12050061CITY OF CUPERTINO BUILDING PERMIT J
BUILDING ADDRESS: 10497 ANSON AVE
OWNER'S NAh1E: MARK J ZAVISLAK & CHEN ZHENG
OWNER'S PHONE: 6509440167
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic.9
Contractor 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.
1 hereby affirm under penally of perjury one of the following two declarations:
I have and will maintain a certificate of consent to scl6insure 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 (he Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
I certify (hat 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 budding 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.
❑ OWNER-RUILDF-R DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, mid the structure is not intended or offered for sale (See 7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contmetors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
declarations:
1 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.
I certify [hat in the performance of the work for which this permit is issued, I shall
not empluy any person in any manner so as to become subject to the Worker's
Compensation laws of Califoxnia. 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 eenify that 1 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, Scclion
9.18.
Signaturllz& - Dater 12_
CONTRACTOR: MARK 3 ZAVISLAK & PERMIT NO: 12050061
CHEN ZHENG
10497 ANSON AVE- DATE ISSUED: 05/04/2012
CUPERTINO. CA 95014 PHONE NO:
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
MECH r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: KITCIiEN REMODEL(120 SQIT) THREE BATHROOM
REMODELS
(70 SQFT)INSTAI.I. (35) NEW L GI ITS AND (2) NEW
OUTLETS
Sq. Ft Floor Area: I Valuation: $20000
APN Number: 32641110.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM /LAAST CALLED INSPECTION.
Issued by: � N /7i7I- 1, Date: I/ -%a-
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. Ira roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of
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. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should 1 store or handle hazardous material.
Additionally, should 1 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 & Safely Code, Sections 25505, 25533, and 25534.
agent:
Date:/l 'X-
APPLICANT
L
CONSTRUCTION LENDING AGENCY
I hereby affmn that there is a construction lending agency for the performance of wirk's
for which this permit is issued (See. 3097. Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
8 ITEMS OF 8
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN 32641110.00
DATE ISSUED.......: 05/07/2012
RECEIPT #......... :,BS000016730
REFERENCE •ID # ...: 12050061
SITE ADDRESS .....: 10497 ANSON AVE
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: patg
COPY # : 1
OWNER ............: MARK J ZAVISLAK & CHEN ZHENG
ADDRESS ..........: 10497 ANSON AVE
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM ....:MARK J ZAVISLAK
CONTRACTOR .......: LIC # *OWNER*
COMPANY MARK J ZAVISLAK & CHEN ZHENG
ADDRESS 10497 ANSON AVE
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
TELEPHONE ........:
FEE ID
UNIT
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
----------
NEW BAL
----------
----------
-ADMIN
-------------
HOURS
-- `-------
1.00
----------
41.00
----------
0.00
41.00
0.00
1BCBSC
VALUATION
20,000.00
1.00
0.00
1.00
0.00
1BREMFIXT
NO. FIXTURES
35.00
125.00
0.00
125.00
0.00
1BREMRECEP
NO. OUTLETS
2.00
44.00
0.00
44.00
0.00
1BSEISMICR
VALUATION
20,000.00
2.00
0.00
2.00
0.00
1EPERMITFE
FLAT RATE
1.00
44.00
0.00
44.00
0.00
1REMRESOTH
SQ FEET
190.00
392.00
0.00
392.00
0.00
1TRAVDOC
FLAT RATE
1.00
44.00
0.00
----------
44.00
----------
0.00
----------
TOTAL PERMIT
----------
693.00
0.00
693.00
0.00
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT :
AMOUNT
---------------
693.00
---------------
693.00
REFERENCE NUMBER
--------------------
#1021
CUPERTINO
OWNER -BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT "BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(408) 777-3228 " FAX (408) 777-3333 " buildina(Mcuoertino.oro
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 lOT47 /j /t�� Ave—
APN �6_q' _"O
BP#
OWNER NAME/y �r�(
M4 t lJ�la
OWNERADDRE S
/O T pS ve-
DESCRIPTION OF WORK: SCS e.
,eh
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 verity this information.)
PSI—T. I 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.
'£. 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.
M9'31 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.
P176-4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
JR115. I 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.
tAR�:_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.
%K4-7. 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.
Atc: . 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.
OwnerBvilderForm 1010. doc remised 04114110
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
LMADDRESS:
10497 Anson Ave
DATE: 05/04/2012
REVIEWED BY: Sean
1,J1 I.-r,vit Fey,
APN:
BP#:
-VALUATION:
$20,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
I71e_ bnP, Pc C.
PENTAMATION 1R3SFDREM
PERMIT TYPE:
WORK
Kitchen remodel 120 sq ft three bathroom remodels 70 sq ft install 35 new lights and 2 new
SCOPE
outlets.
NOTE: This estimate does not includejees due to other Departments (ie. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the oreliminary information available and are only an estimate Contact the Dept for addn'I info.
FEE ITEMS (hcc Resolution I7-053 Eff. 717//1)
I tr, h. M,u, i'h,-,:{.
Pnu„h. Pio„ Owe A
Elec. Plan Check 0.0 1 hrs $0.00
1,J1 I.-r,vit Fey,
Ph"O. P'!,nw Fe :
Elec. Permit Fee: IEPERMIT
or/w, � y„ h. Imp,.
ndw, Plwnh ln'p.Ll I
Other Elec. Insp.0.0 hrs$44.00
.Ilr,h. M,p. I,"
Plu.. h. luny. Fe"
I71e_ bnP, Pc C.
NOTE: This estimate does not includejees due to other Departments (ie. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the oreliminary information available and are only an estimate Contact the Dept for addn'I info.
FEE ITEMS (hcc Resolution I7-053 Eff. 717//1)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
190 s.f.
$392.00
Remodel, Other
IREMRESOTII
Suppl. PC Fee: (j) Reg. 0 OT
F0,01
hrs
$0.00
PME Plan Check:
$0.00
F-2-1
$44.00
Electrical
/BREMRECEP Recep/Switch/Outlets
Permit Fee:
$0.00
Suppl. Insp. Fee.0 Reg. 0 OTF0_01hrs
$0.00
= Electrical
$125.00IBREMFIXT I Fixtures, Lighting
PME Unit Fee:
$0.00
PME Permit Fee:
$44.00
ConYll'lwlion Tay.
Administrative Fee: (ADMIN
$41.00
O
E)
Work Without Permit? 0 Yes ID No
$0.00
Advanced Plannine I'ce:
$0.00
Select a Non -Residential
Building or Structure
(D
0
A
Travel Documentation Fee: ITRAVDOC
$44.00
Strom; Motion Fce: IBSEISMICR
$2.00
Select an Administrative Item
131de Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$132.00
$561.00
TOTAL FEE:
$693.00
Revised: 04/01/2012
CUPERTINO I
❑ NEW CONMUCTION
2c
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING OMSION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildina65�cupertino ora
❑ ADDITION ® ALTERATION/TI M Rt=_VTSTnNinpc on nvrrrver RVRurra
PROJECT ADDRESS /OfiA7 AR,e^ Ave
A"Na 3atog1-/10
OWNERNAME/Qrk. ZNvI;6� -r Cke"71"
PHONE 6sO-7ff—ZO7, /E-wkm
"" /OtR 7 HKOn Ave—
FAX
arr. STATE ZIP C SNC (A I
gj011f
CONTACT NAME
/WdL#_L A V {SIU
o7r E-MAIL
STREET ADORESS iO%(� -? Aasc ,-
CITY.
Y•STATE IIP C "ro CA ICO/Y
1
FAX
u
Lofow ❑ OwNER- arLDER❑ OWNERAGENT E3 CONTRACTOR ❑CONTRAC;ORAGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVE[APER ❑ TE*IAJ�r
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS. LIC k
COMEANYNAbIE
E-MAIL
FAX .
STREET ADDRESS
CITY. STATE, IIP
PHONE
ARCHITECDENOINEER NAME
LICENSE NUMBER
BUS. LIC!
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY. STATE ZIP
PHOTO?
DESCRIPTION OF WORK //
tel.✓ /alJ
/�/TG /✓� ,- SG /-77-)T GCJ
E;OSTW OSE
PROPO USE
CONSTATYPE
JMRffS
G
-5
V
USE
TYPE
OCC
SQ -FT.
VALUATION (s)
EOSTONEW
AREA,:??/e) D
FLOOR -
AREA � -1
DEMO
AREA
TOTAL
NEr AREA a/Go
-
BATHROOM KITCHEN OTHER
REdOOELAREA //o REMODELAREA
REMODELARE1 7,9 1
PORCHAREA OECXAREI
TOTALOECK/PORCHAAEA GARAGEAREA: -DETACH
I
ATTACH
I
O DWELLING UNITS:
6A SECOND UNIT YES
SFCONDSTORY CIM
/
BEENG ADDED? O
ADDLTTOM �NO
PRE -APPLICATION LJYES [F=PROVDECCPYOF
PLANNINGAPPLp 0 PLANNING APPROVAL LEITER
LS THE BIDG AN
KICHLDI H0MX?. NO
RECEIVED -
TOTAL VALUATION:
By Dry sigDatme: below, r cerCfy to each of the fallowing: lain Lhe property aWner or aathorized aaenr to act on the pr pperty owaeb^half I Gave mud tL4s
application and the mfinania r. I have provided is correct I have read the Description of Work and verify it is accemte. I agree to comply with a➢ applicable local
ordinances and state laws relator ding CCOn. I amahoria repLeseutatives of Cupertino to enter the above-identifed property for inspection parposes.
Siguatne of Applicant/ Date: S- <0)
SUPPLEMENTALUgF TIONREQU=
PLANCRECXTYPE
ROUTING SLIP
LJ�OVYR.TtZ{om=
❑
New SFD or Muldfamily dwel][ings; Apply for demolition permit for
existing bmlding(s). Demolition permit is required prior to issuance of building
/
N(n 1)ING PLAN REVIEW
permit for Dew building.
❑ EXPRPss
❑ PLANPNG PLAN REVIEW
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ STANDARD
❑ PDBLIC WORKS
form if nay Hazardous Materials are being used as part of this project
❑ LARGE
❑ FIRE pppT.
_ Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
❑ sACBTARYSEWER
submittal of Building Permit application.
nrsralcr .
❑ MWIRON:YD:MTAL BEAT TH.
Bldghpp_2077.doc revised 06/2!/77
JOB COPY
THIS PLAN SHALL REMAIN ON
THE JOB AT ALL TIMES DURING
CONSTRUCTION
I04q7 A"on Avc, c-farf to
APN 9 -3a6 -q1 -0C)
Qzvz Par�14 Am 'g-/4/2012-
COMMUNITY
/4/2012
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COMMUNITY DEVELOPMENT DEPARTMENT
BUILDING DIVISION - CUPERTINO
APPROVED
This set of plans and specifications MUST be kept at the
Job site during construction. It is unlawful to make any
J�p
changes or alterations on same, or to deviate
therefrom, without approval from the Building Official.
The stamping of this plan and specifications SHALL NOT
be held to permit or to be an approval of the violation
of any provisions of any City Ordinance or State Law.
BY ✓�A/VAT�ji
I]}3
JD
DATE
�:i
QPr *3
PERMIT NO. �a q
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