B-2016-1469 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1469
10777 ALDERBROOK IN CUPERTINO,CA 95014-4652(3 69 21 043) Ho Chun Edison Wong
And Xingying Cheng
10777 ALDERBROOK
IN
OWNER'S NAME: Ho Chun Edison Wong And Xingying Cheng DATE ISSUED:03/04/2016
OWNER'S PHONE:2156888989 PHONE NO:2156888989
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor Ho Chun Edison Wong And Xingying Cheng Date 3/4/2016 X BLDG —ELECT —PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
REMODEL KITCHEN(126 S.F)AND HALLWAY_BATHROOM(49 S.F.)
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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.
2. 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. Sq.Ft Floor Area: Valuation:$6000.00
APPLICANT CERTIFICATION
certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county APN Number:. Occupancy Type:
ordinances and state taws relating to building construction,and hereby 369 21 043
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 PERMIT EXPIRES IF WORK IS NOT STARTED
expenses which may accrue 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 with all non-point source regulations per the Cupertino Municipal 180 DAYS FROM LAST CALLED INSPECTION.
Code,Section 9.18.
Issued by:PAUL O'SULLIVAN
Signature Date /4 2/ 016 Date:3/4/2016
OWNER-BUILDER DECLARATION RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed.If a roof is
following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
:-1. I,as owner of the property,or my employees with wages as their sole inspection.
compensation,will do the work,and the structure is not intended or offered
for sale(Sec.7044,Business&Professions Code) Signature of Applicant:
2. I,as owner of the property,am exclusively contracting with licensed Date:3/4/2016
contractors to construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 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 HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance,as provided for California Health&Safety Code,Sections 25505,25533,and 25534. I will
by Section 3700 of the Labor Code,for the performance of the work for which maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
this permit is issued. Health&Safety Code,Section 25532(a)should f store or handle hazardous
3. I certify that in the performance of the work for which this permit is issued,I material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the 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
Worker's Compensation laws of California. If,after making this certificate of the Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner or authorized agent:
be deemed revolted. Date:314/2016
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance
correct.I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued(Sec.3097,Civ C.)
relating to building construction,and hereby authorize representatives of this city Lender's Name
to enter upon the above mentioned property for inspection purposes. (We)agree
to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally,the applicant ARCHITECT'S DECLARATION
understands and will comply with all non-point source regulations per the I understand my plans shall be used as public records.
Cupertino Municipal Code,Section 9.18. ,
Licensed
Professional
Signature Date /4/3 2016
................_.._..._.........._.....
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333 build ing(aD-cupertino.org
CUPERTINO
NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/Ti ❑ REVISION/DEFERRED ORIGINAL PERMIT#
PROJECT ADDRESS '®)17 -A LL1 0 L Lou,e- APN# Yoq � 0 3 q
OWNER NAME l �" a PHON /7-� `Q E-MAILn P,(e&6�
Vy
1-/
E`ab°IN
STREET ADDRESS dr CITY, STATE,ZIP FAX
CONTACT NAME t J PHONE S(`�f g C E-MAIL
ss 7�j{� (�
STREET ADDRESS C�7 7-7 � O 1 CITY,STATE, ZIP r FAX
Epn 127Y7
& OWNER ❑ OwNEI R.BUILDER( ❑ OWNERAGENT`_r-, �CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECTS ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER 7CFNISE TYPE BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
'STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK . ?
EXISTING USE PROPOSED USE- CONSTR.TYPE #STORIES T -USE TYPE OCC. SQ.FT. VALUATION($)
EXISTG NEW FLOOR DEMO TOTAL -
AREA AREA AREA NET AREA
BATHROOM - KITCHEN / OTHER -
REMODEL AREA f REMODEL AREA REMODEL AREA
PORCH AREA DECK AREA TOTAL.DECKTORCH AREA GARAGE AREA: DETACH
ATTACH
#DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY []YES
BEING ADDED? E]NO ADDITION? E]NO
PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN []YES M
D BY °- TOTAL ALUATION:
PLANNING APPL# F NO PLANNING APPROVAL LETTER EICH LER HOME? NO
1
By my signature below,I certify to each of the following: I am the property thorizeb 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 co cti I authorize representatives of Cupertino to enter the above-idea'fled property or ins ection purposes.
Signature of Applicant/Agent `_ -,Date: -
SUPPLEMENTAL INFORMATION REQUIRED ' F
New SFD or Multifamily dwellings Apply for demolition permit for
OVER THE COL7�TEA �UILDIAG PLA71 I2E\IE$' �
existing building(s). Demolition permit is required prior to issuance of building '
permit for new building. 1] EREss PLAVNiI�4GPL4hI2EYIEw r
a
_Commercial Bldgs: Provide a completed Hazardous Materials Disclosure STA''DARU'° ❑`PrJBLIcoxxs ,
form if any Hazardous Materials are being used as part of this project.
LARGE FIRE DEPT
_Copy of Planning Approval Letter or Meeting with Planning prior to
D MAJORz } SAVITAR7SE\4ERDISTRICT
submittal of Building Permit application. .'
I] .ENS IRO\15IENTA HEALTH'
BIdgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 10777 ALDERBROOK LN DATE: 03/04/2016 REVIEWED BY: PAUL
APN: 369 21 043 BP#: "VALUATION: 1$6,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition
PRIMARY SfD or Duplex PENTAMATION
USE: pPERMIT TYPE: 1 R3SFDREM
WORK REMODEL KITCHEN 126 S.F AND HALLWAY BATHROOM 49 S.F.
SCOPE
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These,fees are based on the prelimina information available and are only an estimate. Contact the Det or addn'l info.
FEE ITEMS (Fee Resolution 11-053I ff. 11/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 F__49__1 s.f. Remodel,Bath(<=300 sf)
Suppl.PC Fee: Q Reg.. Q OT Fo.0 hrs $0.00 $645.00 IREMRESBAT
PME Plan Check: $0.00 129 Js.£ Remodel,Kitchen(<=300 sf)
Permit Fee: $0.00 $645.00 IREMRESKIT
Suppl.Insp.Feer Reg. 0 OT 0.0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
1C.32'r P :l` ISL} 1•s:s`;'.. 0
Work Without Permit? 0 Yes No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential •>
Travel _c,c r�, rt„ f`_'es.' Building or Structure 0
A
Strong Motion Fee: IBSEISMICR $0.78 Select an AdministrWItBldg SStds Commission Fee: IBCBSC $1.00
SUHTOTALS:: $1,290.00- TOTAL FESRe
s OWNER-BUILDER DISCLOSURE FORM
G COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO, CA 95014-3255
(408)777-3228 FAX(408)777-3333•buildino(a)cuoertino.org
CUPERTINO
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 .(: -�
0A ok -. APIC BPS 9 .
OWNE NAI��iEr-, �/ OWNER ADDRESS. �JJ
n �t v1 E�,1, bX011 VV t9 _. I 4 17x6
DESCRIPTION OF WORK: fbom
- 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. l 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.
W3. I 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,
I �!L4. I 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" under state and federal law,
F,f&L16. 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." 1 also understand my failure to abide by these laws may subject
me to serious financial risk.
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
is performed under contract with a licensed general building Contractor.
i8. 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
LW�9. I 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 understandI may contact the California Contractors' State
License Board(CSLB) at 1-800-321-CSLB (2752)or wvAv.cslb.ca.gov for more information about licensed
contractors.
10. I am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that 1
am the party legally and financially responsible for proposed construction activity at the site address'fisted above.
PRIXil 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.
E/(A/12. I agree to notify the issuer of this form immediately of any additions, deletions, or changes to any ofthe
information-I-have-provided on this form. Licensed contractors are regulated by.Jaws 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 maybe in civil court. Itis 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
yod 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 drivers 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. 44
Property Owner's Signature: Date: EW6
---- ------------------------------------------------------------------------------------------------------------------ ---------------------
(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
c N
FcGO
o 0
f M N
/ OTC
5� � I
,3
CFC
A
Py.OFI yoo r.II
156" "t '
cup .'. . , , 33" 30" 15 36"
120 • b
nu
MARp c' t
54" 822," 2
19 " o
3 30" 15"11„ 3 " 1 ,„ s~ 12
REVIEWED FOR c 1, 'U N ,t
Reviewed B �
o a.,�.
. �
W3330 W3042 W1542
RW362124
co S 6 B30 BTP 9 24 o g rn 00 ey
:h "' m w dMM
o3Utw�
N N z
r N R m
T
T
(J"T�
0
Z
M r ch o00
oce Me
w0
co
x
NPB o
N N m +� rl
O
m ++ m r
COMMUNITY D6!NT!NT DEP,i�TMEN o ��� 't
3UiLDIN OIVl3i0 !-GUPSP INiO m
APP FIOVED
This set of plans and specifications MUST be kept t the
ON
job site during construction. it isunlawful to make any d M o �
charges or sitet'aUons on same,or'LO deviate �.
therefrom,vvithout approval from the Building O idai.
The stamping of this plan and spe cifications SHALL.NOT REPC EI
be hold'to permit or to be an aprC)`Y.eil of to 9e 1,:ih'& ,S:1
of`.t y rovisi®a`1s of any City Ordinance or eo,,v,
BY
DATE BYPERMIT N9
i
Cly
4
CUPERTINO
Building Department
E q 0 4 2096
REVIEWED FOR CODE COMPLIANCE
Reviewed By;
�g
:kNja
C
r �