B-2017-1410CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1410
7834 ORION LN CUPERTINO, CA 95014-5001 (362 20 013)
OWNER'S NAME: XIANGKE LIU
DATE ISSUED: 08/23/2017
OWNER'S PHONE: 650-804-2235
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class Lie. #
Contractor `Date
X BLDG —ELECT —PLUM
MECH X 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
licensels in full force and effect.
JOB DESCRIPTION:
KITCHEN REMODEL (151 SF); BATHROOM REMODEL (60 SF);
I hereby affirm under penalty of perjury one of the following two declarations: '
CONVERT EXISTING FAMILY ROOM TO MASTER BEDROOM (440
m. I have and will maintain a certificate of consent to self-insure for Worker's
SF); SEAL OFF FIREPLACE
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 37,00 of the Labor Code, for the performance of the work for which this
Sq. Ft Floor Area:
Valuation: $40000.00
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
APN Number:
Occupancy Type:
and state laws'relating to building construction, and hereby authorize
362 20 013
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 180 DAYS OF ,PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LASTCALLED INSPECTION.
Signature' Date 8/23/2017
Issued by: Jasmine Archbold
Date: 08/23/2017
OWNER-BUILDER DECLARATION
Thereby affirm thatI am exempt from the Contractor's License Law for one of the
RE-ROOFS:
follow two reasons:
All roofs shall be inspected prior to, any roofing material being installed. If a roof is
i.' 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
compensation, will do the work, and the. structure is not intended or offered for
inspection.
(Sec.7044, Business & Professions Code)
as'owner of the property, am exclusively contracting with licensed
Signature of Applicant:
'contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 8/23/2017
I hereby.affirmjunder penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
i.' l,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.
HAZARDOUS MATERIALS DISCLOSURE,
z.' '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 Health & Safety Code, Sections 25505, 25533; and 25534. I will
permit is'.issued.
maintain compliance with the Cupertino Municipal Code, Chapter 912 and the
a. j ! ;'I certify that in the performance of the work for which this permit is issued, I
Health &Safety Code, Section 25532(a) should I store or handle hazardous
I '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
air contaminants as defined by the Bay Area Air Quality Management District I
j 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 Health & Safety Code, Sections 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
OwnVig0thorized agent:
APPLICANT CERTIFICATION
D
I certify that I have, read this application and state that the above information is
IP&IM2 CONSTRUCTION LENDING AGENCY
correct., I agree to complywith 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,
juddments, 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 willi comply with all non-point source regulations per the Cupertino Municipal
ARCHITECT'S DECLARATION
Code; S tion'9.18.
I understand my plans shall be used as public records.
tune : Date 8/23/2017
Licensed
Professional
s
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO,'CA 95014-3255
1#1
(408) 777-3228 • building@cupertino.or PEMIT#B- [ C)
REV.# DEF #
I -I NEW CONSTRucTION I -I ADDITION n ALTERATION n T T_ F- MF.P FIRE -ROOF n SWIMMINGPOOL/SPA
PROJECT ADDRESS
APN # —2-0 — O 12
OWNER NAME / V lii / L' L PHONE
f '
SJ s jo 4
E-MAIL
te K kat & k "le t CJ
STREET ADDRESS dl_ LA,6
CITY, STATE, ZIP
❑ CONTRACTOR NAME 2'OWNER-BUILDER COMPANY
NAME
LICENSE NUMBER LICENSE
TYPE
STREET ADDRESS
CITY, STATE, ZIP
E-MAIL
PHONE BUS. LIC #
❑ ARCHITECT 9 OWNER ❑ OWNER AGENT ❑ CONTRACTOR AGENT [I ENGINEER ❑ DEVELOPER ❑ TENANT
CONTACT NAME'
Y\ (A ti G L uA
E-MAIL r (� �I�
L 0) h' -f a4a t. cs ItA
STREET ADDRESS ��}}
704 &LA Ln,
CITY, STATE, ZIP ` PHONE
�iL ��I+� _ cA p�.�ot ,
st) CPO
DECRIPTON
mw
❑SINGLE-FAMILY/DUPLEX ❑MULTI -FAMILY ❑ INDUSTRIAL [I COMMERCIAL
USE
TYPE
OCC
SQ.FT.
VALUATION ($)
EXISTING USE
EXISTING SF
,NEW FLOOR SF
PORCH
SF DECK SF
DEMO SF
STORIES #
TOTAL NET SF
REMODEL
BATHROOM ,SF �'�
REMODEL KITCHEN
SF
REMODEL OTHR GARAGE
SF SF
❑ ATTACHED
❑ DETACHED
EXISING '❑ YES
FIRE SPRINKLERS El NO
-''IC.HLER � ❑ YES
❑ NO
SECOND STORY ADDITION E] YES
❑ NO
DWELLING SECOND DWELLING ❑'YES .❑ ATTACHED[] DETACHED OTHER
UNITS # UNIT ADDITON: " i, ❑I NO SF
POOLS '❑ FIBERGLASS' 0 VINYL -LINED ❑ GUNITE ❑ PREFABRICATED
POOL - SF SPA - SF, SPA ATTACHED ❑ YES N NO TOTAL - SF
Commercial or Multi-Finaih Bi uildings with Public SraimminAPools requires Department of Environmental Neath alroroval
EIVED BY:
d✓ �N31A
TO L VALUATION:
t
REfLOOJ
EXISTING ROOF TYPE: ❑ BUILT-UP ROOF [JASPHALT SHINGLES E]WOOD SHAKES F]
WOODSHINGLES ❑ TILE OTHER (SP IFY) -
REMOVE /REPLACE ❑ NO'
❑YES
IF NO
I # OF LAYERS
PLYWOOD ❑'� ❑ 3/8" PLYWOOD
THICKNESS ❑ 5/8" OTHER
TYPE:
❑ OSB ❑ CDX OTHER
PITCh:
12
ROOF CLASS
I A
PROPOSED ROOF TYPE: ❑BUI T -UP ROOF ❑ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES ❑ OTHER
*Provide a signed copy of the Cupertino's Tear -Off Policy SF #of SQUARES
By my signature below I certify to each of the following: I am the property owner or authorized agent to act on the property owner'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 representatives of Cupertino to
enter the above -identified property for inspection purposes. I acknowledge and authorize all information contained on this application form
to be made available for public'record.
Signature of Applicant/Agent: ! Dater
SUPPLEMENTAL INFORMATION ItEdUIRED
*New SFD/Second Dwelling Units/Multifamily Dwellings: A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter or. Meeting with Planning prior to submittal of Building Permit application.
*HOA -Provide a letter of approval from the Home Owner's Association
B1dgApp_2017.doc revised 08101117
ti
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
Oils 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
CUPERTINO (408) 777-.3228 - FAX (408) 777-3333 - buildingQcupertino.ong
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
All
BP#
OWNER NAME
OWNER ADDRES �
�3
L
/U L
Lit(
`f
DESCRIPTION OF WORK: L'
a&c , ow>Ae
We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you ma`y 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.)
X,&1. V 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 herown 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.
X4'2. I 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.
3. 1 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.
L_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.
�5. 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.
-. I understand if I am considered an "employer" under state and federal law, I must register with the state and
federal 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.
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 all 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.
X1.8. 1 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.
Oii,7ie7BLrilderFor7nz 1010.doc revised 04114/10
06L9. 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 Cal ifornia,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.cs[b.ca.gov for more information about licensed
contractors.
)qt,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.
f✓11. I 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.
a 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' 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.)i
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'themgency, 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;,oroperty owner's sion.ature.
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 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 Constrct,on Project (or Description of Work):
Project LocOoh;or,Address:
I„
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:
OlNT2e7BuilderFo7.7PC 2010.doc revised 04114110
City -Of Cupertino
10300 ToTr e Avenue
Cupertino, CA 95014-3255
Telephone: 408-77-3'-'/"-.g
Fax: 408-777-3333
JOB ADDRESS p � �t �
PERMIT MiT 0
OWNER'S NAME.
LION. 4
?'-E,NE ALCONTRAC"TOR � � _
T V ohs
i .SIN SSLICENSE � ,k1
`
ADDRESS s :� _ _
CITYIZIPCO E, f .
+Our rnuuichml code requires all businesses wor h.g in tae crry iq crave a *-uv (n c-.0 ertlalu 'W1€t:a0N lid CA9G,
O BUILDING FINAL OR FINAI_ OCCUPA C INSPECTION( WILL BE SCHEDULED UNTIL THE
GENERAL C ONO C:TO . AND ALI, SUBCONTRACTORS I-IAVE OBTAINED A CITN OF CUPFRTI NO
BUSINESS LICENSE. b w
I am not using any subcontractors:
Signature Date
Please check apOlicab a subcontractors and complete the following information:
Owner 1 Contractor r Signature
hate
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
C,ena.cat Finishing
Electrical
Excavation
».
Fencing
Flooring / Carpeting
Linoleum/ Woo
--
Glass ! Glazing
Heating
Insulation.
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tanta
Sheet Metal
Skeet Rock
Tile
Owner 1 Contractor r Signature
hate