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15070188CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 7497 BOLLINGER RD CONTRACTOR: ZHANG HENGLIANG ET PERMIT NO: 15070188 AL OWNER'S NAME: ZHANG HENGLIANG ET AL 7497 BOLLINGER RD DATE ISSUED: 07/27/2015 OWNER'S PHONE: 4083076298 CUPERTINO, CA 95014 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL ❑ ENCLOSE (E) FRONT PATIO (90 S.F.). REMODEL (E) License Class Lie. # KITCHEN (140 S.F.) & REMODEL (E) MASTER BATH (74 Contractor Date S.F.) 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 Sq. Ft Floor Area: Valuation: $80000 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. APN Number: 35923027.00 Occupancy Type: 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 to building construction, and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PE OR upon the above mentioned property for inspection purposes. (We) agree to save r ��SUANCE 180 DAYS F SPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the LA granting of this permit. Additionally, the applicant understands and will comply s e YI with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date FS: All roofs shall be inspect o any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. �1 IV OWNER- BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation, ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) I, 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 I hereby affirm under penalty of perjury one of the following three California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: I have and will maintain a Certificate of Consent to self - insure for Worker's Health & Safety Code, Section 25532(a) should I store or handle hazardous 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 I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Secti 25505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized Dater permit is issued. - agent: I 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 Compensation laws of California. If, after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION 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 source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. gg Signature Da CUPERTINO F-1 WW CONSTRIJCTiON CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255 (408) 777 -3228 • FAX (408) 777 -3333 • building )cuoertino.org /,5-0 -�- /,o G 4 ADT)MON n ALTERATION / Ti- F-1 REVISION / DEFERRED ORIGINAL PERMIT #_ PROJECT ADDRESS 74--j-7 (3-0 L 1-1 ` T7N o27 OWNERNAME ( PHONE r -MAIL ag1G t• r Elii�S�Q�� Qlt llGl�dA �7�� STREET ADDRESS - (� � CITY, STATE, ZIP _,+p -`) N�jIJ 7 / 1 `� CONTACT NAME �, PHONE � �� / ,� C� E -MAIL f 2 � �. STREET' ADDRESS /I CITY, STATE, ZIP FAXh oL V7 OWNER ❑ OWNER- BUILDER ❑ OWNER AGENT ❑ CONTRACTOR •❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTORNAME f �_ LICENSE NUMBER LICENSE 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 P 1.5 to Z t ® p s v 1 6 v's', EXISTING USE PROPOSED USE CONSTPL TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM -] KITCHEN REMODEL AREA REMODEL AREA OTHER REMODEL AREA - { t PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: DETACH ❑ ATTACH I # DWELLING UNITS: IS A SECOND UNIT []YES SECOND STORY ❑ YES BEING ADDED? []NO ADDITION? ❑ NO PRE - APPLICATION ❑YES IF YES, PROVIDE COPY OF is THE B B� _ _ � � � TOTAL VALUATION: � # PLANNING APPROVAL LETTER EICHL OME? ❑ N PLANNING APPL []NO - n ? ;Sc 0015Z By my signature below, I certify to each of the following: I am the property o or au on agen o act on the prope 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 comp y 1 a plicable local ordinances and state laws relating tobuilding construction. I authorize repr sen i es of Cupertino to enter the above - identified property for inspection purposes._ . Signature of Applicant/Agent: Date: SUPPLEMENTAL T0N REQ n Iir�TUiF� , F _ New SFD or Multifamily dwellings: Apply for demolition permit for AHFr E SUILDGPLrV ItEti iRW NEW existing building(s). Demolition permit is required prior to issuance of building x r permit for new building. r rL$1n�TG E�IT2EVIEW P g t ❑,rs�ticvQTUCS Commercial Bldgs: Provide a completed Hazardous Materials Disclosure'sTANn f _ form if any Hazardous Materials are being used as part of this project.�� `Y x �}u ' �y� Copy offlanning Approval Letter or Meeting with Plannin g P rior to su_ bmittal of Buildin g PP Permit application. BIdgApp_2011.doc revised 06121111 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION lial. ADDRESS: 7497 BOLLINGER RD DATE: 0712712015 REVIEWED BY: MELISSA PC FEE ID APN: 359 23 027 BP #: *VALUATION: $80,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRIMARY USE: SFD or Duplex 2nd Unit? = Yes (D No .OTC? Yes (j)N0 PENTAMATION 1 R3SFDADD PERMIT TYPE: WORK ENCLOSE .E FRONT PATIO :90 S.F.. REMODEL E KITCHEN 140 S.F. & REMODEL E SCOPE MASTER BATH (74 S.F.) 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 90 $1,091.00 IADDPLCK $1,057.00 IADDINSP ] :lee. Insp. Fee: $0.00 74 s.f. $645.00 Remodel, Bath (< =300 sf) IREMRESBAT Permit Fee: $1,057.00 Suppl. Insp. Fee: Reg. OOT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 TOTALS; 90 $1,091.00: $1,057.00 MEI✓H2OVRLY Fes s No 6 PLUlVIB,IOI)RLY Yes ' No ELC, $UURLY Yes No 11e ch..P1cin Check I'lzrmb. Plan t;heek ]Flee. Plan Check: Alech. Permit Fee: F1,111mb'Perinit Fee: Llec. Permit Fee: Other 11ech. bssp. Other Plun b In pS Weir lase. Insp. Afech. hnp. Fee: Plumb. Insp. Fee: ] :lee. Insp. Fee: $0.00 74 s.f. $645.00 Remodel, Bath (< =300 sf) IREMRESBAT NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public rrurks, rare, -uaacu•y Y•�.• Nn�atn_ Cnntact the Dent for addn'1 info. District, etc.. Inese ees are based on ine reurraaur FEE ITEMS (Fee Resolution 11 -053 Ef. 7/f 1/13) us o•..wsw•• ��••��•� FEE �••� �• QTY /FEE -•• - -_ __.______ MISC ITEMS Plan Check Fee: $1,091.00 MZ Remodel, Kitchen (< =300 sf) IREMRESKIT Suppl. PC Fee: Reg. OT 0.0 hrs $0.00 PME Plan Check: $0.00 74 s.f. $645.00 Remodel, Bath (< =300 sf) IREMRESBAT Permit Fee: $1,057.00 Suppl. Insp. Fee: Reg. OOT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 C "onstr uetlnn Tax: f &ninL4lrative Fee: Work Without Permit? 0 Yes No $0.00 Advanced Planning Fee. IPLLONGR $12.60 Select a Non-Residential Building or Structure E) 0 Travel Strong. Motion Fee: IBSEISMICR $10.40 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $4.00 SUBTUTAL;a $2,175.00 $1, 290.00 TOTAL FEE ° $3,465.00 Kevisea: 07/02/2-0-15 CAPER ENGINEERING INC. P.O BOX 14198, FREMONT, CA 94539 Tel: (510) 668 -1815 Fax: (510) 490 -8690 Project No. 10381 October 7, 2015 Building Department City of Cupertino 10300 Torre Avenue Cupertino, CA 95014 -3232 Subject: Addition and Remodeling at 7497 Bollinger Rd. Cupertino, CA (Permit No. 1507088) SPECIAL INSPECTION SERVICES FINAL AFFIDAVIT FOR DOWELS INSTALLATION WITH EPDXY Dear Sir: CAPEX ENGINEERING INC., has provided testing and special inspection services at the subject site in accordance with section 1701 of the California Building Code (2013 Edition) as listed below: (1) Inspection of #4 x 6" min. embedment; dowels installation with Epoxy for connection of new and existing footings at specific locations. (2) All drilled holes for receiving dowels installation were cleaned of dust and debris and adequate in depth to embed into existing concrete. Personnel under the general supervision of a registered Civil Engineer performed these inspections. Based on the inspections performed and upon our substantiate reports that the inspected work was performed, to the best of our knowledge, in conformance with the approved plans and specifications and the applicable workmanship provisions of the California Building Code. Sincerely, APEX ENGINEERING INC., G U, Principal roQPorE IS S,oti� Q� Gp,RY H � 1 U w No. ; E* v'� !�! qV� OF t 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 cDcupertino.org — ar Property Owner(s): application for a building permit has been submitted in your name listing yourself as the builder of the property ,rovements specified at: ADDRESS F3a1' 1 APN.:. e Z BP NER NAME OWNER ADDRESS :. fi RC-i r ;CRIPTION OF WORK: "Cf 0 2M-rdmce- Ar 1 . ASV OOM . IrWe are providing you with an Ownet- 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.) . I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - r" building permit that erroneously implies that the property owner is providing his or her own labor and material sally. I, as'an Owner - Builder, may be held liable and subject to serious financial risk for any injuries sustained by icensed person and his or her employees while working on my property. My homeowner's insurance may not e coverage for those injuries. I am willfully acting as an Owner - Builder and am aware of the limits of my nce coverage for injuries to workers on my property. �2. 1 understand . building permits are not required to be signed by property owners unless they are responsible for , onstruction and are not hiring a licensed Contractor to assume this responsibility. 13. 1 understand as an "Owner- Builder" I am the responsible party of record on the permit. I understand that I may ;ct myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her e instead of my own. A. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license bers on permits and contracts. Z. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the value of my construction is at least five hundred dollars ($500), including labor and materials, I may be ;idered an "employer" under state and federal law. �6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and eral government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to ;mployment compensation for each "employee." I also understand my failure to abide by these laws may subject to serious financial risk. . I understand under California Contractors' State License Law, an Owner - Builder who builds single - family ntial structures cannot legally build them with the intent to offer them for sale, unless all work is performed by :d subcontractors and the number of structures does not exceed four within any calendar year, or all of the work ormed 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 incial or personal injuries sustained by any subsequent owner(s) that result from any latent construction in the workmanship or materials. OwnerBuilderForm 2010.doc revised 04114110 I understand I may obtain more information regarding my obligations as an "employer" from the Internal e Service, the United States Small Business Administration, the California Department of Benefit Payments, California Division of Industrial Accidents. I also understand I may contact the California Contractors' State Board (CSLB) at 1- 800 - 321 -CSLB (2752) or www.cslb.ca.gov for more information about licensed 10. 1 am aware of and consent to an Owner - Builder building permit applied for in my name, and understand that I ie party legally and financially responsible for proposed construction activity at the site address listed above. 11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide I applicable laws and requirements that govern Owner - Builders as well as employers. l f 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the in i7rmation- [-have- provided on this form. Licensed contractors are regulated by-laws designed to protect.the..public. If . y 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. 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 maybe 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 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.) 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. Property Owner's Signature: Date: _.. 5 (NOTE: The following Authorization Form is required to -b- e completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner - Builder). AUTHORIZAT[ON 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: 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 owners signature. Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revised 04114110