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B-2016-2300CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-201.6-2300 604 MILLER AVE CUPERTINO, CA 95014-4640 (375 42 016) OWNER -BUILDER OWNER'S NAME: JAN SEAWAY AND HUNG CHIAYING TRUSTEE OWNER'S PHONE: 408-887-2301 LICENSED CONTRACTOR'S DECLARATION License Class Lie. # Contractor OWNER -BUILDER Date 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: 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. 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. 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 to building construction, and hereby 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 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 9.18. Signature Date 09/20/2016 I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: a. 1, 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) (N • i. , "I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three 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. 1 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. `J( ti 3. , I certify that in the performance of the work for which this permit is issued, I 1 shall not employ any person in any manner so as to become subject to the Worker's 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 forthwith comply with such provisions or this permit shall be deemed revoked. 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 to building construction, and hereby 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 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 9.18. l Date 09/20/2016 ISSUED: 09/20/2016 PHONE NO: BUILDING PERMIT INFO: X BLDG —ELECT _ PLUMB _ MECH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: ENCLOSE INTERIOR PATIO TO CREATE (1) BEDROOM, BATHROOM, LAUNDRY CLOSET AND LIVING ROOM (345 S.F.). REMODEL/CONVERT (E) DINING ROOM TO (N) BEDROOM #5 (150 I Sq. Ft Floor Area: 345 I Valuation: $45000.00 APN Number: Occupancy Type: 375 42 016 Deferred Submittal (R -3),R-3 (Custom) PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued Date: ( RE -ROOFS: 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. Signature of Applicant: Date: 09/20/2016 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous 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 the Health & Safety Code, Sections 26505,25533, and 25534. c Owner or authorized agent:, - — Date: 09/20/2016 CONSTRUCTION LENDING AGENCY hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE CUPERTINO, CA 95314-3255 CUPERTINO (408) 777-3228 • FAX (408) 777.3333 • buildinng@cuoeriino.ora 1 r 2 El NEW CONSTRUCTION 9 ADDITION D(ALTERATION / TI 1 rI RRVTRH\N i T)EFRRR Fn 0DIf:TATAT ARTthRTT 44 P 0 CT ADDR SS APN # y - O HRk ON E-MAIL S RSET ARE !' TY, STATZ FAX 0 TACT NA95 lau, -. av AIL. STREET ADDRESICITY, STATE ZIP 1,02 0 pAX © OWNER ❑ OWNHR-BUILDER © OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ARCH= ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSENUMBER LICENSETYPE BUS, LIC# COMPANY NAME E-MAIL FAX S'T'REET ADDRESS CITY, STATE, ZIP PHONE R HPrECT/ENGIN ER NAME LICENSE NU, BER BUS, LIC A!- C-28 4 COMPANY NAME MAIL // FAX t G • hf I, $TREE Aa�DRES� n ,n t� e_ TY, STAT IP 0 A PHO -�� 2dLAdt9 - :2 49 1�iESCRIP'TIONZ7F WORK— �-- a � X_ 'e !!r G! � FrTwl2 JAW OA bAt 2 a Lau r , EXISTING USE PROPOSED USE CONSUL TYPE ilSTOR7E5 - L 1 f t Vb USE TYPE OCC, SQ,FT, VALUATION ($) EXISTG AREA 1S4 NEW FLOOR AREA' DEMO AREA TOTAL NET AREA (goo i 4 - BATHROOM KITCHEN _ OTHER -- - - REMODEL AREA REMODEL AREA REMODEL AREA 50 PORCHAREA DECKAREA TOTALDECK/PORCH AREA GARAGHAREA: ❑DETACH - - 2 O )4 ATTACH #DWELLINGUNITS: ISASECONDUNIT ❑YES SECOND STORY - [I YES - - �- BEING ADDED? gNO ADDITION? O -17 PRE -APPLICATION ❑YES IF YES, PROVIDE COPY OF ISTHEBLDGAN YE -VALUATION: PLANNING APPLN tl 'NO PLANNING APPROVAL LETTER EICHLER HOML"� � - - -••_•••, MU By Dry signature below„ I certify to each of the following: I am the property owner or authorized agent to act o e property owner's behalf. I have react this application and the information I have provided is correct. I have read the Description of Work and verify i ]s accurate. I agree to comply with all applicable local ordinances and state laws relating to building coil tluction. I representatives of Cupertino to enter the above -identified property for/ inspection purposes. authorize Signature ofApplicant/Agent: A=t�I~ a �i Date: 7LL� 2 2trl to SUPPLEMENTAL INFORMATIQX REQUIRED WW. -. . :.ROUTING 5I,TP= :- ❑ o\ ER TI 40oIIT�TER ❑ BUTLD1IiG PLAN RELIE\3 — New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition pen -nit is regaircd prior to issuance of building permit for new bulldrng.©_-YI ANINGPLAN RE\iEN.. -.: ... :. Commercial 13idgs: Provide a completed Hazardous Materials Disclosure _._ s�aNDARD . ....:.......:::. „ ,,_rvxT IC \ orclts . ...::. Tor—in if any Hazardous Materials are being used as ;part of this project. ❑ - D . LARGO; .:', `FIREDEPT- Copy of PI u'n Approval Letter or Meeting With Planning ri r to - - - - - - ❑ R3AdOR - -- - ❑ SAM1tTARY,SE\iERDISTRICT,;,--'`:. submittal of Building Permit application. : "- : : B1dgApp_2011.doc revised 06121111 OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE + CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 , buildinpna.cupertino.ord 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 l I e APN 3 7 f — I ry r O/ c OWNER NAME rGii �� Un OWN AD R 6v� SS / a DESCRIPTION OF WORK: Ch GIT if t [ (r C 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 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. 1, 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. 2. l 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. L (NA 4. L understand Contractors are required by law to be Licensed and bonded in California and to list their license numbers on permits and contracts. 041. " 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. CA r�6. l 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. 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. 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. ON?72e7BuilderF'oi7n 2010.doc revised 04114110 011 l 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. C��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. Q11-1111. 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. c4— 2. I 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 to the city may be required to be presented when the permit is issued to verify the property owner's signature. c\ l I Property Owner's Signature:,,' \ Date: c\;Do, 2.0. ---------------------------------------------------------------------------------------------------------------------------------------- (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: OwnoBuilderFo»n 2010. doe revised 04/14/10 CONTRACTOR/ SUBCONTRACTOR LIST City Of Cupertino 10300 Torre Avenue Cuperti-aq, &S601 -325`5 Telephone: 408-711-3228 Fax: 408-777-3333 _s W sUTIV BUSINESS NAME BUSINE SS LICENSE # !�-7 17 Busmss Ll NSE myfju �WC1TY/Z1PC0DE: j,r utimicypat coae reqmres an businesses working in the city to have a City of Cupertin# t- R FINAL OCCUPANCY INSPECTION(S)WILL BE SCHEDULED UNTIL ME GENERAL CONTRACTOR AND ALL SUBCONTRA, 'PTORS ILXVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. -7 1 am not using any subcontractors: -Z& Sigdature Date Please check applicable subcontractors and complete the following informaflon! V SUBCONTRACTOR BUSINESS NAME BUSINE SS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flowing I Carpeting Linoleum I Wood Glass / Glazing Heatrag Insulation Landscapbig Lathing Masonry Painting /"Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile ONVidr / dontractor sq%naAjre n IT /� 17 Date I i CUPERTINO Address PURPOSE SMOKE / CARBON MONOXIDE ALARMS OWNER CERTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building 1..cupertino.org 4{ QY-+ I g 9 B -d� 1 1 r dd t'i s� lE�## nf� army c Cmn�ra �PERMIYCANNOT BE FINALED AND coMPLETEI) UNTEL THISt t `'EEN SIGN 7 ` TO ill ► ■ 16-x.30 This 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 access for inspections are required. GENERAL INFORMATION 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 $1000.00, CRC Section R314 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 ALARM CO ALAR_ M Outside of each separate sleeping area in the immediate vicinity of the bedroom(s) X X On every level of a dwelling unit including basements X X Within each sleeping room X Carbon Monoxide alarms are not required in dwellings which do not contain fuel -burning appliances and that do not have an attached garage. Carbon monoxide alarms combined with smoke alarms shall comply with CBC Section 420.6 and shall be approved by the Office of the State Fire Marshal. - - Power Supply: In dwelling units with no commercial power supply, alarm(s) may be solely battery operated. fit existing dwelling units, alarms are permitted to be solely battery operated where repairs or alterations do not result in the removal of wall and ceiling finishes or there is no access by means of attic, basement or crawl space. Refer to CRC Section R314 and CBC Sections 907.2.11.4 and 420.6.2. An electrical permit is required for alarms which must be connected to the building wiring. As owner of the above -referenced property, I hereby certify that the alarm(s) referenced above has/have been installed in accordance with the manufacturer's instructions and in compliance'with the California Building and California Residential Codes. The alarms have been tested and are operational, as of the date signed below., 1 have read and agree to comply with the terms and conditions of this statement Owner (or O�nrne� Agents} Namei� e 4 a., ................... ........ I............. .......................................................•. Dafe: iA2.4.:.: -Cdnfractor_Nam.d {Si nafure..........................................ic.#...................................s.Date: :.................. Smoke and CO form.doc remised 03/18/14 X97 CUPERTINO Owner N WATER -CONSERVING PLUMBING FIXTURES OWNER CEIRTIFICATE OF COMPLIANCE COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE a CUPERTINO, CA 950143255 777-3221® FAX (403) 777-3333 • buildino(a.cugertino.org FILE Address i 9 H 1eAVe � y+ (11 CA O 4 w 1. Is your real property a registered historical site? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. ,r �1 No Go to Question 2. 2. Does your real property have a licensed plumber certifying that, due to the age or configuration of the properly or its plumbing, installation of water -conserving plumbing fixtures is not technically feasible? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. ❑ 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? ❑ Yes Civil Code Sections 1101.1 through 1101.8 do not apply. Skip the rest of the form and sign bottom of form. JJR 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. JAf 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 and sign bottom of form.. �ease 5. check ONE of the following: ir— MY property Y is a single-family residential real property. ySee 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). ❑ 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 plumbing fixtures throughout the building (regardless of whether property undergoes alterations or improvements). ❑ My properly 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 improvements). I, 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 naee. Owner or Owner Agent's Signature. ^_ Date. ;_a I. 0 6 Upon completing and signing this Certificate, please return it to the-l�uilding Division in order to final your building permit. SB4072015.doc revised 08/26/15