11060011CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20902 DUNBAR DR I CONTRACTOR: THEODORE M CHAO I PERMIT NO: 11060011 I
OWNER'S NAME: THEODORE M CHAO 1598 VALERI RUTH CT I DATE ISSUED: 06/02/2011 I
OV,WIER'S PHONE: 9493318759
License Class
Contractor
LICENSED CONTRACTOR'S DECLARATION
Lic. #
Date
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 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
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 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
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.
Signature
Date
i
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
t, 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)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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
permit is issued.
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, I
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 revoked.
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
to building construction, and hereby authorize 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,
cc and expenses which may accrue against said City in consequence of the
g of this permit. Additionally, the applicant understands and will comply
WILI. all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature l i. u Date 1
SANTA CLARA, CA 95050 1 PHONE NO:
BUILDING PERMIT INFO: BLDG r- ELECT I— PLUMB r-
MECH RESIDENTIAL COMMERCIAL
JOB DESCRIPTION: TEMPORARY POWER POLE FOR CONSTRUCTION
SITE(10110047)
Sq. Ft Floor Area: I Valuation: $300
APN Number: 32630141.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued b 6
.._-� _ Date:
RE -ROOFS:
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.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 255059 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent:
-jP1 Date:
--7-4e,c .4, ec- G�ee-c
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of wrk's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Ad
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
6 ITEMS OF 6
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 32630141.00
DATE ISSUED.......: 06/02/2011
RECEIPT #......... BS000013633
REFERENCE ID # 11060011
SITE ADDRESS 20902 DUNBAR DR
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......
OWNER THEODORE M CHAO
ADDRESS ..........: 598 VALERI RUTH CT
CITY/STATE/ZIP ...: SANTA CLARA, CA 95050
RECEIVED FROM HU H CHAO
CONTRACTOR LIC # *OWNER*
COMPANY THEODORE M CHAO
ADDRESS ..........: 598 VALERI RUTH CT
CITY/STATE/ZIP ...: SANTA CLARA, CA 95050
TELEPHONE .........
OPERATOR: patg
COPY # : 1
FEE ID
UNIT
QUANTITY
AMOUNT
PD -TO -DT
-------
THIS REC
NEW BAL
----------
lADMIN
-------------
HOURS
----------
0.50
----------
39.00
0.00
39.00
0.00
1BCBSC
VALUATION
300.00
1.00
0.00
1.00
0.00
1BSEISMICR
VALUATION
300.00
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
----------
166.50
0.00
166.50
0.00
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT :
AMOUNT
---------------
166.50
---------------
166.50
REFERENCE NUMBER
--------------------
VISA
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- -----
402 TEMPORARY POWER
� :'"11
CITY OF CUPERTINO
r, r, r, r, crmTl�:r A Tl1D R7TTT ill(N!'_' ll>I-VICT(1N
APPLIANCE / EQUIP TYPE
1' iJL �-•w.� s
-
QTY/FEE
QTY
UNITS
ADDRESS: 20902 dunbar dr.
DATE: 06/02/2011
REVIEWED BY: bob s.
im
BP#:
'VALUATION: $300
$42
APN:
PERMIT TYPE: Electrical Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
SFD or Duplex
7ENTATITATION 1REAP14
RMIYPE:
USE:
$42.00
PME Permit Fee:
$42.00
WORK
install temp power pole
SCOPE
APPLIANCE / EQUIP TYPE
FEE ID
-
QTY/FEE
QTY
UNITS
BP FEES
Temporary Power
1 ERT<200
100
Amps
$42
PME Unit Fee:
$42.00
PME Permit Fee:
$42.00
Work Without Permit? 0 Yes G No
$0.00
TOTALS:
Travel Documentation Fee: IIRA VDOC
$42.00
Strom Motion Fee: IBSEISMICR
!'n"mrt tho Dont fnr addn'1 info.
IVVI C: I nese.Lees ure UUJeu "it Li{G i cuiiuiauiy ss Iv
FEE ITEMS jI ee Resolution 09-05.1 Eff. '/I;"!0)
FEE
-
QTY/FEE
---- -
MISC ITEMS
PME Plan Check:
$0.00
PME Unit Fee:
$42.00
PME Permit Fee:
$42.00
Work Without Permit? 0 Yes G No
$0.00
Travel Documentation Fee: IIRA VDOC
$42.00
Strom Motion Fee: IBSEISMICR
$0.50
0.5 hrs Admin./Clerical Fee
$39.00 ]ADMIN
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$127.50
$39.00 TOTAL FEE:
$166.50
Revised: U4/Z9/ZU I I
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building4,cupertino.org
❑ PLUMBING ❑ MECHANICAL ❑ ELECTRICAL Q MISCELLANEOUS
MEP
MISC
MEPMiscApp_201 1. doc revised 03/16/11
PROJECT ADDRESS 2 C , v� h 1j aT V L,1��C t,tc'
APN # - ,3 0 — j 4 1
OWNER NAME
N• U GjiHv
PHONE
E -MAI -U . C 6 it
c14AC,14C1�l ETW N Y
STREET ADDRESS U/�(ITC G L/ �" yS 4v4_
Com, �A� �
L, i� r/��i/-+s .� Ce 13;5
FAX
CONTACT NAME5�
Ti,r�^1 v�2 c'hCao
PHONE C��, 3%.-
7�
E f Al v , C 4e(;t 1vrc�./, !o° t
STREET ADDRESSn
5 j b' �Gt /c ✓ i G L t .
CITY, STATE ZIP
S a� y, fic /cc Y c < , C f) `i v
FAX
❑ OWNER E OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ARCHITECT ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAMELICENSE NUMBER LICENSE TYPE
C_X111 iY 7/LL' ClC-�.l> UX/
BUS. LIC # _
IS"c?..z�'l�iSe -t%
/V.. ixstvwcr
COMPANY ME NAE-MAJL
/ - n
FAX
STREET ADDRESS
CITY, STATE, ZIP-17
"77
•_
S �i
ARCHITECTIENGZMER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
SE OF I& SFD or Duplex ❑ Multi -Family
PROJECT IN WILDLAND
PROJECT IN
Commercial
URBAN INTERFACE AREA ❑ Yes No
FLOOD ZONE ❑ Yes � No
STRUCTURE: ❑
DESCRIPTION OF WORK
L.c "r^ f rv-c t"�x S• / e
ale Lr s
�c
TOTAL VALUATION: 3 d U „r z _ $'"F
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 -P. C� '" �` r` �` ` ` Date: G i -2 2 t; �
Signature of ApplicantlAgent IZH a�
SUPPLEMENTAL INFORMATION REQUIRED
e
=exp
r
MEPMiscApp_201 1. doc revised 03/16/11
<�9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal
Revenue 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
contractors.
X10. 1 am aware of and consent to an Owner -Builder building permit applied for in my name, and understand that
am the party legally and financially responsible for proposed construction activity at the site address listed above.
A , 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.
t4�L(12. I 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.)
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 si nature.
T- 1" 6 c" L -u z Date: I4 j /
Property Owners Signature: Ar r fir• L Fy
---------------------------------------------------------------------------------------------------------------------------------------------
(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:
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:
OwnerBuilderFornz 2010.doc revised 04/14/10
LIMITED POWER OF ATTORNEY
BE IT KNOWN, that I Theodore Chao of Santa Clara, California has made and appointed, and by
these presents does make and appoint Hu Chao of Las Ve-gas. Nevada true and lawful attorney for
His/her and in his/her name, place and stead, for the following specific and limited purposes only:
(1) Signing construction contracts related to the re -build of the house at 20902 Dunbar Drive,
Cupertino, CA 95014, and
(2) Signing applications related to the re -build of the house at 20902 Dunbar Drive, Cupertino, CA
95014
giving and granting said attorney, full power and authority to do and perform all and every act and thing
whatsoever necessary to be done in and about the specific and limited premises (set out herein) as fully,
to all intents and purposes, as might or could be done if personally present, with full power of substitution
and revocation, hereby ratifying and confirming all that said attorney shall lawfully do or cause to be done
by virtue hereof.
This Limited Power of Attorney is granted for a period of one and half years and shall become effective
immediately.
IN WITNESS WHEREOF, I have hereunto set my hand and signed
this > j day of
Signature of the Principle:
Signature of the Attorney -in -Fact:
State of California
County of Santa Clara
On 2/Sr ,&14 X -3c)// before me, 1 'T / -1 04 % I --
a notary public, personally appeared 7ih C)r✓1� 6A1,4 C !L 140 hy,4 t)
who proved to me on the basis of satisfactory evidence to be theperson(s) whose name(s) are
subscribed to the within instrument and acknowledged to me that ./s�/they executed the same in
t*h,0r/their authorized capacity(ies), and that by � r/their signature(s) on the instrument the
person(s), or the entity upon behalf of which the person((�s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph
is true and correct.
.. ^-. ., d. d.ac
WITNESS my hand and official seal. r� KIRTI I. PATEL
COMM. #1833519
c7NOTARY PUBLIC . CALIFORNIA
~QMy
SANTA CLARA COUNTY
(seal) Comm. Expires Jan. 27, 2013 A
Signature
z�
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(d)CUDertino.orq
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
APN ` ..
BP#
OWNER NAMEOWNER
%�
�e<<
ADDRESS
DESCRIPTION OF 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.)
1. 1 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 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 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
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.
(� 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
-_;jj-5. 1 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' understate and federal law.
121�,' 6. 1 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.
41 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.
OwnerBuilderFornt 2010.doc revised 04/14/10