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10100128 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10540 WUNDERLICH DR COP[TRACTOR:JASON TAN PERMIT NO: 10100128 OWNER'S NAME: JASON TAN 10540 WUNDERLICH DR DATE ISSUED: 10/18/2010 1ER'S PHONE: 4084161170 CUPERTINO,CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r, ELECT r PLUMB r— License Class Lic.# MECH r— RESIDENTIAL r— COMMERCIAL r Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOE DESCRIPTION:TEMP POWER POLE (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 performance of the work for which this permit is issued. Sq.I t Floor Area: Valuation:$200 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 permit is issued. APN Number:37527037.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 'WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities,judgments, g0 DAYS FROM LAST CALLED INSPECTION. 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. Issued b Date./It,IV Signature Date RE-ROOFS: OWNER-BUILDER DECLARATION All rc ofs shall be inspected prior to any roofing material being installed.If a roof is instal led without first obtaining an inspection,I agree to remove all new materials for I hereby affirm that I am exempt from the Contractor's License Law for one of inspe;tion. the following two reasons: I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Date: 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 c ..tors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). It I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I hav:read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain a Certificate of Consent to self-insure for Worker's Calif anis Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& performance of the work for which this permit is issued. Safet✓Code,Section 25532(a)should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance,as provided for by Addii Tonally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. main-ain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Owner or autl orized agent: Compensation laws of California. If,after making this certificate of exemption,I Date: Z(D 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 re I_J CONSTRUCTION LENDING AGENCY I I here)y affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for wl rich this permit is issued(Sec.3097,Civ C.) I certify that I have read this application and state that the above information is Lend!r's Name 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 Lend!r's Address upon the above mentioned property for inspection purposes.(We)agree to save i• inify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. with all non-point sours regulations pethe Cupertino Municipal Code,Section 9.18. / Licensed Professional Signature Date CITY OF CU PERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: DATE: REVIEWED BY: APN: BP#: "VALUATION: $200 *PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair PRIMARY SFD or Duplex , 1, PENTAMATION 1 REAP 14 USE: 1 I OO a1tI ,L PERMIT TYPE: WORK SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Temporary Power 1 ERT<200 100 Amps $42 TOTALS: $42.00 z,. Elec.PlanC heck 0.0 1 hrs $0.00 << Elec.Permit Fee: l EPERMIT Other Elec.Insp. 0.0 1 hrs $42.00 NOTE. Thesefees are based on the preliminary information availG hie and are only an estimate. Contact the De t or addn'1 info. FEE/ITEMS(Fee Resohitzon 09-051 Elf T'1/10) FEE QTY/FEE MISC ITEMS PME Plan Check: $0.00 /'cr wil rr`.: S1 rj?J)/, li ? tii `�t.: PME Unit Fee: $42.00 PME Permit Fee: $42.00 .1t-C3j11t`(S:CfI fit".It' i`i .., Work Without Permit? 0 Yes E) No $0.00 l%IalIni7Ig 1 d`r'S: Travel Documentation Fee: ITRA VD0C $42.00 Strong Motion Fee: $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $127.50 $0.00 TOTAL FEE:` $127.50 Revised: 9/29/2010 CITY OF CUPERTINO 5 ITEMS OF 5 PERMIT REICEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Iot : APN . . . . . . . . : 37527C37 . 00 DATE ISSUED. . . . . . . : 10/18/ 2010 RECEIPT #. . . . . . . . . : BSOOOC11765 REFERENCE ID # . . . : 10100128 SITE ADDRESS . . . . . : 10540 WUNDERLICH DR SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . . JASON TAN ADDRESS . . . . . . . . . . : 10540 WUNDERLICH DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : JASON SZE-YIT TAN CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : JASON TAN ADDRESS . . . . . . . . . . : 10540 WUNDERLICH DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ----- ----- ---------- ---------- ---------- 1BCBSC VALUATION 200 . 00 1 . 00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 200 . 00 0 .50 0 . 00 0. 50 0 . 00 1EPERMITFE FLAT RATE 1 . 00 42 . 00 0. 00 42 . 00 0 . 00 1ERT<200 UNITS 1 . 00 42 .00 0. 00 42 . 00 0 . 00 1TRAVDOC FLAT RATE 1 . 00 42 .00 0. 00 42 . 00 0 . 00 ----- ----- ---------- ---------- ---------- TOTAL PERMIT 127 .50 0. 00 127 .50 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -- ------------------ CHECK 127 .50 #%299 --------------- TOTAL RECEIPT 127 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 402 TEMPORARY POWER r OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228• FAX(408)777-3333• builcinaQ)cupertino.org CUPERTINO 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 r �r4� UV,, N)P77 _i C�� j APIA `\-7 ` �� - C ? � BP# r l � ` OWNER NAMEOWT 4 NER ADDRESS I \\ `� V1 ��,L}C4 �\ ,� DESCRIPTION OF WORK: ,;��+ 1 � 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 havinc this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initiafod 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 I NFORMATION (DIRECTIONS:Please read and initial each statement below;o signify you understand or verify this information.) J1. I understand a frequent practice of unlicensed pemons is to have the property owner obtain an "Owner- Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner-Builder, may be held liable anc 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. i 2. 1 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. r 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 licer sed Contractor and having the permit filed in his or her name instead of my own. 4. 1 understand Contractors are required by law to bo- licensed and bonded in California and to list their license numbers on permits and contracts. _)l 5. 1 understand if I employ or otherwise engage any )ersons, 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. j 6. 1 understand if I am considered an "employer" un('er 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. 1 17. 1 understand under California Contractors' State L icense Law, an Owner-Builder who builds single-family residential structures cannot legally build them with the irtent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures duos not exceed four within any calendar year, or all of the work is performed under contract with a licensed general build ng Contractor. )T 8. 1 understand as an Owner-Builder if I sell the pror,erty for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subse luent owner(s)that result from any latent construction defects in the workmanship or materials. a vnerBuilderForns 2010.doc revised 04/14/10 understand I may obtain n more information regardirg my obligations as an "employer"from the Internal Revenue Service, the United States Small Business Administration, the California Department of Benefit P and the California Division of Industrial Accidents. I also understand I may contact the California Contractors, License Board (CSLB)at 1-800-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed Payments, contractors. s State __10. I am aware of and consent to an Owner-Builder bui din am the part,/legally and financially responsible for proposed construction activity at the site address lis g permit applied for in my name, and understand that I �1 ted above. 1 1. I a,,ree that, as the party legally and financially responsible for this proposed construction activitY. I will abide by a �,, ;c;,ble laws and requirements that govern owner-E,uilders as well as employers. 12. 1 agree to notify the issuer of this form immediately of any additions, deletions or changes to any the informa"on I have provided on this form. Licensed contractors are regulated by laws designed to protect he public. If you r ".rt-yet with someone who does not have a license, the Contractors'State License Board may be unable to ass.-t yc �,,;th any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed r-ay be in civil court. It is also important for you to understand that if an unlicensed Contractor or em; at individual or firm is injured while working on ourproperty, ro ert for damaes. YOU c :AL n a ,permit as Owner-Builder and wish to hire Contractors, Youu will be esp nou mays bleeld forliable verifying whether orf not thos,- (-'-: tmctors are properly licensed and the status of thei,workers'compensation insurance coverage. CONSP,'fc.;-10'4 LENDING AGENCY (DIREC ase complete the following construction lendin7 agency information.) hereby there is a construction lending agency for the performance of the work for which this permit is issued (Sec K Lender N�:rnEr._ Lender Address: Before ::rmit can be issued,this form must be completed and signed by the property owner and returnee n t ;ency responsible for issuing the permit. Nate:A copy of the property owner's driver's license, form no rlher verification cceptable to the city may be required to be presented when the permit is issued to verify ✓owner's si natur . Property signature: "��'�� — --. Date: -------------------------------------------------------------------------------------------------------------------- (NOTE. ; i,uthorization Form is required to be completed by the property owner only when designating an agent of. ;owner to apply for a construction permit for the Owner-Builder). HORIZATION OF AGENT TO ACT ON PROPERTY, OWNER'S BEHALF Excluding to Property Owner, the execution of which I understand is my Personal responsibility, I hereby authoriz - )erson(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an Owner-F -)r my project. Scope o: Project (or Description of Work): Project L, Adress'. Name r „Ant: Tel No Address ' ,",gent: I declare of perjury that I am the property owner for the address listed above and I personally filled out the above i� certify its accuracy. Note:A copyf the property owner's driver's license, form notarization, or owner's verifica!: ,le to the city may be required to be p resented when the permit is issued to verify the property signatt; Date: ^f I 11e�Bu\\derForm 2010.docre,ised04f14110 CITY OF CITERTINO 24> TEMP POWER CITY OF CUPEkTINO PERMIT APPLICATION FORM APN # Date: Building Address: -P Owner's Name: Phone #: t4 Contractor: Phone #: (7 Fax #: Contact: Phone #: Contractor License #: Cupertino Business License #: Job Description: Residential Commercial F-1 Valuation (cost of project): Type of Constructiod��NA Quantity Fee ID Fee Description Fee Group Permit Type IERT>lK Res. Temp Power>lK E 1REAP14 Amps 1ERT<200 Res. Temp Power---200 E Amps IERT2001K Res. Temp Power :Z00-1 K E Amps IEPERMITFE Electric Permit Iss-iance E IELCPLNCK Electric Plan Chec.< E IBCBSC Cal Bldg Standard;; B ALL PERMIT Commission Fee TYPES IBSEISMICR Seismic Residentiz I B 1TRAVDOC Travel & Documentation B Fee Revised 01/07/09