15010159CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10397 AVENIDA LN
CONTRACTOR: DING IGNATIUS Y AND
PERMIT NO: 15010159
JOSEPHINE
OWNER'S NAME: DING IGNATIUS Y AND JOSEPHINE
10397 AVENIDA LN
DATE ISSUED: 03/30/2015
OWNER'S PHONE: 4084462011
CUPERTINO, CA 95014-3946
PHONE NO:
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL E]
❑ LICENSED CONTRACTOR'S DECLARATION
CONSTRUCT ENCLOSURE AT GARAGE (144 SQ FT) TO A
License Class Lie. #
ELEVATOR SHAFT (36 SQ FT) AND INSTALL
RESIDENTIAL
Contractor Date
ELEVATOR TO THIRD FLOOR.
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:"aluation:
$60000
I have and will maintain Worker's Compensation Insurance, as provided for by
APN Number: 34245041.00
Occupancy Type:
Section 3700 of the Labor Code, for the performance of the work for which this
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
WITBIN 180 DAY + RMIT 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 OM L ALLED 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
ssued
granting of this permit. Additionally, the applicant understands and will comply
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.
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)
as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.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(x) 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
'ons
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Se 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized ag t: Date3l-51CVI�
permit 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
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, after making this certificate of exemption, I
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
with all non -point sourc lations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Date
Signature til
V v
CUPERTINO
F7
'� 9
CONSTRUCTION PERMIT APPLICATION \D
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION / O
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX ((408) 777-3333 • building o-kupertino.org \
I8) 1 . I 1 AT =D ATTn i I 7 M Az'VTQ1nM /7lFFFpPPn nRT(-TNAT. PFRMTT4
PROJECT ADDRESS
APN # r
OWNER NAME
(V
PHONJ/ �r
ej
t&mfff1 1 N
(� C��
STREET AD RE 5
CITY, STATE, ZIP
FAX / r , I [ Z� 1
zi4 �1
Mu
C 7c / ,
�! j`; D
CONTACT N lk
-T
PHON J
b ?SOI1A
E-MAIL
di
STREET DRES`
CITY, STATE, Z,,IpP u AX 1 Q I)
im
❑ OWNER OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME T ,
I
LICENSE NUMBER 7T
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 nn .-
w �� -E LO 1�t ��t� l.�Or
j\ p
V'h 18UN i
E ISTIN USE
PROPOSED USE CONSTR.
TYPE
# STORIES
USE TYPE OCC.
SQ.FT.
VALUATION (S)
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECKAREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
❑ ATTACH
# DWELLING UNITS:
IS A SECOND UNIT El YES
SECOND STORY ❑ YES
BEING ADDED? ❑NO
ADDITION? ❑NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ RE C TOTAL VALUATION:
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
By Iny signature below, I certify to each of the following: I am the property owner or authorized agent to aAon tl perty owner's behalf. I have read this
application and the information I ha provided is correct. I have read the Description of ork and verify i accurate. I agree to comply with all applicable local
ordinances and state laws relating to uilding c I authorize.representatives o upertino to enter the above- identifie roperty for inspection purposes.
Signature ofApplicant/Ag t: l Date: y
SUPPL MENTA IN ORMATION UIRED
PLAN CHECK TYPE
ROUTING SLIP
❑ OVER-THE-COUNTER
❑ BUILDING PLAN REVIEW
New SFD or Multi roily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ EXPRESS
❑ PLANNING PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PuBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
[],LARGE
❑ PTRE DEPT
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH-
BldgApp_201 1. doc revised 06/21/11
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
OCCUPANCY TYPE:
ADDRESS: 10397 AVENIDA LN
DATE: 01/27/2015
REVIEWED BY: MELISSA
PC FEE ID
APN: 342 45 041
BP#: Q
*VALUATION: $60,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY
USE: SFD or Duplex
2nd Unit? - Yes •` No
OTC? QYes GNo
PENTAMATION 1 R3SFDADD
PERMIT TYPE• i
WORK
ADD 180 S.F.-TO ENCLOSE (N) PERSONAL ELEVATOR FROM GROUND TO 3RD FLOOR
SCOPE
Suppl. Insp. Fee:Q Reg. Q OT
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
R-3 (Custom)
II-B,III-B,IV,V-B
180
$1,091.00
IADDPLCK
$1,057.00
IADDINSP
Permit Fee:
$1,057.00
Suppl. Insp. Fee:Q Reg. Q OT
0.0
Iirs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
0
E)
Work Without Permit? Yes E) No
$0.00
TOTALS:
180
$1,091.00
�7°iaV€'1 1)CaCltfYtc't7itZllllf9 fetes
$1,057.00
Strong Motion Fee: IBSEISMICR
MECH, HOURLY 0 Yes (j) No
PLUMB, HOURLY 0 Yes No
ELEC, HOURLY 0 Yes 0 No
•-- --- ----------
MISC ITEMS
Plan Check Fee:
Fk; f.:..f Cnbnn/
NOTE: This estimate does not include fees due to other Departments (Ge. Planning, ruouc Rurns, Fire, ou,tstury Jcrrcr .�.�.•.�y �•
_ _ Contact the Dent for addn'1 info.
District,et, . mese ees are oases un the retarrarsa,
FEE ITEMS (Fee Resolution 11-053 E . 7/1/13)
trt �,,,...... ,. ».�..»
FEE
•� _..— ---
QTY/FEE
•-- --- ----------
MISC ITEMS
Plan Check Fee:
$1,091.00
Select a Misc Bldg/Structure
or Element of a Building
• OT
Suppl. PC Fee: 0 Rr 0
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$1,057.00
Suppl. Insp. Fee:Q Reg. Q OT
0.0
Iirs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
0
E)
Work Without Permit? Yes E) No
$0.00
Advanced Planning Fee. IPLLONGR
$25.20
Select a Non -Residential 0
Building or Structure 0
A
�7°iaV€'1 1)CaCltfYtc't7itZllllf9 fetes
Strong Motion Fee: IBSEISMICR
$7.80
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$3.00
SUBTOTALS:
$2,184.00
$0.00 TOTAL FEE:
$2,184.00
Revised: U1/Ub/2015
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
I Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS:
SUBCONTRACTOR
PERMIT # iS01 0 /
OWNER'S NAME:
NE # -65C) —'FE - Oq 53,
GENERAL CONTRACTO —
BUSINESS LICENSE #
ADDRESS: 10 S
CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL S O=CTORSBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE. &
I am not using any subcontractors: b
ignature Date
Please check applicable subcontractors and complete the following information:
r/
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner / Contractor Signature
Date
1�
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building olcupertino.org –
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#
OWNER NAM`
� k
OWN ADDRESS
� fl � � C &(Z T f,4
DESCRIPTION OF WORK: E71 — D
a �' 1.kt 0 �a kek
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)
AC N 1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner -
B Bi
lder" 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.
�V_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.
(fix 3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may
111 p—rrTTot— ect 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 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
tofal value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
�
conn�sidered an "employer" under state and federal law.
N`V 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.
(W7. 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.
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 04/14/10
1 A-49. 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 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.
110. 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.
%A911. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
Gy All applicable laws and requirements that govern Owner -Builders as well as employers.
12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
info mation 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 pe(mit is issued
to verify the property owner's si.wat r l pe(
Property Owner's Signature: °�_�)� Date:
------------------------7--------------------------------------------------------------------------------------------------------------------
(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:
Address of Authorized Agent:
Tel No
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