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14060175 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21451 COLUMBUS AVE CONTRACTOR:LAM HENG-MUN AND PERMIT NO: 14060175 AGNES T OWNER'S NAME: LAM HENG-MUN AND AGNES T 21451 COLUMBUS AVE DATE ISSUED:06/26/2014 OWNER'S PHONE: 4085064345 CUPERTINO,CA 95014-4972 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL ADD ELECTRICAL CONNECTIONS TO(2)SHEDS TO License Class Lic.# INCLUDE (6)OUTLETS AND(4)LIGHTS(2)SWITHCES,LOCATION Contractor Date AND HEIGHT APPROVED BY PLANNING 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. Sq.Ft Floor Area: Valuation:$100 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 APN Number:36204010 00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS T CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the /I G granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: (y ' with all non-point source regulations per the Cupertino Municipal Code,Section 9 18. RE-ROOFS: Signature Date 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. IAV OWNER-BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,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 HAZARDOUS MATERIALS DISCLOSURE c nstruct the project(See.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: p mit is issued. 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 Califomia. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply th all on point sourc reg ions per the Cupertino Municipal Code,Section Licensed Professional 8 ignature Date GENERAL PERMIT APPLICATION <{' PA E P COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 85014-3255 ! (408) 777-3228• FAX(403)777-3333•buildina(Dcuoerino.ora m I S ❑PLUIJ,BITG dELECTIUCa-L ❑jA�ZEEL�L.AXI-Po(US� PROM-K7 ADDRESS '/ C/� D, J�- A I A?-N," /,•� —l V�0 - `� O v.TI�'It t l Q % l m Gl Ll La tt" I PfiOAE � Sv6 ��� STRE=f ADDPMS CM, STAT E,ZIP. �7 I FAX I CON Aar NPA NLu ( kn I PHOA'E AD� Svb �3 5�S IC``''- 9a" ST? .SDDRESS CrrY,STATE,, ZIP F• 04`lDt Q o"AN.—w-BI-MMER ❑ OV.lhcMAC—OST ❑ camucioR ❑cOTTRSCTORAGrI`T ❑ ARa'—mCT ❑E.*'GR—R ❑ D1`.0PER ❑ TENluN''T CONT.kCTOR NF Nr S I LICENSE NUIJMER I L IMPKISE TYPE I BUS.LIC n CO2�ANYNtt� I E-IJ�dII I FAX ST--ET DP SS I .CITY,STATE ZIP PHONE L ARM i---CTIENa]N Err.RNAlymL ICc''.SENu-1aER. I BUS.LIC' COMPFNYNAIJE I E-1J,An. I FAX STREET ADDRESS CrIY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAI My PROTECT L*I WILDLAND ❑ YES moTECT TN ❑YES IS Thr.BLDG AN ❑ YES BIJII DRG ❑ I v OI NO EICRHO�4 CONm&mL URANIL= — NO DESCRIPTION OF WORKJ >✓(�. C c1.Q GBh n/e ./, / f a oC �[ 1� .L �5 -W J l�Lt/�2�5' / �/` dL/ { 1►1 S%de t 1 / a Sr de t 4d # a J ��s l li � i�si`de i ©ufsro�e� coh ned7 rz- sh �►, ed � 1. eem-per cam- ., hear 6'use • v i a u�d-Q,- v e. czc .S' eP1 erg - v(a a "d-en [ C TOTAL VALUATION: By r„y sienave belo�,,I certify to each of tha foil tiring: I zm u,e property ov mer or authorized went to act on u:e prope•y owner's behalf. I have read this application and the information I have provid d is rrect I have read the Description of'Work-and veriY it is accurate. I agree to comply vrith all applicable local ordinances and state la\vs relating to bLilov' o coon horze representatives of Cupertino to enter the above-identii ed pr pen ty for iapection purposes. a ✓ Da d Simnature of Applicant!. en-t: ate: SUPPLEMENTAL LNTMILATION REQU�fi tED t ' Im - ---._ - x �f= — W 1PAIiscpp_2011.doc revised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 21451 COLUMBUS AVE DATE: REVIEWED BY: MENDEZ APN: BP#: "VALUATION: $100 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY SFD or Duplex PENTAMATION 1 REAP10 USE: p PERMIT TYPE: WORK ADD ELECTRICAL CONNECTIONS TO 2 SHEDS 6 OUTLETS AND 4 LIGHTS 2 SWITCHES SCOPE Elec.Plan Check 0.0 hrs $0.00 L/P ;I Elec.Permit Fee: IEPERMIT F1,11"'I'lh, . ln,5r=. Li t dwiv Plumb/Ylsp. � Other Elec.Insp. 0.0 hrs $47.00M.>A l�ec'' I'lloilb. /ins/�. Tee' E:iet.'. lust.!,'ec�� NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). These _f fiees are based on the relimina information available and are onlyan estimate. Contact the Detor addn'l info. FEE ITEMS (Fee Resolution 11-053 a.* 7/1/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 ® # Electrical Suppl. PC Fee: Reg. 0 OT 0.0 hrs $0.00 $47.00 IBREMRECEP Recep/Switch/Outlets PME Plan Check: $0.00 2 Electrical Permit Fee: $0.00 $70.00 IBREMFIXT Fixtures,Lighting Suppl. Insp. Fee:Q Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $47.00 it Tay.- F Administrative Fee: ]ADMIN $44.00 0 Work Without Permit? 0 Yes (E) No $0.00 E) Advanced Planning Fee: $0.00 Select a Non-Residential Travel Documentation Fee: 1TRAVDOC $47.00 Building or Structure , Strom Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldp,Stds Commission Fee: IBCBSC $1.00 $139.50 $117.00 TOTAL FEE: $256.50 � v Revised: 04/0112014 a OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE CUPERTINO,CA 95014-3255 CUPERTtNO (408)777-3228• FAX(408)777-3333•building0cupertino.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 ADDRESS ' _ / APN BP# Qyj ! OWNER NAME w t _ OWNER ADDRESS DESCRIPTION OF WORK: r0V 11'e 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.) L�1_1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner- Builder"building permit that r 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. l9 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. �Jr—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. \_2-�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. 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. W- 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. t�7. I 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 ��8. ispunder contract with a_licensed general building Contractor. 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. OwneYBuildeYFonn 2010.doc revised 04114110 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. �K10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I —mthe party legally and financially responsible for proposed construction activity at the site address listed above. ��y11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide —all applicable laws and requirements that govern Owner-Builders as well as employers. V 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 t ecity ma be required to be presented when the permit is issued to verifythe property owner's signature. Property Owner's Signature: -/" Date: --------------------------------------------------------------------------------------------------------------------------------------------- (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: OwnerBuilderForm 2010.doc revised 04/14/10 a 1�S'1 All" �v . [q- Property line back TINS CUPERpartment co JUN O��`1p�L1ANCE OR GONE '�D' EVIEWE�� • I Reviewer ey" 7ft 3" 1%r, � N ®� side Ju 'I 2" 5ft 4" MENT ERARTMEN / - C U,' bi,NG C; ERTINO S r¢ V'/a Pv, e 00 y 0') P s MUST bo Fra at the /+ g_ dzr�se� d d C XD 1 r W Yl/�64— gkd Ir - �' 3". ."a, ,j -, ,I- �tT�! r M, '��&71�/ U or to dPLOT PLASb m ',� r , `i;cial. CHECKED BY it .i,�, L.NOT «, o, -14 ovd of i' . V,U L - I � 4 DAT <. "'�� �I C, UiiCi f y lil flc ll(2 Or i.r:ia Law. 3LANNIDEPT. D � DATE Pcov.,IT NO.z � 7 a BLDG. DEPT.