the property owner is personally. I, as an Owner -Builder, may be held liable and subject to seri( an unlicensed person and his or her employees while working on my prof provide coverage for those injuries. I am willfully acting as an Owner -Buil( insuran a coverage for injuries to workers on my property. fi Z. I understand building permits are not required to be signed by pro the construction and are not hiring a licensed Contractor to assume this n r3� I understand as an "Owner -Builder" I am the responsible party of I p tect myself from potential financial risk by hiring a licensed Contractor name instead of my own. VY_ Y4 I understand Contractors are required by law to be licensed and b n ke,.rrs on permits and contracts. T °5 I understand if 1 employ or otherwise engage any persons, other tl tal value of my construction is at least five hundred dollars ($500), inclu considered an "employer' under state and federal law. 6AI) understand if I am considered an "employer" under state and fec federal government, withhold payroll taxes, provide workers' compensati( unemployment compensation for each "employee." I also understand my meito serious financial risk. 3 7. I understand under California Contractors' State License Law, an reslaential structures cannot legally build them with the intent to offer thel licensed subcontractors and the number of structures does not exceed fc is performed under contract with a licensed general building Contractor. J'' I understand as an Owner -Builder if I sell the property for which tl arfy financial or personal injuries sustained by any subsequent owner(s) t defects in the workmanship or materials. or verify this information.) ie property owner obtain an "Owner - providing his or her own labor and material is financial risk for any injuries sustained by ;rty. My homeowner's insurance may not .r and am aware of the limits of my owners unless they are responsible for d on the permit. I understand that I may having the permit filed in his or her in California and to list their license in California licensed Contractors, and the ng labor and materials, I may be al law, I must register with the state and disability insurance, and contribute to lure to abide by these laws may subject iwner-Builder who builds single-family for sale, unless all work is performed by r within any calendar year, or all of the work permit is issued, I may be held liable for t result from any latent construction OwnerBuilderForm 2010. doe revised 04/14/10 i . I understand I may obtain more information regarding my obligatiol s 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.csib.ca.gov for more information about licensed contrarytors. � 10. I am aware of and consent to .an Owner -Builder building permit applied for in my name, and understand that I am thepartylegally and financially responsible for proposed construction activity at the site address listed above. 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide y all pplicable laws and requirements that govern Owner -Builders as wO as employers. 2. 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' Istate License Board may be unable to assist you with any financial loss you may sustain as a result of a complai' t. 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 proper. , 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 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: 4 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 -wilder). I Excluding the Notice to Property Owner, the execution of which I understand authorize the following person(s) to act as my agent(s) to apply for, sign, and Owner -Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address of Authorized Agent: MNER'S BEHALF my personal responsibility, 1 hereby the documents necessary to obtain an Tel No 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 ermit is issued to verify the property owner's signature. Property Owner's Signature: I Date: OwnerBuilderForm 2010.doc revised 04/14/10