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B-2016-1819 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1819 10466 ANN ARBOR AVE CUPERTINO,CA 95014-1660(326 28 018) OWNER/BUILDER OWNER'S NAME: WANG CHANGDEE AND CHIANG PEI-CHUN DATE ISSUED:04/22/2016 OWNER'S PHONE:408-656-0397 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic.# Contractor OWNER/BUILDER Date 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: REPLACE(E)WATER HEATER-50 GALLONS 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:$1300.00 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 APN Number: Occupancy Type: and state laws relating to building construction,and hereby authorize 326 28 018 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 PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CAL SPECTION. Signature Date 04/22/2016 Issued by:MELISS �AME Date:04/22/2016 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for compensation,will do the work,and the structure is not intended or offered for inspection. sale(Sec.7044,Business&Professions Code) NV , If I,as owner of the property,am exclusively contracting with licensed Signature of Applicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date:04/22/2016 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 performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 3Z I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)should I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District 1 Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent APPLICANT CERTIFICATION Date:04/22/2016 1 certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec. 3097,Civ C.) to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabilities, judgments,costs,and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code,Section 9.18. 1 understand my plans shall be used as public records. Signatu e 04/22 016 Licensed Professional GENERAL PERMIT APPLICATION MEP " COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 CUPERT(N0 (408)777-3228• FAX(408)777-3333• building(d)cupertino.org I �-�(i1(o- 1�t� <BI?�G ❑MECHANICAL ❑ELECTRICAL [:1 MISCELLANEOUS PROJECTADDRESS , U`t ` Ann nn /I r b U r ^v f- APN O� an I _- 21 O\\TERNAALE E-1ZAL C \Cr-' q ) 03 ee- D W" F s'Yl STREETADDRESS H /�r� CITY, STATE,ZIP n �i CA F G y N 1" Y,�.j l/ v i CONTACT NAME ',, 1�h PHONTE r'-� ) E-DZAIL STREET.ADDRESS to 6 ri r&� AJ� CITY,STATE,ZIP FAQ $U'ORR.ER ❑ ON NIR-BUII.DER ❑ OR'NER AGENT ❑ CONTRACTOR ❑CONTRACTOR�AG(ENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TEN.kNT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE I BUS.LIC COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC r COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECTWI ❑YES I IS THE BLDG AN ❑ YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOODZONE ❑ NO EICHLERHOME? ❑ NO DESCRIPTION OF WORK R l:.r LA m Cr\--7 Utf S U A U V dU UJ A-re i2 N (,,A—rE—a leo FGj2 TOTAL VALUATION: �� RECEIVED BI ' By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on ths property owner's behalf. I have read this application and the information 1 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. thorize re r tatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED OFFICE f y: O\ER THE CbINtitR �.� ❑..,EaPRESSs � �r _ ❑`ST'A.t�'D'-ARD : ;c '`� ;r; 44' LARGE � t A•1EPA,fisc,4pp=2011.doc revised 06121/11 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)7..77-3333 • building cr cuoertino.cro — CUPERTINO Dear Property Owner(s): An application for a building permit has been submitted in your name lisping yourself as the builder of the property mprovements specified at: - SITE ADDRESS - �..APN.. i3P� OWNER NAMEDDRESS: 1. . "o)- Ala CU ,ere" :. 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 notAssue 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.) G(N 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. U-J 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. Ct1v 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. C� 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. Gw 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. C*� 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. CA,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. OwnerBuilderForm 2010.doc revised 0'/1!/10 Gw 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 wvnv.cslb.ca.gov for more information about licensed contractors. Gw 10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am the parity legally and financially responsible for proposed construction activity at the site address listed above. Q^ 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, l will abide by all applicable laws and requirements that govern Owner-Builders as well as employers. C 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the info rmation-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 maybe in-civil court. Itis also important for you-to understand that if an unlicensed Contractor or employee of that individual or rirm is injured while working on your property, you maybe held liable for damages. If you obtain a perrriifi as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or note 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.) 1 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 owners 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. ---------------------------- ----------------------------------------------------------------------------------------------------------------- (NOTE: The "ollott✓ing Authorization Form is required to be completed by the property ov✓ner 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 verity the property owner's signature. Property Owner's Signature: Date: CxvneYBuild,;-Form ?0J0.doc revised 0!/14/10 SMOKE I CARBOW40ROXIDE ALARMS F1 OWNER CERTIFICATE OF COMPLIANCE COMMUNITY'DEVELOPMENT DEPARTMENT* BUILDING DIVISION 10300 TORRE-AVENUE•CUPERTINO,CA 95014-3255 (408)777-3228•FAX(408)77.7-3383+=building(a cupertino.org .- Okj PURPOSI n—iis affidavit is a self-certification for the installation of all required Smoke and Carbon Monoxide Alarms for compliance with 2013 CRC Section R314,2013 CBC Sections 420.6 and 907.2.11.2 where no interior acc ess.for inspections are required. GENERAL 1N,FORMATION Existing single-family and multi-family dwellings shall be provided with Smoke Alarms and Carbon Monoxide alarms. When the valuation of additions,alterations, or repairs to existing dwelling units exceeds $10001.0`0,CRC Section 8314 and CBC Sections 907.2.11.5 and 420.6 require that Smoke Alarms and/or Carbon Monoxide Alarms be installed in the following locations: AREA SMOKE AL iRM CO t ARM Outside of each separate sleeping area in the irnrnediate vicinity of the X liedroorn(s) On,every level.of a dwelling unit including.basements X Within each sleeping room X Carbon Monoxide alarms are not required in dwellings which do not contain fuel-burning ap .phances and that do not Have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comp y with CSC Section 429.6 and shall be approved by the Office of the State Fire Marshal. Power Supply.In dwelling units with no commercial power supply,alarm(s)nnay be solely battery o;era-ted. In existing;dwelling units, alarms are permitted to be solely battery operated where repairs or alterat ons do not result in the removal'.of wall aild ceiling.fi islnes©r there is na access by means of attic,basement or crawl space.Refer• to CRC Section RZ314 and CBC Sections907.2.11.4 and 420.6.2.An electrical permit is,req irired!for alarins which must be co unected to the building wiring. As owner of the above-referenced pr operty,I Inereby certify that the alarm(s)referenced above hash we been installed inn accordance with the manufacturers instructions and in compliance with the California B uildiilg and Cal�fonaia Residential.Codes.The alarmshave been tested and are operational, as of the date signed below. I have rea, and 2.gree to com,G, with,tha terms anal`conditions of this.statement W div n2EUre:. ...................................A, ie f Z� fD .......... ........... .......... . .. . . I - Si' ........ ......... ......... .. ...._...........L[c .r:............._................... D,te,:. WATER-CONSERVING PLUMBING FIXTURES FIL 1 OWNER CERTIFICATE OF COMPLIANCE 7 COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION CUPERTIINO 10300 TORRE AVENUE.CUPERTINO,CA 95014-3255 408)777 3228•FAX(408)777-3333 buitdingCa)cupertino.org Owner Name n rJ (A)QhA Permit Nof 1 k Address _ h U 1. Is your real property a registered historical site? 0 Yes Civil Code Sections 1101.1 through 110.1.8 do not apply. Skip the rest of the form and sign bottom of forin. K No Go to Question 2: 2. Does your real property have a licensed plumber certifying that,due to the age or configuration of the property or its plumbing,installation of water-conserving plumbing fixtures is not technically feasible? 0 Yes Civil Code Sections 1101.1 through 1101.8 do not apply. 0 The licensed plumber's certification has been provided to the Building Division. Skip the rest of the form and sign bottom of form. No Go to Question 3. 3. Is water service permanently disconnected for your building? 0 Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of form and sign bottom of orm. E`3& No Go to Question 4. 4. Is your real property built and available for use or occupancy on or before January 1,1994? No My real property is built and available for use or occupancy after January 1, 1994. Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. 1A Yes My real property is built and available for use or occupancy on or before January 1, 1994. Civil Code Sections 1101.1 through 1101.8 apply. Check one of the three following statements andsign bottom of form.. 5. Please check ONE of the following: �� N My property is a single-family residential real property. See Civil Code Section 1101.4. On and after January 1, 2014,building alterations or improvements shall require all non-compliant plumbing fixtures to be replaced with water-conserving plumbing fixtures throughout the building.On or before January 1,2017,all non- compliant plumbing fixtures shall be replaced with water-conserving plumbing fixtures (regardless of whether property undergoes alterations or improvements). 0 My property is a multifamily residential real property. See Civil Code Section 1101.5. On and after January 1,2014,specified building alterations or improvements shall require non-compliant plumbing fixtures to be replaced with water-conserving plumbing fixtures. On or before January 1,2019,all non-compliant plumbing fixtures shall be replaced with water- conserving plumbingfixtures throughout the building(regardless of whether property undergoes alterations or improvements). El My property is a commercial real property. See Civil Code Section 1101.5. On and after January 1,2014,specified building alterations or improvements shall require non-compliant plumbing fixtures to be replaced with water-conserving plumbing fixtures. On or before January 1, 2019, all non-compliant plumbing fixtures shall be .replaced with water- conserving plumbing fixtures throughout the building(regardless of whether property undergoes alterations or improveme ats). 1,as the owner or owner',s agent of this property,certify under penalty of perjury that non-compliant plumbing fixtures will be replaced prior to date specified above with water-conserving plumbing fixtures in accordance with Civil Code Sections 1101.1 through 1101.8,the current California Plumbing Code and California Green Building Standards Code,and manufacturer's installation requirements,and that the water-conserving plumbing fixtures comply with the requirements as indicated in the table on the following page. Owner or Owner Agent's Signature Date: , Upon completing and signing this Certificate,please return it to the Building Division in order to final your building permit. SB4072015.doc evised 08/26/15