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13040136CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10504 N STELLING RD CONTRACTOR: THINH PHAN & ANH PERMIT NO: 13040136 DAO OWNER'S NAME: THINH PHAN & ANH DAO 10510 N STELLING RD DATE ISSUED: 07/16/2013 OWNER'S PHONE: 4083068552 CUPERTINO, CA 95014 PHONE NO: ❑ JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIALE] LICENSED CONTRACTOR'S DECLARATION License Class Lic. # FIRE DAMAGE - REPAIR AND REMODEL SECOND DWELLING Contractor Date UNIT (800 SQ FT). DEMOLISH UNPERMITTED ATTACHED I hereby affirm that 1 am licensed under the provisions of Chapter 9 STORAGE AND 2ND STORY BALCONY (130 SQ FT), TWO (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: $25000 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: 32630101.10504 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. l 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 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the ?�� /�' 7 granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: Y with all non -point source regulations per the Cupertino Municipal Code, Section LIXI 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: 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 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 Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code 505, 5533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this % l permit is issued. Owner or authorize agent: G �� Date: I certify that in the performance of the work for which this permit is issued, I shall 1 , 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 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 l 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. / SignatureDate 1 2,4 f� 3 CUPER"I INO NEW CONSTRUCTION CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(Dcugertino.org ❑ ADDITION ❑ ALTERATION /TI ❑ REVISION / DEFERRED ORIGINAL PERMIT P PRO C5Aj�R KESS _ c ��d d ( APN H Y��f-� O '[..� ...� t V ��. PHO �y 7 ... ..... E -MA M STREET ADD/� /� , CITY, TATF. i� CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME .wrr•- q l �J LICENSE NUMBER LICENSE TYPE BUS. LIC H COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS, LIC H COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, PHONE DESCRIPTION OF WORK 17) „ZIP EXISTING USE PROPOSED USE CONSTR. TYPE N STORIES USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA ady 4, BATHROOM REMODEL AREA KITCHEN REMODEL AREA OTHER REMODEL AREA P r PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: ODETACH / ❑ ATTACH I 9 DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑ YES *" . - BEING ADDED? ❑ NO ADDITION? ❑ NO PRE -APPLICATION ❑YES IF YES, PROVIDE COPY OF PLANNING APPLa ONO PLANNING APPROVAL LETTER IS THE BLDG AN ❑YES` TO V UATION: EICHLERHOME. 0Nco By my signature below, I to each of the Mowing: I am the property owner or autho ze gent to act on the property owner's behalf I have read this application and the inf ation I have provided I correct.�arize e Description of Work d verify it is accurate. I agree to comply with all applicable local ordinances and state I ws relating to buil co structipresentatives of Cu Ino to enter the above-identifi d property for inspection purposes. Signature of ApplicanUAgen r� '' � Date: _G �, SUPP MENTAL ORM ON REQUIRED New SFD or ultifamil wellin s: 1 for demolition permit for existing buildin s De ition ermtt is utred riot to issuance of building s ng O g . P 4 permit for new b, ing. P Commercial Bldgs: Provide a completed Hazardous Materials Disclosures, form If any Hazardous Materials are being used as part of this project. of Planning Approval Letter or Meeting with Planning prior to ✓%Copy _MIT submittal of Building Permit application. ;i;, ,/ / �� %iii„/;��/!��%!%v//iri ✓ i, i/�,, �'I,l'?"1,� ; ' I�%'i�1L t��!�/� BldgApp_201I.doe revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION w ADDRESS: 10504 N STELLING RD DATE: 04/18/2013 REVIEWED BY: Mendez APN:. BP#: "VALUATION: $25,000 *PERMIT TYPE: Building Permit j:lo ,tr",'I"wit j'ce PLAN CHECK PE: Alteration / Repair PRIMARY SFD or Duplex USE: o(6 cr C1f'f Insp. PENTAMATION 1GENRES PERMIT TYPE: WORK FIRE DAMAGE- REMODEL ENTIRE GRANNY UNIT 895 SQ FT ATTACHED GARAGE 210 SQ FT SCOPE $0.00 �,,,,�� , � 1 ii ,41111111/1111' �„� � i„ � , i NOW, ')"Zech' Plell'1 CIJef'k l'hwlh l'hm Cj7cH, fJluc 1"'icin Chcrk Plan Check Fee: Hourly Only? 0 Yes Q No 1,11w215, 1rcrmi/I'<.'(': j:lo ,tr",'I"wit j'ce 01heP Afi,ch. h7.S'p, 0hf- PCtmjh b'XSp' o(6 cr C1f'f Insp. 0.0 hrs $0.00 NOTE: This estimate does not inehide fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc.). These tees are based on the preliminary information available and are only an estimate. Contact the Dept for addn'1 info. FEE ITEMS (Fee Resolution 11-033 E f 7/1/12) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes Q No $0.00 4 hours $532.00 Plan Check, Hourly ISTPLNCK Suppl. PC Fee: (j) Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee:: Hourly Only? 0 Yes Q No $0.00 Suppl. Insp. Fee -.0 Reg.. Q OT p p hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Const ta.Iioll Tax: 'Idfnlll ist/ at ive Fee".. Work Without Permit? 0 Yes Q No $0.00 Advanced Planning Fee: $0.00 10 hours $1,330.00 Inspections 1STINSP Inspection, Hourly Q 0 7)-("n;(4 Docaranef'aalrwi UCS: Strong Motion .Fee: IBSEISMICR $2.50 Select an Administrative Item. Bldg St& Commission Fee: IBCBSC $1.00 $3.50 $1,862.00 $1;865.50 Revised: 04/01/2013 CUPERTINO 0 CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: i ! °:', {.,� r l° PERMIT # .�" OWNER'S NAME: ¢.. ' PHONE # CONTRACTOR: / ., r �i BUSINESS LICEN,E —— S.CO _ ADDRESS: r'l °I CITY,/Z[PCQDE:JS� *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR .FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTI,ACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. � Dm: Siate I am not using any subcontractors. 2- g Please check applicable subcontractors and complete the following information:. Owner / Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &c Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner / Contractor Signature Date CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(a.cupertino.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 ADD R _C; Zj 11 APN BP# % OWNER NAMOWNER ADDRESS ptaL� !�- DESCRIPTION OF WORK: — "'tkfJiT/S 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 - building building permit that erroneously implies that the property owner is providing his or her own labor and material rsonally. 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. 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for e 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 tect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her ame instead of my own. 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license bers on permits and contracts. 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the I value of my construction is at least five hundred dollars ($500), including labor and materials, I may be nsidered. 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 deral 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. *I understand under California Contractors' State License Law, an Owner -Builder who builds single-family dential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by n ed 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 financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction efects in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04/14/10 r6r�f�PW , I understand I may obtain more information regarding my obligations as an "employer" from the Internal -. ue Service, the United States Small Business Administration, the California Department of Benefit Payments, d 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. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that I e party legally 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 all 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 i ation I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If y 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.) 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 acc le to the city may be required to be resented when the permit is issued to verifv the property owner's sian� I _. _ p Property Owner's Signature: "-'_ t Date: _/ I 1 to /.--)- JS - - ------------------------------------- --- -------------- --------------------------------------------------------------------------------- (NOTE: The following Authorization orm is req red 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. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Address.of Authorized Agent: 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 permit is issued to verify the property owner's signature. Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revised 04/14/10