12060118 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 10357 WESTACRES DR CONTRACTOR:SU IIUBI-MGI TRUSTEE PERMIT NO: 12060118
OWNER'S NAME: SU IIUEl-MEI TRUSTEE 10357 WF.STACRF.S DR DATE ISSUED:06/198012
OWNER'S PHONE: 4084468432 CUPERTINO,CA 95014 PRONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lie.p
MECH RESIDENTIAL COMMERCIAL
Contractor Date
-
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:WATER HEATER REPLACEMENT
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
1 hereby affirm under penally of perjury one of the following two declarations:
I have and will maintain a ceniticale 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.FI Floor Arca: \'alualion:$1275
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of die work for which this
permit is issued. APN Number:35914024 00 Occupancy Type:
APPLICANT CERTIFICATION
I cenify 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 properly for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indenmify and keep harmless the City of Cupertino against liabilities,judgments. 180 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 Issued by �-J Date:��
9.18.
Signature Date
RE-ROOFS:
IK OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any),rooting material being msmlled.If a roof is
installed 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 inspection.
the following two reasons:
1,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(he property.am exclusively contracting with licensed contractors to ALI-ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sce.7044,Business&Professions Code).
1 hereby affirm under penalty of perjury one of the following three IIA%ARDOUS MATERIALS DISCLOSURE:
declarations: I have 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 California Ilealth&Safety Code.Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided far by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ileallh&
performance of the work for which this pcmtil is issued. Safety Cade,Section 25532(x)should 1 store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,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 maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Health&Safely Code,Sections 25505,25533,and 25534.
1 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 Own art authorj agen��•y.�
Compensation laws of Cali fornix. If,after making this certificate ofexemption,I (y 0 AJ� UJ�Xr\ Date:
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
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Cir C.)
I cenify(hat I have read this application and state that the above information is Lender's Name
correct.1 agree to comply with all city and county ordinances and state laws relating
EO building construction,and hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against l iabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARClDTE:C]"S DECLARATION
granting of(his permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. / }/� Licensed Professional
Signature �� Dale `zo I L
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT"BUILDING DIVISION
10300 TORRE AVENUE"CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228" FAX(408)777-3333" buildinof@cuoertino.ora
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 AD REQ ,Ar, APN L P#
OWNER AMQ'E�—/N `jA _ OWNER ADDRESS 413r� Ct4
DESCRIPTION OF WORK: W A1" dL fj-- n
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.)
lr 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.
1'4 * 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.
N-S' 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 finailcia irlsk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
f K- 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.
ls• 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" under state and federal law.
6. 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.
14 S- 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 numbei 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.
�1-S• 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.
a,,nerBuilderForm 1010.doc revised 04/l4/l0
�. 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.
(TLi z-
jz 10. I 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.
)��11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
''b/Iy all applicable laws and requirements that govern Owner-Builders as well as employers.
fr S 12. 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.)
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 properlyowneros signature.
Property Owner's Signature: Zf Date:
--- -- - - - --- -------- --- ------- ---------------- ------------------------ -- -- -----------------------------
(NOTE: The following--A--uthorization 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: Dale:
O,rnerBuilderForm 2010.doe revised 04//4/10
CITY OF CUPERTINO
6 ITEMS OF 6 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35914024 .00
DATE ISSUED. . . . . . . : 06/19/2012
RECEIPT#. . . . . . . . . : BS000017110
REFERENCE ID # . . . : 12060118
SITE ADDRESS . . . : 10357 WESTACRES DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA.. . . . . . .
OWNER . . . . . . . . . . .. : SU HUEI-MEI TRUSTEE
ADDRESS . . . . . . . . . . : 10357 WESTACRES DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : HUEI MEI SU
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : SU HUEI-MEI TRUSTEE
ADDRESS . . . . . . . . . . : 10357 WESTACRES DR
CITY/STATE/ZIP CUPERTINO, CA 95014
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
-ADMIN HOURS . 1.00 41.00 0 . 00 41 . 00 0 . 00
1BCBSC VALUATION - 1,275..00 1.00 0.00 1 . 00 0. 00
1BSEISMICR VALUATION 1,275.00 0. 50 0.00 0 .50 0.00
1PPERMITFE FLAT RATE .1 . 00 44 . 00 0. 00 44 .00 0. 00
1PRWHEATR UNITS _ .1.00 26. 00 0. 00 26. 00 0. 00
1TRAVDOC FLAT RATE 1 .00 44 . 00 0. 00 44 . 00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 156 .50 0 . 00 156 .50 0 .00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 156.50 #211
---------------
TOTAL RECEIPT 156.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
518 WATER HEATER
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10357 west acres dr. DATE: 06/19/2012 REVIEWED BY: bob s.
it] APN: BP#: 'VALUATION: $1,275
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY SFD or Duplex PENTAMATION PRWHEATR
USE: PERMIT TYPE:
WORK water heater replacement.
SCOPE
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Water Heater 1PRWHEATR 1 # $26
TOTALS: $26.00
Plumb.Plan Check 0.0 hrs $0.00 Lle,: !'hw o„,:A
Ilr:h_ I....n.a Fe" Plumb. Permit Fee: IPPERMIT
D,hrt/r,h, bnp. Other Plumb Insp. 0.0 hrs $44.00 Udn-r/lice l,np. Li
llcrh, hr,p. /I(' Plmnh. Lop. Fve.-
NOTE: This estimate does not include fees due to other Departments(ie.Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc). Thesefees are based on the prefindna information available and are only an estimate. Contact the De 1 or addn'I info.
FEE ITEMS (Vcc Resolution II-053 fn 7111112 FEE QTY/FEE MISC ITEMS
Man ( ho k /'ccs
S7q,pl_ l'C Fc-r
PME Plan Check: $0.00
11•rnril l�'r�•:
.Suppl. ln,;p F<<
PME Unit Fee: $26.00
PME Permit Fee: $44.00
c oa,n w tion T n.
Administrative Fee: IADMIN $41.00
Work Without Permit? O Yes 0 No $0.00
A(il'elm cd P1,umb)t' l'�cs.
Travel Documentation Fee: ITRA VDOC $44.00
A
SII'Un2 Motion Fcc: IBSEISMICR $0.50 Select an Administrative Item
Bldg,Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $156.50 $0.00 TOTAL FEE: $156.50
Revised: 06/30/2012
� 2,'en
GENERAL'PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 950143255 MIS C
CUPERTINO (408)777-322,88•FAX(408)777-3333•buildina(cDcuoertino.orG
PLUMBING '� 5MEC/ CAL ELECTRICAL NESCELLANEOUS
PROJECT ADDRESS
OWNER NAME E MALL nr N�d
STREET ADDREf� tstc+�5 O CRY STATE,IIP �d FAX
r, tAT
CONTACT NAME //"^ A./Q f 1PH NE E-MAIL
�I J
STREW ADDRESS CITY,STATE. ZIP FAX
OWNER ❑ OWNER-BUOJ)ER ❑ OWNERAGENT ❑ CONTRA T=& ❑CONTRACTOR AGENT ❑ ARanTECr 13 ENGINEER ❑ DEVELOPER ❑ Te LWT
CONTRACTORNAME K f�/ /II LICENSENUF ER LICENSE TYPE BUS.LIC q
COMPANY NAME San •�/ TD ID. E-MAIL
STREET ADDRESS Y CITY,STATE ZIP PHONE
� : rag- T/-Zo � — 8ao
ARCHITEMENGINEER NAME LICENSE NUMBER BUR.yo
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF .DUPLEX ❑ MULTI-FAMLLY PR==IN WBDLAND'. ❑ YES PROIER DI ❑YES I51liE BLOC AN ❑ YES
BURDDIG: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO ElO HOME ❑NO
DESCRITTON OF WORK
ahL.
TOTAL VALUATION: /,�,• r,Ob �� RECEIVED BY: 4J�
By my signature below,I certify to each of the following:. I am the property owner or authorirsd agent to act on die property owner's behalf. I have read This
application and the information I have provided is comet I have mad the Description of Work and verify it is accu c. I agree to comply with all applicable local
ordinances and state laws relating to buil ' construction. I anrhoriu representatives of Cupertino to enter the ab`gLg,ve-idrnofied pe,-1;cr inspection purposes.
Signanue of Applicant Dare: V/� / 7,
SUPPLEMENTAL INFORMATION:REQUIRED OFFICE US NLY
m OVFA-THE{OUNTER
❑ EXPRESS
U
❑ STANDARD
U
e ❑ LARGE
3
L
❑ NWOR
M@PAfucApp_011.doc revised 06/2I/l1