11110054 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20559 RODRIGUES AVE CONTRACTOR:CHEN TSU KUANG AND PERMIT NO: 11110054
LIAO YU TING
OW ER'S NAME: CHEN TSU KUANG AND LIAO YU TING 20559(16DRIGUES AVE DATE ISSUED: 11/09/2011
R'S PHONE: 4088650336 CUPERTINO,t",A 95014 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATIONr'
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lie.k r r, r
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL FOUR(4)DOORS&THIRTEEN(13)
(commencing with Section 7000)of Division 3 of the Business&Professions WINDOWS;NON-STRUCTURAL
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.
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 Sq.Ft Floor Area: Valuation:$7000
permit is issued.
APPLICANT CERTIFICATION APN Number:35910047.00 Occupancy Type:
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
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accme against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section -
9.18.
Issued Date��
Sire Date
OWNER-BUILDER DECLA�TION
RE-ROOFS:
hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages m their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
1 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 1 have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner r author i d agent: /y
forthwith comply with such provisions or this permit shall be deemed revoked. Date: /_ nvl I I '
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that 1 have read this application and state that the above information is 1 hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
uhe above mentioned property for inspection purposes.(We)agree to save
i Ily and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
a. nd expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
t
t
Signature Date DV 0 I Licensed Professional
• CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35910047. 00
DATE ISSUED. . . . . . . : 11/09/2011
RECEIPT 4. . . . . . . . . : BS000015282
REFERENCE ID # . . . : 11110054
SITE ADDRESS . . . . . : 20559 RODRIGUES AVE
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : CHEN TSU KUANG AND LIAO YU TIN
ADDRESS . . . . . . . . . . : 20559 RODRIGUES AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : TSUKUANG CHEN
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : CHEN TSU KUANG AND LIAO YU TIN
ADDRESS . . . . . . . . . . : 20559 RODRIGUES AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . :
• FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 7, 000. 00 2 . 00 0 . 00 2 .00 0.00
1BSEISMICR VALUATION 7, 000. 00 1.40 0. 00 1.40 0 .00
1WINREP EACH 8 17.00 1304 . 00 0. 00 1304 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 1307.40 0. 00 1307.40 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 1, 307.40 #1257
---------------
TOTAL RECEIPT 1, 307.40
•
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
• ADDRESS: 20599 rodrigues ave. I DATE: 11109/2011 REVIEWED BY: bobs.
APN: BP#: "VALUATION: $7,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration I Repair
PRIMARY SFD or Duplex PENTAMATION 1GENRES
USE: PERMIT TYPE:
WORK install 4 doors and 13 windows non structural
SCOPE
:tfech. Plan Chaelr plump Ilan Check Elea Plan Check
41ech, Permit Hire: Plund'. Termtt free: F,-1- lleml:F% e:
0 Odle :tfwrh.lnap. 0,her Plumb hup. /bher E'km. lrrsp.
yeelt.Imp. Fee. Plulwh. Insp.ke,t Bier.Inca.
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works, Fire,Sanitary Sewer District,School
District etc. . These.fees are based on the prefinina Information available and are only an esdaude. Contact the Dept foraddn'l Infa
FEE ITEMS LEee Resohttion 11-053 EB" 7/1.Q1J FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 17 1 # Window/Sliding Glass Door
Suppl. PC Fee: Q Reg. 0 OT 0.0 hrs $0.00 $652.00 iwINREP7 Replacement
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl.Insp. Feer Reg. 0 OT0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
('(instruction Tax
.Administrative Fee: 0
Work Without Permit? 0 Yes (F) No $0.00 0
Advanced Planning Fee: $0.00 Select a Non-Residential 0
Y'ravel Docione-nia.tion Fees: - Building or Structure 0
• Suong Motion Fee: 1BSEISMICR $0.70 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.70 $652.00 'TOTAL FEE $653.70
Revised: 10/01/2011 Z
OWNER-BUILDER DISCLOSURE, FORM
• COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228- FAX(408)777-3333-buildm (a)
acuoertino.orCI
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: r
o 14
SITE A SS _ p _ e .� A7PN BP# ! / iV56S
N N EIiuvig N641 VN n OWNER S12
Q U- _l n / _w,
DESCRIPTION F WORK:
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.)
LIP 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
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 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 homeowners 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. 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.
AJ 3. 1 understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
r ect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
umbers on permits and contracts.
5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
t a value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
�conssidered an "employer" under state and federal law.
AL,(�_6. I understand if I am considered an "employer"under state and federal law, I must register with the state and
I 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
ntial 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
defects in the workmanship or materials.
OwnerBuilderForm 2010.doc revised 04/14/10
ie
1 understand I may obtain more information regarding my obligations as an "employer"from the Internal
venue 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.cslb.ca.gov for more information about licensed
tractors. 17
10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I
9a the 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
by all 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 rmation 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.)
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 signature
Property Owner's Signature: te:
-----------------------------------------------------------------------------------------------------------------—-------—-----------------
(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:
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:
OrrnerBuilderForm 2010.doc revised 04/14/10
xCL -
W a s0 0) � n
°o ' 3 s o
J
S N ..
xcoN
CrQ
.. O N r+
n n p
a O O
mm
A 'y O.
• }( awo S
:3 orq
-p
n a <po 'Dm
C C 0 3 � � sm � N �
W � N z N Q N m p
w Q• I 0 0 05. 3 W) c,o 3
a C' <_.vm E � 3a mz
- - o o °m cc
m 0 00 P z
DO
= . O °z3
C 8 nE9
3 CD
fin
'A `C O O
c
00
`a, OXF 1� �V
7. Sect: 7.0-7.1 Water Heater:
PLUMBING:Per our Standards of Practice:The inspector shall: '
A.inspect:•1.interior water supply and distribution systems including all fixtures and faucets.2.drain,waste,and vent systems including all fixtures.3. •
water heating equipment and hot water supply system.4:vent systems,flues,and chimneys.5.fuel storage and fuel distribution systems.6.drainage
sumps,sump pumps,and related piping.B.describe: 1'water supply,drain,waste,and vent piping materials.2.water heating equipment including energy
source(s).3.location of main water and fuel shut-of valves. ,
The inspector is NOT required to: '
A.inspect:1.clothes washing machine connections.2.interiors of flues or chimneys that are not readily accessible.3.wells,well pumps,or water sloraga
related equipment.4.water conditioning systems.5.solar water heating systems.6.fire and lawn sprinkler systems.7.private waste disposal systems. B.
determine: 1.whether water supply and waste disposal systems are public or private.2.water supply quantity or quality. C.operate automatic safety
controls or manual stop valves.
WATER HEATER MANUFACTURE&FUEL TYPE:
YES - =GALLONS
GAS
A ERICAN
7.0 HOT WATER SYSTEMS;;CONTROLS, CHIMNEYS, FLUES AND VENTS
Comments:
Where visible and accessible the water heater tank and it's components, controls, chimneys, Flues and vents were
inspected for hot water response, signs of active leaking, for proper connections, and general conditions. Any visible
indications of needed further evaluation or needed repairs/corrections will be noted in the summary section 1.10
Please note: Whenever there are gas systems in the home we strongly recommend properly installing carbon
monoxide detectors for the safety of the occupants.
1
CATER HEATER SEISMIC STRAPPING •
omments:
Where visible and accessible an inspection for the proper installation of seismic strapping, and blocking (if needed)on
the water heater is conducted.Any lack of strapping or visible indications of needed further evaluation or needed
repairs/corrections will be noted in the summary section 1.10
Please note:We are unable to verify that any installed lag screws are compliant. I recommend contacting the installer
about any installed straps to verify that the size and diameter of the lag screws comply with the State standards.
8. Sect: 8.0-8.3 Heating, A/C'Systerw
HEATING:Per our Standards of Practice:The inspector shall:(Heating system) _
A.open,readily openable access panels.B.inspect:1.installed heating equipment.2.vent systems,flues,and chimneys.C.describe:1.energy source(s).
2.healing systems. : '
The.'Inspector is:NOT required to: C i
A:inspect:1 Ambdors of flues or chimneys that are not readily accessible.2.heat exchangers.3.humidifiers or dehumidifiers.4.electronic air fillers.5.
solar space Beating systems.B.determine heat supply adequacy or distribution balance.
^' 7
The inspector shall:(Cooling system) [ T
k t•- > It 6
A.open readily openable access panels.B.inspect: 1.central and through-wall equipment.2.distribution systems.C.describe: 1.energy source(s).2.
cooling systems.
The inspector is NOT required to:
A.inspect electronic air fillers.S.determine cooling supply adequacy or distribution balance.C.inspect window air conditioning units. •-
Ii < iL)
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA-0014-3255
• CUPERTINO (408)777-3228•Ft(4O777-3333•buildinGfalcuoertino.oro
NEW CONSTRUCTION ❑ ADDITIONTERATION ALTERATION/T1 ❑ REVISION/DEFERRED ORIGINAL PERMIT N
PAOIECT ADORE59I-. AIN a'36,7
OWNER NAME - PMOtJE {Ellam¢
< i a J UEC;
STREET D E . STATE ZIP I FAX
kip lo�/AQ
COMA N PHONEqDq E-MAIL n
STREET ADDRESS p J n CITY,STATE ZIF FAx k
WNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTORACENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME ) LICENSE NTIMBER LICENSE TYPE BUS.LEC 0
COMPANY NAME I E-MAIL. FAX
STREET ADDRESS CITY,STATE.ZIP PHONE
ARCIHTECT/ENGINEEt NAME LICENSE NUMBER BUS.LLC M
COMPANY NAME E-MAIL FAX
SITtEEI ADDRESS CRY,STATE Z@ PHONE
DESCRIPTION OF WO
Dcov CkN'
EXLSTINGUSE PROPOSED USE CONSILTYPS OsTORIES
USE TYPE OCC. SQFT. VALUATION(S)
EXLSTG NEW PT.00R DEMO TOTAL V13AREA AREA AREA NETAREA
BATHROOM KITCIDN OTHER
REMODELAREA REMODEL AREA REMODEL AREA
PORCHAREA DECK AREA TOTALDECIVPORCHAREA GARAGE AREA DETACH
ATTACH
0 DWELLING UNITS: LS A SECOND ONrf YES SECOND STORY YES
BEINGADDIDT N ADDITION, MNq.
PLANK UCATION [ YES O'YES,PROVIDE VOPY OFALLE IS TBLDG ETCH ERHOMN V(]YEq RECEIVEBY. /7 TOTAL VALUATION:
PLANNLNG APPLM NO PLANNING APPROVAL LEI-IE.4 IICBI.EA HOMEi 'C'IVN6 _J �,l \n
or authorized arrant to act on the prpp
By my signature below,I cerdfy m each of the following: I am the property ownererty owner's behalf. i hav read this
application and the information I have provided is correct I have read the Description of Work and verify it is accurate. r 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.
Signature ofAppficant/Agenn Date:
SUPPLEMENTAL INFO ON REQUEED PLAN CHxCKTYPE R G SLIP
_New SFD or Multifamily dwellings: Apply for demolition permit for -com�rtax BUILDING PLAN xEv>Ew
existing building(s). Demolition permit is required prior to issuance of building
permit for new,building. ❑ EXPRESS ❑ PE.ANNING PLAN REVIEW
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ ETANDAxD ❑ PUBLIC WOREs
form if any Hazardous Materials are being used as part of this project 13 LARGE ❑ I=nEPT
Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ sANITARYSEwER DISTRICT
of Building Permit application.
❑ ENVIRONMENTALHEALTH.
B/dgApp_2011.doC revised 06/21/11