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11010026 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21765 HYANNISPORT DR CONTRACTOR:WEUTAN WANG PERMIT NO: 11010026 OWNER'S NAME: WEUTAN WANG 21765 HYANNISPORT DR DATE ISSUED:01/04/2011 OWNER'S PHONE: 4083985268 CUPERTINO,CA 95014 PHONE NO: L 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 JOB DESCRIPTION:POOL REMOVAL WITH POOL FRAME REMAINED (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.Ft Floor Area: Valuation:$3000 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. APN Number:35613041.00 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, 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--f-___1- 9.18. Signature Date RE-ROOFS: OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is v 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: 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) I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7 4,Business&Professions Code). I hereby affir ;i'L� nalty of perjury one of the following three HAZARDOUS 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 Health&Safety Code,Sections 25505,25533,and 25534. I 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. Safety Code,Section 25532(a)should I 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 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 authorized age t^ /r Compensation laws of California. If,after making this certificate of exemption,I - 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 revok CO UCTION 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(See.3097,Civ C.) I certify that I have read this application and state that the above information is Lender'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 Lender's Address upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, cots,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION ng of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records. all non-point source regulations pCupertino Municipal Code,Section 9.18. Licensed Professional Signature _ Date CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35613041 . 00 DATE ISSUED. . . . . . . : 01/04/2011 RECEIPT #. . . . . . . . . : BS000012396 REFERENCE ID # . : 11010026 SITE ADDRESS . . . . . : 21765 HYANNISPORT DR SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : WEIJIAN WANG ADDRESS . . . . . . . . . . : 21765 HYANNISPORT DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : H CHEN & M WANG CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : WEIJIAN WANG ADDRESS . . . . . . . . . . : 21765 HYANNISPORT DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 3, 000. 00 1.00 0. 00 1.00 0 .00 1BSEISMICR VALUATION 3, 000. 00 0 .50 0.00 0.50 0 .00 1DEMOPRE EACH 1. 00 291 .00 0.00 291. 00 0 .00 - ---------- ---------- ---------- ---------- TOTAL PERMIT 292 .50 0 .00 292 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 292 .50 #1575 --------------- TOTAL RECEIPT 292 .50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 704 DEMO OWNER-BUILDER DISCLOSURE FORM IsION COMMUNITY DEVELOPMENT DEPARTMENT•BUILD ING 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228•FAX(408)777-3333•buiid_1n_g9cu e-rtino.ora CUPERTINO '�� '� Dear Property Owner(s): ourself as the builder of the property.�.w An application for a building permit has been submitted in your name listing y improvements specified at: APN 3 c)�'C SITE ADDRESS 14-t �l )w' G� �r C"1 P� CT OWNER ADDRESS S G YY�Q � OWNER NAME � ,}�i j 0, � (4 tp DESCRIPTION OF WORK: rm to make you aware u with an Owner-Builder Acknowledgment and Information sueden your namrification oe as the Owner-Builder. We We are providing you incur by having this perm your responsibilities and possible risk you may' �e f Cannot execute this notice unless will not issue a building pe until you have read,initialed your understanding of each provision,signed,an ent of returned this form to us at our official approval dd oval ofess �the pe mitting icated. An authority6 you,the property owner,obtain the priorpp initial each statement below to signify you understand or verify this information.) OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATIO (DIRECTIONS:Please read an the property owner obtain an"Owner- W w•1. I understand a frequent practice of unlicensed persons is to have providing his or her own labor and material Builder"building permit that erroneously implies that the property e M homeowner's insurance may not an unlicensed as an Owner-Builder, may be held liable and subject to serious financial Y ial risk for any injuries sustained y an unlicensed person and his or her employees while working on my prop a for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my provide covera 9 insurance coverage for injuries to workers on my property. owners unless they are responsible for WW-2. I understand building permits are not required to be signed by property the construction and are not hiring a licensed Contractor to assume this responsibility. permit. I understand that I may vi-W- 3. I understand as an"Owner-Builder" I am the responsible party of record on the nfinancial risk by hiring a licensed Contractor and having the permit filed in his or her protect myself from potential name instead of my own. re required by law to be licensed and bonded in California and to list their license %a-W.4. I understand Contractors a numbers on permits and contracts. if I em loy or otherwise engage any persons, other than California licensed Contractors, and the %4-0J5. I understand p To—tai value of my construction is at least five hundred dollars($500), including labor and materials, I may e considered an"employer"under state and federal law. I must register with the state and deral " under state and fe nce, and contribute to W.w.6. 1 understand if I am considered an axes, provide rwo kers'compensafon disability deb these laws may subject federal government,withhold payrollp failure to ab Y ensation for each"employee." I also understand my unemployment comp me to serious financial risk. uilds understand under California Contractors' State License Law, an for sae, unle shalbworrk s'performed by understa k residential structures cannot legally build them with the intent to 0 e tractors and the number of structures does not exceed four within any calendar year, or all of a work IinoncP.d SUbCOn or.i hl iildina Contrctor. CITY OF CUPERTINO DEMO CUPEFZTINO PERMIT APPLICATION FORM APN# 35 l p 1 f I Date: r �$ �go 1 U Building Address: ath S f-�J yr hto;s p r , Cry Mailing Address (if different from building address): Owner's Name: Phone: w.-eA`j i R w cog 3 q g Contractor: Phone o l/a Fax: Contractor License #: Cupertino Business License #: Contact: ... Phone: Fax: Residential Q Sq Footage -2 1110 Commercial ❑ Sq Footage Job Description: GoI remova( WIA Poll -fp-w T- malnod Valuation: Project Size: Express © Standard ❑ Large ❑ Major ❑ Please complete relevant portions of the Green Building Checklist & attach it to the application or if applicable, include on the plan set & the sheet index. Quantity Fee ID Fee Description Fee Group Permit Type 1DEMORES Demo-Residential B 1SFDWL-DEM 1 1DEMOPRES Pool Demo Residential B 1SFP00L-DEM- 1BCBSC Cal Bldg Standards B ALL PERMIT Commission Fee TYPES 1BSEISMICRE Seismic Residential B Revised 01/07/09