13070135 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21064 MARCY CT CONTRACTOR:DANIEL CHOW PERMIT NO: 13070135
OWNER'S NAME: DANIEL CHOW 21064 MARCY CT DATE ISSUED:07(22/2013
OWNER'S PHONE: 4082559106 CUPERTINO,CA 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMNIERCIALL
License Class Lie.ti REMODEL KITCHEN 160 SQ,BATHROOM 180 SQ,
LAUNDRY
Contractor Date ROOM 60 SQ FT-REMOVE(1)DOOR,INSTALL NEW DOOR
1 hereby affirm that I am licensed under the provisions of Chapter 9 AND COVERT DOOR TO WINDOW.(NEW WINDOW
(commencing with Section 7000)of Division 3 of the Business&Professions SHOULD
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 ofconsent 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. Sq.Ft Floor Arca: Valuation:$150000
1 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:32654030.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I 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 DA F OM 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 22,1
granting of this permit. Additionally,the applicant understands and will comply Issued by: Ante:
with all non-point source regulations per the Cupertino Municipal Code,Section 70
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,1 agree to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION
(, Signature of Applicant: Date:
ri 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)
g' 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. Iwill
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
Q I have and will maintain a Certificate of Conscnt 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 Day Area Air Quality Managcmcnt District 1
performance of the work for which this permit is issued, will maintain compliance with the Cupe no M Code,Chapter 9.12 and
1:1 1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 5 ,. d 25534.
Section 3700 of the Labor Code,for the performance of the work for which this .
Oti et.a_r,atrthorrzed'age _
omit is issued. liF:$.�.-t�irubb
_
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,1 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,1 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 1 have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and stale 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.A itionally, ca licant understands and will comply
with all non-point sou regulati r Cupertino Municipal ode,Section Licensed Professional
9.18.
S. 9 it
CONSTRUCTION PERMIT APPLICATION
oil COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTIO (408)777-3228•FAX(408)777-3333•buildinptfcupertino.orq 1
PI
❑NEW CONSTRUCTION ❑ ADDITION X❑ALTERATION I TI ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROIF.CTADDRESS 21064 Marcy Court APN" 326-54-030
OWNERNAME Daniel and Shirley CHOW PHONE 4082559106 E-MAIL dtschow@aol.com
STREETADDRESS 21064 Marcy Court CITY,STATE,ZIP Cupertino CA 95014 FAX
CONTACT NAME Daniel CHOW PHONE 4153108040 E-MAIL dtschowC�aol.com
STREETADDRESs 21064 Marcy Court CITY,STATE,ZIP Cupertino CA 95014 FAX
0 OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER D TENANT
CONTRACTOR NAME Rudy Chan LICENSE NUMBER 9 4 5 9 2 6 LICENSE TYPE g BUS.LIC#
COMPANY NAME E-MAIL FAX
Re-Creation Construction Inc. re creationinc@yahoo.com
STREETADDRESS 1166 Fairford Way CrrY,STATE,ZIP San Jose, CA 95129 PHONE 6508688245
ARCHITECTIENGINEER NAME LICENSE NUMBER BUS,LIC 4
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIP7IONOFWORK Remodeling kitchen,
��laundry area, and bathrooms
EXISTING USE PROPOSED USE CONSTR.TYPE #STORIES
SFD SFD two USE TYPE OCC. SQ,FT. VALUATION(S)
EXISTG NEW FLOOR DEMO TOTAL
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA 18 0 s f REMODEL AREA 16 Q s f REMODEL AREA 6 0 s f
PORCH AREA DECK AREA TOTAL DECKIPORCHI AREA GARAGE AREA: ll
M ATTACH
#DWELLINGUNITS; IS A SECOND UNIT" ❑YES SECOND STORY ❑YES
BEING ADDED? [NNO ADDITION? IZNO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS TAE BLDGAN ❑YES RECEiU D - �a TOTAL VALUATION:
PLANNING APPI.# ANO PLANNING APPROVAL LETTER E1CHLER HOME? l NO
$150, 000
By my signature below,I certify to each of the following: I am thero owner or authorized a nt to act on the property owner's behalf. I have read this
application and the information I have provided is ect. I ha th escrill of Work a/8 verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building c cLt
ion. a presentatives of Cupertino to enter the above-identified property for inspection purposes,
- t n , en. Date: July 22, 2013
r�Z?N g
SUPPLEMENTAL INFORMATION-REQUIRED PLAN CiItCK fYL itoUTirvc`stie
_New SFD or Multifamily dwellings: Apply for demolition permit for pvElE,,TII&COUNTER t HLDiNG PLANAUVIIlEW p s
existing building(s). Demolition permit is required prior to issuance ofbuild g w
permit for new building. '"EX
rREss pI NNiNcp A>W REVIEW
_Commercial Bldgs: Provide a completed Hazardous Matcrials Disclosure �4 sTANDARU° ' a' „Di'ru>3L ctivoxxs
form if any Hazardous Materials are being used as part of this project. ��°�� -- -'
0''PIREDEPT; '
_Copy of Planning Approval Letter Or Meeting With Planning prior t0 0 MAJOR, :.�=.:.�< ❑* $AN17nARY SE\VE,S DISTRI(:[`
submittal of Building Permit application.
0,.ENPIItONMENTAL1HEALTHt
BldgApp 2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR --BUILDING DIVISION
ADDRESS: 21064 Marcy Ct DATE: 07122/2013 REVIEWED BY: Mendez
APN: BP#: 1,50'701,3S 'VALUATION: $150,000
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration 1 Repair
PRIMARY SFD or Duplex PENTAMATION 1 R3SFDRFM
USE: PERMIT TYPE:
WORK remodel kitchen 160 sq, bathroom 180 sq, laundrV room 60 sq ft- remove 1 door, install new door and
SCOPE covert door to window.
Me& Plan Check Phiorb.Plan Check Elec.Plan Check
,Llech. Pernfit Fee: Plurnh.Permit Fee: Elec,Pennir Fee:
Other Alech.Insp. Ocher Plumb Insp. Other Elec.Insp.
1lech. hap.Fee: Plum& hisp. Fee: Elec.Insp.Fee:
NOTE:This estimate does not include fees dne to other Departments r.e.Planning,Public Works,Fire,Sanitary Server District,School
District,etc. . Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution I1-053 E . 7/1/12) FEE QTYI EE MISC ITEMS
Plan Check Fee: $0.00 180 s.f. Remodel,Bath(<=300 sf)
Suppl. PC Fee: Q Reg. Q OT 0.0 1 hrs $0.00 $626.00 1REMRESBAT
PME Plan Check: $0.00 EKI s.f. Remodel,Kitchen(<=300 s fl
Permit Fee: $0.00 $626.00 1 1REMRESKIT
Suppl. Insp. Fee-.0 Reg. Q OT F0707 hrs $0.00 60 s.f. RemodeI,Other
PME Unit Fee:. $0.00 $418.00 IREMRESOTH
PME Permit Fee: $0.00 �_J # Window I Sliding Glass Door
Conslivetion lax: $834.00 1WINMEWSTR New(Shearwa11/Masonry)
Administrative Fee: (D
Work Without Permit? Yes Q No $0.00 E)
Advanced Planning Fee: $0.00 Select a Non-Residential G
Travel Doewnentation Tees: Building or Structure 0
i
Stroniz Motion Fee: 1BSEISMICR $15.00 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $6.00
SUBTOTALS: $21.001$2,,504.001 TOTAL FEE: 1 $2,525.00
Revised: 07/01/2013
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
C U P S RT I IV O Telephone: 408-777-3228
Fax: 408-777-3333
CONTRACTOR/SUBCONTRACTOR LIST
JOB ADDRESS: / Q(rJ C PERMIT# 1'24--o 7V / S
OWNER'S NAME: PHONE# ry So z 3 6,c?
GENERAL CONTRACTOR: IV—e BUSINESS LICENSE#
ADDRESS: &(o CITY/ZIPCODE: o �y
"Our municipal code require all businesses orldng 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 SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Sig Date
Please check applicable subcontractors and complete the following information:
V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE#
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass/Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
PIastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
° Owner 1 Contractor Signature Date
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228- FAX(408)777-3333•building(cDcupertino.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:
E ADDRESS ♦'� � r,p APN BP#
- V WIC'•
OWNER
. N OWNER ADDRESS'OL64J
% _ZSGRIRT.0 OF W0RK:"M � &AVIrgalm-
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.)
Al
. 1.understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner
-
I r" building permit that erroneously implies that the property owner is providing his or her own labor and material
peTsonally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
ar 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
in[trance coverage for injuries to workers on my property.
A. I understand building permits are not required to be signed by property owners unless they are responsible for
th4donstruction and are not hiring a licensed Contractor to assume this responsibility.
463. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. l understand that I may
pr6tect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
AI understand Contractors are required by law to be licensed and bonded in California and to list their license
nu ' hers on permits and contracts.
fir.
I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total _{ lue 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
ungmployment compensation for each "employee."I also understand my failure to abide by these laws may subject
met 01 serious financial risk.
.,I 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.
�8. I 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
def ct�s in the workmanship or materials.
UvnerBudderForm 2010.doc revised 04/14/10
I understand I may obtain more information regarding my obligations as an "employer"from the Internal -
Revbo,ue Service, the United States Small Business Administration, the California Department of Benefit Payrimehts,
%and`tW 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.
.�70. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
am t!a party legally and financially responsible for proposed construction activity at the site address listed above.
I agree that,as the party legally and financially responsible for this proposed construction activity, I will abide
by 611 applicable laws and requirements that govern Owner-Builders as well as employers.
. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
in or90"tion I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
youtract 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.)
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 issuig the permit. Note:A copy of the property owner's driver's license;
form notarization, or other verification accept a to t=1e required to be presented when the pe it is issued
to verifytheproperty.owner' s! nat
Pro rty Ow er' tSjynatur - :'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 Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
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