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15050025CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: 15050025 18196N ,}jJSOM AVE CUPERTINO CA 95014 (375 30 014) }}ff 1404 THIEL RD HAYWARD, CA 94544 OWNER'S NAME: DONG LINDA N AND DAVID M DATE ISSUED: 08/14/2015 OWNER'S PHONE: 408-859-1707 PHONE NO: 510-305-9411 LICENSED ONTR .TOR' DECLARATION BUILDING PERMIT INFO: License Class CONTRACTOR - GENERAL Lic. # Contractor Date 08/31/2016 —BLDG _ELECT _PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing MECH _ 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: CONSTRUCT A ONE STORY ADDITION (493 SQ FT) TO CREATE (N) I hereby affirm under penalty of perjury one of the following two declarations: BEDROOM, BATHROOM & LIVING ROOM. RE-ROOF (E) 1 I SQ'S, 1. I have and will maintain a certificate of consent to self-insure for Worker's UPGRADE ELECTRICAL PANEL (200 AMP). Compensation, as provided for by Section 3700 of the Labor Code, for the "SUNNYVALE SANITARY" C performance of the work for which this permit is issued. have and will maintain Worker's Compensation Insurance, as provided for by Revision #2: Revise scope of work to convert addition into a second Section 3700 of the Labor Code, for the performance of the work for which this dwelling unit (493 Sq ft)-ISSUED 5/4/2016 permit is issued. APPLICANT CERTIFICATION REV #1 - DIMENSION CHANGE AT HALLWAY TO FAMILY I certify that I have read this application and state that the above ROOM information is correct. I agree to comply with all city and county ordinances ISSUED 10/27/2015 and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for Sq. Ft Floor Area: Valuation: $73000.00 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. APN Number: Occupancy Type: Additionally, the applicant understands and will comply with all non-point 375 30 014 source regulations per the C ertino Municipal Code, Section 9.18. PERMIT EXPIRES IF WORK IS NOT STARTED Signature Date 05/04/2016 WITHIN 180 DAYS OF PERMIT ISSUANCE OR OWNER-BUIL ER DECLARATI N 180 DAYS FROM LA N. I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: Issued by: MELISSA AMES 1. I, as owner of the property, or my employees with wages as their sole Date: 08/14/2015 compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) RE-ROOFS: z. I, as owner of the property, am exclusively contracting with licensed All roofs shall be inspected prior to any roofing material being installed. If a roof is contractors to construct the project (Sec.7044, Business & Professions Code). installed without first obtaining an inspection, I agree to remove all new materials for I hereby affirm under penalty of perjury one of the following three declarations: inspection. 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 Signature of Applicant: performance of the work for which this permit is issued. Date: 05/04/2016 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 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER permit is issued. I I certify that in the performance of the work for which this permit is issued, I HAZARDOUS MATERIALS DISCLOSURE shall not employ any person in any manner so as to become subject to the I have read the hazardous materials requirements under Chapter 6.95 of the Worker's Compensation laws of California. If, after making this certificate of California Health & Safety Code, Sections 25505, 25533, and 25534. I will exemption, I become subject to the Worker's Compensation provisions of the maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Labor Code, I must forthwith comply with such provisions or this permit shall Health & Safety Code, Section 25532(x) should I store or handle hazardous be deemed revoked. material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I APPLICANT CERTIFICATION will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I certify that I have read this application and state that the above information is the Health & Safety Code, Sectio s 25505 25533, and 25534. 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 Owner or authorized agent: to enter upon the above mentioned property for inspection purposes. (We) agree Date: 05/04/2016 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 I hereby affirm that there is a construction lending agency for the performance and will comply with all non-point source regulations per the Cupertino Municipal of work's for which this permit is issued (Sec. 3097, Civ C.) Code, Section 9.18. Lender's Name Lender's Address Signature Date 05/04/2016 DECLARATION _ARCHITECT'S I understand my plans shall be used as public records. Q—A CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(a.cupertino.org ❑ NEW CONSTRUCTIOX ❑ ADDITION ❑ .ALTERATION / TI 7 REVISION/DEFERRED ORIGI NTAL PER 2S PROJECT ADDRESS .APN R &WS0 t ,�rV " 34s- - 3 v - o OWNER NAME PHONE E-MAIL WNPA STREET.ADDRESS CITY, STATE, ZIP FAX CONTACT NAME PHONE E-MAIL f MH P 6r U U - ISH I a) i>NHI u STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OIA-NER-BUILDER ❑ ON'NERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX V N HI L G STREET ADDRESS CITY, STATE, ZIP HAYL)� PHONE ARCHITECT/ENGIN'EER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME EAIALIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WORK �i1J�>(✓Q(�tTI�I�,' 'iy EXISTING USE PROPOSED L CONSTR. TYPE r STORIES USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG NEN\' FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECY PORCH AREA GARAGE AREA: DETACH ❑ ATTACH r DWELLING UNITS: IS A SECOND UNIT ❑ YES SECOND STORY ❑YES BEING ADDED? E] No ADDITION"? ❑NO PRE -APPLICATION ❑ YES IF YES. PROVIDE COPY OF IS THE BLDG AN ❑ YES RECEIVED. BY- -' TOTAL V 'PION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO By my signature below, I certify to each of the following: I am the property owner or authorized agent t act on the o erty owners 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 comply with all applicable local ordinances and state lames relating to buildiiA constl ion. I authorize presentatives of Cupertino to enter the above 'denti Ied property for inspection purposes. I Signature of Applicant/Agent: �1Date: SUPPLEMENTAL ENTFORI\7ATION QUIR PLAN CHECK TYPE ROUTING SLIP © ovEu-TxE-cotJNrER ❑ BUILD1N6 PLAN REVIEW Nei',' SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building hermit for new building. '.❑ EXT RE ❑ PLA-N\PLAN. REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure © STANnARD; ❑ PUBL1CNVORKS' form if any Hazardous Materials are being used as part of this project. AFCE Copy of Planning Approval Letter or Meeting with Planning prior to © NLaaoR ❑ 5.4�\IT.4R] SE"ER DISTRICT _ submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH Bldg4pp_2011.doc revised 06/21111 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18790 NEWSOM AVE CONTRACTOX PERMIT NO: 15050025 uIVt-1lQiSE C:ON.1-12ucl—ioiJ OWNER'S NAME: DONG LINDA N AND DAVID M DATE ISSUED: 08/14/2015 OWNER'S PHONE: 4088591707 PHONE NO: ,g LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL ❑ License Class__ 1Sl CONSTRUCT A ONE STORY ADDITION (493 SQ FT) TO Li,. #�O CREATE (1) BEDROOM, BATHROOM & LIVING ROOM. Contractor RE -ROOF (E) 11 SQ'S "SUNNYVALE SANITARY" 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: $73000 performance of the work for which this permit is issued. 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: 37530014.00 Occupancy Type: APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IFOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating �SSUANCE to building construction, and hereby authorize representatives of this city to enter WITHIN 180 O OR upon the above mentioned property for inspection purposes. (We) agree to save 180 D LED INSPEC ION. 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 compl s Y: Date: with all non -point source regulations per the Cupertino Municipal Code, Se ion 9.18. 1/ l Signature Date b 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 ElOWNER-BUILDERDECLARATION in I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. of Applicant: Date: q (,s— the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation; ALL ROOF COVERINGS 40 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. 1 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 Compensation, as provided for by Section 3700 of the Labor Code, for the material. Additionally, should I use equipment or devices which emit hazardous 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 Section 3700 of the Labor Code, for the performance of the work for which this the Health & Safety Code, Sections 2 50�5,,� 5533, and 25534. , permit is issued. Owner or authorized agent: vvt/ T%"� Date:T 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 1 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 Lender's Address 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, 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. Signature Date CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228• FAX (408) 777-3333 • building(d)cuoertino.org ❑ NEW CONSTRUCTION ❑ ADDITION I I AT.TF.RATTow/TT n nFVTcrnr.I/ IIDT!_TKTAT 'D= PROJECT ADDRESS 18 7c. O n 1 (zm-,,5-OrrL- Avg r . rr APN 7/^- ^ OWNER NAME�� P O E-MAIL Devi of la)(K;l _ !) STREET ADDRESS CITY, STAT ,ZIP � 7 FAX CONTACT NAII_ , e / HONE E-MAv STET ADDRE$3 , CTIY�STATE FAX 1 n. O El OWNER ElOWNER-BUIIAER N5/ 0"NERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT` CONTRACPORNAMELT 7i d, CENSE NUMBER LICENSETYPE 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 ` 2 04- 664 EXISTING USE PROPOSED USE • CONSTR TYPE 41 STORIES A-1 USE TYPE OCC. SQ.FT. VALUATION (S) AREA AREA NEW I-LOOR• AREA EMO AREA TOTAL NET AREA -7 3 BATHROOM. KITCHEN. OTHER. REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA . DECK AREA TOTAL DECK11 /PORCH AREA GARAGE AREA: LJ DETACH ❑ ATTACH DWELLING UNITS: ISASECOND UNIT AYES SECOND STORY []YES BEING ADDED? E] NO ADDITION? [:]NO PRE -APPLICATION ❑YES IF YES, PROVIDE COPY OF PLANNING APPL n E] NO . PLANNING APPROVAL LEITER IS THE BLDG AN ❑YES EICHLER HOME? ❑ NO .s11.s-'"}'"- "''� _-� � � TOTAL VALUATION: �..�"' l By my signature below, I certify to each of the following: I am the property aut n e���� act On erty owner's behalf. I have Tea this application and the information I have provided is c ect. I ave read the Description of o Fa[fd veli curate. I agree to comply with all applicable local ordinances and state laws relating to building con tion. I uthorize representativ Upertino r the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: �✓� SUPPLEMENTAL INFORI,4A N REQUIRED Q : t7 �3� CHECKTYP� s _�'. v.: ROTiT13�GSLIP� =F ' s _ New SFD or Multifamily d«vellings: Apply r demolition ermit for p� w� existing building(s). Demolition permit is required prior to issuance of buildmQ OVERH.1rCOUNTER — FBUILDIIV#GPLALIREYIESi permit for new building. cEXPRESS ® k�i g �* �g�` RLANp�NGPL6N REVIEw� ` $An _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure C s�pNDARn r ��`�, form if any Hazardous Materials are being used as part of this project. �J �rTr DY LaR> 4 �I�Err yfUZI- AN _ Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. tix-LF1MA70R W R;DISTRIC� 3� BldgApp_2011.doc revised 06/21/11 MGM CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION FEE ID ROOF AREA s.f. 1 REROOFFRES 1,100 ADDRESS: 18790 newsom ave DATE: 08/14/2015 REVIEWED BY: melissa 1 Meeh. Perazit Fee: APN: BP#: G C 0 . *VALUATION: Iso PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re -roof PRIMARY SFD or Duplex USE: P 1'htmb. lash. (itc: PENTAMATION PERMIT TYPE: 1 SFDWLROO i WORK add re -roof a 11 s 's to scope SCOPE aSuppl. 177sp Fee FEE ID ROOF AREA s.f. 1 REROOFFRES 1,100 NOTE: This estimate does not include fees due to other Departments (i. e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the vreliminary information available and are only an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 E . 7111132 leclr..Plcni Check Phunb. Plan C'lieek Elec. Plan Check 1 Meeh. Perazit Fee: Plumb. P, rntit Fee: Elec. Perrrrit Fee: Other.adccli. lna'I'• Other- Phanb .h p. Other Flee. hasp. Ll rilech. Insp. Fee: 1'htmb. lash. (itc: F,iec. /nSp. Fee: NOTE: This estimate does not include fees due to other Departments (i. e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the vreliminary information available and are only an estimate. Contact the Dent for addn'l info. FEE ITEMS (Fee Resolution 11-053 E . 7111132 FEE QTY/FEE MISC ITEMS Plan Check Fee: Supy)l. PC Fee Plumb. ilAxh.lVec Permit Fee: $187.00 aSuppl. 177sp Fee 1'1 urnb.,%Tech. ;`Flee Plumb.;'!lfech.l'Clec .Pernut Fee: Construction Tax: Acln inistrative Fee: Work Without Permit? 0 Yes (F) No $0.00 4dvanced .Plitnning Fees: Travel Doc:urnentaiion Fees: Strong Motion Fee: IBSEISMICR $0.00 Select an Administrative Item Bldg Stds Commission Fee: $0.00 S.LTBTOTALS` $187.00 $0.00 TOTAL FEE _ $187.00 Revised: 07/02/2015 CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 18790 NEWSOM AVE DATE: 05/06/2015 REVIEWED BY: MELISSA APN: 375 30 014 BP#: *VALUATION: $73,000 PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition pRMpgy 2nd Unit? Yes No PENTAMATION 1 R3SFDADD USE: SFD or Duplex OTC? C) Yes GNo PERMIT TYPE: WORK I ADD 493 S.F. TO CREATE N BEDROOM BATHROOM & LIVING ROOM SCOPE 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 493 $1,626.00 IADDPLCK $1,323.00 1ADDINSP PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: Achninistrative Fee: Work Without Permit? 0 Yes (F) No $0.00 Advanced Planning Fee: 1PLLONGR $69.02 Select allon-Residential Building or Structure Trm,el Documenlalion fees: Strong Motion Fee: IBSEISMICR $9.49 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $3.00 TOTALS: 493 $1,626.00 $3,030.51 $1,323.00 1VIECH, HOURLY 'Yes No PLUMB, HOURLY, Yes HAURLY M . 6 Yes , No. Mech, Plan Check Plumb. Plan C:'lr,7ek Elec. Plan Check Afech. Permit Fire., Plumb. Permil Fee: I Elec. permit Tee: LjOther ;1 /ech. Insp. 011ier Plumb Insp. Oiher Elec. Insp. Ilech. Insp. fire: Plumb. Insp. Fee: Elec. Insp. Fee: LL_ ill..Wwrirt .School NOTE: This estimate does not tnctuae fees a to orner vepararrucru3 1tic. 1--sy District, etc.). These ees are based on the preuntuna FEE ITEMS (Tee Resolution 11-053 E . 7/1/1A3 m ormuuorz uvuuuum FEE u, -- QTY/FEE MISC ITEMS Plan Check Fee: $1,626.00 Select a Misc Bldg/Structure or Element of a Building • Re OT 0.0 hrs Suppl. PC Fee: � g. PME Plan Check: $0.00 $0.00 Permit Fee: Suppl. Insp. Feer Reg. Q OT 0,0 hrs $1,323.00 $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: Achninistrative Fee: Work Without Permit? 0 Yes (F) No $0.00 Advanced Planning Fee: 1PLLONGR $69.02 Select allon-Residential Building or Structure Trm,el Documenlalion fees: Strong Motion Fee: IBSEISMICR $9.49 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $3.00 SVBTOTALS� $3,030.51 $0.00 TOTAL FEEz $3,030.51 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 18790 NEWSOM AVE CONTRACTOR: UNHIQUE PERMIT NO: 15050025 CONSTRUCTI6N OWNER'S NAME: DONG LINDA N AND DAVID M 1404 THIEL ROAD DATE ISSUED: 08/14/2015 OWNER'S PHONE: 4088591707 HAYWARD, CA 94544 PHONE NO: (510) 305-9411 LICENSED CONTRACTOR'S DECLARATIONJOB DESCRIPTION: RESIDENTIAL E] COMMERCIAL License Class !� �Q CONSTRUCT A ONE STORY ADDITION (493 SQ FT) TO CREATE BEpROOM, Lia. # �/ (N) BATHROOM & LIVING ROOM. RE-ROOF (E)11SQ'S "SUNNYVALE SANITARY** Contractor_O 1 1 Date 1 1( j Rev #1 I hereby affirm that I am licensed under the provisions of Chapter 9 — Dimension change at hallway to family room —Issued 10/27/15 (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 Co ensation, as provided for by Section 3700 of the Labor Code, for the Sq. Ft Floor Area: Valuation $73000 ormance of the work for which this permit is issued. 1). APN Number: 37530014.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter 180 DAYS FROM LAST CALLED INSPECTION. 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 Issued b Date: tjc" Z granting of this permit. Additionally, the applicant understands and will comply with all non-point source r lati s per the Cupertino Municipal Code, Section 9.18. Signature ,/ v Date 0 G E/ t RE-ROOFS: RE-ROOFS: —i— All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without ,rst obtaining an inspection, I agree to remove all new materials for El OWNER-BUILDER DECLARATION inspection. I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: 1. I, as owner of the property, or my employees with wages as their sole ALL; ROOF COVERINGS TO BE CLASS "A" OR BETTER compensation, will do the work, and the structure is not intended or offered for 1 HAZARDOUS MATERIALS DISCLOSURE sale (Sec.7044, Business &Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sea7044, 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 maintain I hereby affirm under penalty of perjury one of the following three declarations: compliance with; the Cupertino Municipal Code, Chapter 9.12 and the Health & 1. I have and will maintain a Certificate of Consent to self-insure for Worker's Safety Code, Section 25532(a) should I store or handle hazardous material. Compensation, as provided for by Section 3700 of the Labor Code, for the Additionally, should I use equipment or devices which emit hazardous air performance of the work for which this permit is issued. contaminants asdefined by the Bay Area Air Quality Management District I will maintain complihnce with the Cupertino Municipal Code, Chapter 9.12 and the 2. I have and will maintain Worker's Compensation Insurance, as provided for by Health & Safety!Code, Sections 25505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Owner orj�nthh ��ent: �✓� 3. I certify that in the performance of the work for which this permit is issued, I shall �iL, J Date: C 2 not employ any person in any manner so as to become subject to the Worker's LCTION Compensation laws of California. If, after making this certificate of exemption, I CONST LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I I hereby affirm that there is a construction lending agency for the performance of work's must forthwith comply with such provisions or this permit shall be deemed for which this permit is issued (Sec. 3097, Civ C.) revoked. Lender's Name Lender's Address 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 ARCHITECT'S DECLARATION to building construction, and hereby authorize representatives of this city to enter I understand my plans shall be used as public records. upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, Licensed Professional 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 - - -- CONSTRUCTION PERMIT APPLICATION COM%4UNITY DEVELOPP+FENT DEPARTI%AENT • BU)LDIt\G DIVISIO 10300 TORRE AVENUE • CUPERTINO, CA 95014-5255 ACU PEE�Tttdi) (408) 777-3228 • FAX (408) 777-3333 • building cuverlino.or I I vipW 71 F" _ _ u it ravivi Li M4 Itbvµ5lUtyr/DEFHRRED ORIGRZALPEiRMITz �`��% ! wL•s PRO.7ECT ADDRESS @ V ® APN r t� 30 i� OGVNERNAIVM PHONE ^ f t STREET ADDRESS CITY, STATE, ZIP a�a ds FAX ' % COIviACT NAIVE Q epi PHONE E-MAIL�10) 1,0 I Aj VIn'% e - C r S TR ET ADDRESS CITY, STATE, ZIP FAX OVhcR ❑. OW-NER-BUILDER ❑ O'A'hcRAGEN`T ❑ CONTRACTOR E3COIvTRACTORAG,N-r ❑ ARC=!',CT ❑ ENGINMER ❑ DEVELOPER ❑ icNAf r CONTRACORNA _H l � LICtfiSENUJJ EIS R i I LICENS TYPE ( BUS. LIC � COIVPANY NA ,S v J 43�✓ L I FAX STREET ADDRESS CITY, STATE, ZIP I PHOlhr ARCHrfECTrNGWEFR NE1VE LICENSE h''JIVBER _ i � I BUS. LIC n COMPANY NAME E•MF3L i FAX STREET ADDRF-SS I CITY, STATE, ZIP PHONE DESCRIPTIONT OF WORK y c a/ I i I EXISTING USE PROPOSED USE CONST& TYPE � STORIES I I I i USE TYPE I occ. I SQ.FT. I VALUATION (S) EXISTG A'Fw FLOOR DEMO TOTAL AREA AREA AREA I ?wTETAREA BATHROOM KiTCHEht OTHER REMODEL AREA REMODEL AREA REMODEL.AREA � PORCHAREA DECKAREA TOTAL DECK/PORCH AREA GARAGE AREA: EDDETACH - - []ATTACH I 4-DWELLINGUNTIS: ISASECONDUNIP ❑YES SECOND STORY ❑YES I BEING ADDED? ❑NO ADDITION? No PRI�4,PPLICATION ❑YES IF YES, PROVIDE COPY OF PLANNING APPL R ❑ NO PLAl.'NING APPROVA T LETTER ( IS THE BLDG AN ❑ Yt5 EICHLER HOME? ❑ 2..0 - '�" _ - - TOT.kL VALUATION: By my signature below, I certify to each of the follov ling: I am the property owner or authorized Qen t o e grope ovmer's behalf. I have read this application and the information I have provi ed is co ect. I have read the Description of'Work and verify it is accurate. I agree to comply with all applicable local ordinances and state lavas relating t b Midi co o I authorize presentatives -of Cupertino to enter the above -id tinned p operty for inspection purposes. SignafureofApplicant/Aeent: Date: ro SL-PPLEAIENTALIlIFOR1,�ATION QLI D nGsi10: - New SFD or Multifamily dvvellinQs: Apply for demolition permit for r OAR TEZCOL ITER "�BiT1LDL�GPL RtiZLR7`�' existing building(s). Demolition permit is required prior to issuance of building - permit for new building. Msss= PS 4�AL�GPL�RPE�TER Commercial Bldgs: Provide a completed hazardous Materials Disclosure ;> c vu— i�rAIARD rLIEI��oR�ts r Torn if any Hazardous Materials are being used as part of this project. — - - Copy of Planning Approval Letter or Meeting with Planning prior to SOR submittal of Building Permit appliCatlOIl._ .1-.�SAgiTAi2YSEii�RIDISTdtTCT - —= -�.�- B?dg .pp_2011. doc revised 06121/11 i CITY OF CUPERTINO I FEE ESTIMATOR — BUILDING DIVISION ADDRESS: 18790 Newson Ave DATE: 10%27/2015 REVIEWED BY: Phuong APN: 375-30-014 F :tleCli. PeJ wil Fee: VALUATION: Iso *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition PRSIIMARY SFD or Duplex { flXi':' Elect- _ Itisl?. PENTAMATION PERMIT TYPE: WORK Dimension change at hallway to family room SCOPE $0.00 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the nreliminary information available and are only an estimate Contact the Dent for addn'1 into. FEE ITEMS (Fee Resolution 11-053 E . 711/13) Ifech. Plan ('heck 1'f2r;.th. f'J,F;t C'iresr: Elec. 1>rfzn (,heck F :tleCli. PeJ wil Fee: Pl mb' I nt in;i Tee: Re(. Permif Fee: Other-Vec'h. frup. i�ff2 r' f'ttt7??% fnt;?. { flXi':' Elect- _ Itisl?. ; t'ri 2, IF25Il. I`ee: P"fZ:7i1b. hiJ'r?. f'2c: t8 c. Insp. Fee: NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District, etc.). These fees are based on the nreliminary information available and are only an estimate Contact the Dent for addn'1 into. FEE ITEMS (Fee Resolution 11-053 E . 711/13) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? 0 Yes (j) No $0.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: Reg. OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl_ Insp. Feer Reg. 0 OT 0 0 hrs $0.00 i PME Unit Fee: $0.00 PME Permit Fee: $0.00 j C'£ ns1ruction Kry: Adininl_strative 1yee 0 Work Without Permit? 0 Yes (j) No $0.00 Advanced Planning Fee: $0.00 hours Plan Check, Hourly $143.00 ISTPLNCK i Trtnvl L, oc°ttmenlation Fees: Strong: Motion Fee:. $0.00 Select an Administrative Item Bldg Stds Commission Fee: $0.00 IIBTUTA.: ' $0.001 $143.00 TITALE. $143.00 Revised: 10/01/2015 "NTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fnv- AOSZ-777-1111 JOB ADDRESS: jQXz �ArAA. &V& PERMIT# OWNER'S NAME: LN f 72& DC3V PHONE# GENERAL CONTRACTOR: OAM I OL)E; C - BUSINESS LICENSE'# ADDRESS: 14-t9q EL_ j CITY/ZIPCODE: 44e•u.4, S4,4 -uur municipal code requires all business6s worldng in the city to have a City of Cupertin% business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signaiure Date Please check applicable subcontractors and complete the following information: V 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 Date CUPERTINO Building Department CITY OF CUPERTINO 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 TELEPHONE: (408) 777-3228 • FAX: (408) 777-7606 OFFICIAL NOTIFICATION OF NEW/ADDRESS CHANGE TO: All Agencies FROM: City of Cupertino DATE: May 03, 2016 RE: New/Change of Address APN #375-30-014 Please note the following new address assignment: 18790 Newsom Ave is adding an attached 2nd unit. The main house will remain 18790 Newsom Ave and the attached 2nd unit will be 18788 Newson Ave. See attached map. The new address will take effect 15 days from the date of this letter. Please update your records accordingly. If you have any questions, please call me at (408) 777-3246. Sincerely, Susan Winslow Administrative Clerk Cupertino Building Dept 408-777-3246 or suew@cupertino.org INK LUg� W981, N'7'1 � G (:Oi- - f—:� 1) The' City of FREMONT UNION HIGH SCHOOL DISTRICT 589 WEST FREMONT AVENUE SUNNYVALE, CALIFORNIA 94087 408-522-2200 Developer Impact Fee Compliance Building permits will not be issued without a completed Certificate of Compliance Building Permit Application has received a request for a Building Permit described as follows: __ New Residential Development Residential Addition (501) sq. ft. or more _ Commercial Development Name of Owner / Developer: Project Address: / f�' ` ' -`� ?'� Lot/Parcel # U/ L/ Square Footage: � � Description: Permit / Plan Check # r C;~, r-- Re `' Zai Date: �% //./-. By. City Building Inspector G Square footage verified by the city prior to issuance of a building permit; fees may be adjusted accordingly. Feeder Elementary District SCHOOL DISTRICT DEVELOPER IMPACT FEE CERTIFICATE OF COMPLIANCE The authorized representative of the Fremont Union Nigh School District has reviewed the City of Building Permit Request described above and hereby certifies that the developer or authorized representative has met the requirements of the District's Developer Impact Fee requirements. Dated: By: Certificate not valid without District Seal, Initial, and Date DisTi bu:ion: Facilities Planning —White City — Yellow De, Impact Fee Compliance (Rev. 11/22/05) Fremont Union High School District Authorized Representative Fee $ Requestor — Pink Accounting — Gold [11/14-10001 Cupertino Union School District 10301 Vista Drive, Cupertino, CA 95014 Tel (408) 252-3000 • Fax (408) 865-0326 10931 Developer Impact Fee Compliance The Cupertino Union School District has adopted Resolution Nos. 1403, 1404, and 141501, imposing developer impact fee pursuant to Government Code 53080. Building Permit Request The City of f L� ,t2 �' �has received a request for a Building Permit described as follows: '"Residential Development Project Commercial/Industrial Development Project Name of Developer/0,(kner f ' (m Project Address: Description:z7n!� _:f�T'- Square Footage: LI 9 Ala Lot/Parcel #: 3 45 -'5? O ' D/ % Permit #: -5:) S 00 Z S �i2�-✓ Z� Date: tr / C7 By: City -A thorized Representative Square footage will be verified by the city prior to issuance of a building permit; fees may be adjusted accordingly. Important Notice: Bring this form and payment to 10301 Vista Drive, Property Office. Cupertino Union School District gives no credit for total demolition of existing square footage area, which makes way for new construction as mandated in the Government Code Sections 53080, 53080.6 and 65995. SCHOOL DISTRICT DEVELOPER IMPACT FEE CERTIFICATE OF COMPLIANCE The authorized representative of the Cupertino Union School District has reviewed the City of Building Permit Request described above and hereby certifies that the developer or authorized representative has met the requirements of the District's Developer Impact Fee requirements. Dated: ttnd _QL'_� I'r_ By: DA f Authorized Representative Cupertino Union School District Fee: $ I� Certificate not valid without District seal, initial, and date. Check No.: '4_9% Facilities Planning - White City - Yellow Requestor - Pink Accounting - Gold ,F S U NA, . June 18, 2015 City of Cupertino Building Department 10300 Torre Avenue Cupertino, CA 95014-3255 Subject: 18790 Newsom Avenue, Cupertino, CA 95014 To Whom It May Concern: Please be advised that the proposed building addition as referenced above will not have any adverse impact on the City of Sunnyvale's sewer system. Please call me if you have any questions at (408) 730-7636. Very truly yours, Manuel Pineda, P.E. Director of Public Works Bennett Chun Civil Engineer CUPERTINO CALGREEN RESIDENTIAL CHECKLIST -- MANDATORY ITEMS CUPERTINO COMMUMTY DEVELOPMENT DEPARTMENT - Ot BUILDINq IVISI� � �. Building DoRertme►nt ALBEP,T%SALVADOR, P.E., C..B4O., BUILDING OFFICIAL 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 JUN 19 2015 (408) 777-3228 - FAX (408) 777-3333 - building6aicupertino.org PURPOSE: �EVIEW/EG FOR (:OJE COMPLIANCE Rev well r3� The 2013 CalGreen Code applies to all newly constructed hotels, motels, lodging o ses, wellings,/�� dormitories, condominiums, shelters, congregate residences, employee housing, factory -built housing and other types of swellings with sleeping accommodations and new accessory buildings associated with such uses. Existing site and landscaping improvements that are not otherwise disturbed are not subject to the requirements of CALGreen. Project Name Project Address: RESIDENCE RENOVATION 18790 NEWSOM AVENUE Project Description: ADDITION / REMODEL Instructions: The Owner or the Owner's agent shall employ a licensed professional experienced with the California Green Building Standards Codes to verify and assure that all required work described herein is,,.properly planned and implemented in the project. 2. The licensed professional, in collaboration with the owner and the design professional shall initial Ca mn 2 of this checklist, sign and date Section 1 - Design Verification at the end of this checklist and have the checklist printed on the approved plans for th9 project. A� ;3. Prior to final inspection by the Building Department, the licensed professional shall complete Column 3 and sign and date Section 2 - Implementation Verification at the end of this checklist and submit the completed form to the Building Inspector. OFFICki C SUBMITTAL #2 Page I of 5 CalGreen_2014.doc revised 01/15/14 Column 2 Column 3 MANDATORY FEATURE OR MEASURE Project Verification • Re uirements A4.1 PLANNING AND DESIGN Planning and Design - Site Development 4.106.2 Storm water drainage and retention during construction. A plan is developed and implemented to manage storm water drainage during ❑X ❑ construction. 4.106.3 Grading and paving. The site shall be planned and developed to keep surface water away from buildings. Construction. plans shall indicate how ® ❑ site grading or a drainage system will manage all surface water flows. SUBMITTAL #2 Page I of 5 CalGreen_2014.doc revised 01/15/14 40 General • 4.201.1 Low-rise residential buildings shall meet or exceed the minimum ❑ ❑ standard design required by the California Energy Standards. Indoor Water Use 4.303.1 Water conserving plumbing fixtures and fittings. Plumbing fixtures (water closets and urinals) and fittings (faucets and showerheads) shall comply with the following: ❑ 4.303.1.3.2 Water Closets. The effective flush volume of all water closets shall not exceed 1.28 gallons per flush. Tank -type water closets shall be certified to the performance criteria of the U.S. EPA WaterSense Specifications for Tank -type Toilets. ❑ 4.303.1.3.2 Urinals. The effective flush volume of urinals shall not exceed 0.5 gallons per flush. 4.303.1.3.1 Single Showerheads. Showerheads shall have a maximum flow rate of not more than 2.0 gallons per minute at 80 psi. Showerheads shall be certified to the performance criteria of the U.S. EPA WaterSense Specification for showerheads. ❑ 4.303.1.3.2 Multiple Showerheads serving one shower. When a shower is served by more than one showerhead, the combined flow rate of all showerheads and/or other shower outlets controlled by a single valve shall not exceed 2.0 gallons per minute at 80 psi, or the shower shall be ❑X ❑ designed to allow only one shower outlet to be in operation at a time. ED 4.303.1.4.1 Residential lavatory faucets. The maximum flow rate of residential lavatory faucets shall not exceed 1.5 gallons per minute at 60 psi. The minimum flow rate of residential lavatory faucets shall not be less than 0.8 gallons per minute at 20 psi. ❑ 4.303.1.3.2 Lavatory faucets in common and public use areas. The maximum flow rate of lavatory faucets installed in common and public use areas (outside of dwellings or sleeping units) in residential buildings shall not exceed 0.5 gallons per minute at 60 psi. ❑ 4.303.1.4.3 Metering faucets. Metering faucets when installed in residential buildings shall not deliver more than 0.25 gallons per cycle. ED 4.303.1.4.4 Kitchen Faucets. The maximum flow rate of kitchen faucets shall not exceed 1.8 gallons per minute at 60 psi. Kitchen faucets may temporarily increase the flow above the maximum rate, but not to exceed 2.2 gallons per minute at 60 psi, and must default to a maximum flow rate of 1.8 gallons per minute at 60 psi. .1 4.303.2 Standards for plumbing fixtures and fittings. Plumbing fixtures q and fittings shall be installed in accordance frith the California Plumbing Code, © ❑ and shall meet the applicable standards reforenced in Table 1401.1 of the California Plumbing Code. Page 2 of 5 CalGreen_2014.doc revised 01115114 Outdoor Water Use 4.304.1 Irrigation controllers. Automatic irrigation systems installed at the t me of final inspection shall be weather -based. 121 4.304.1.1 Controllers shall be weather- or soil moisture -based controllers that automatically adjust irrigation in response to changes in plants' needs as weather conditions change. ❑ ❑ 0 4.304.1.2 Weather -based controllers without integral rain sensors or communication systems that account for local rainfall shall have a separate wired or wireless rain sensor which connects or communicated with the controller(s). Soil moisture -based controllers are not required to have rain sensor input. .. .4 MATERIAL CONSERVATION AND RESOURCE EFFICIENCY Enhanced Durability and Reduced Maintenance 4.406.1 Rodent proofing. Annular spaces around pipes, electric cables, conduits, or other openings in plates at exterior walls shall be protected ❑ ❑ against the passage of rodents by closing such openings with cement mortar, concrete masonry or similar method acceptable to the enforcing agency. Construction Waste Reduction, Disposal and Recycling 4.408.2 Construction waste management plan. Where a local jurisdiction does not have a construction and demolition waste management ordinance, a ® ❑ construction waste management plan shall be submitted for approval to the enforcing agency. Building Maintenance and Operation 4.410.1 Operation and maintenance manual. At the time of final inspection, an operation and maintenance manual shall be provided to the building ® ❑ occupant or owner. A4.5 ENVIRONMENTAL QUALITY Fireplaces 4.503.1 General. Install only a direct -vent sealed -combustion gas or sealed ❑ ❑ wood -burning fireplace, or a sealed woodstove. Pollutant Control 4.504.1 Covering of duct openings and protection of mechanical equipment during construction. Duct openings and other related air ❑X ❑ distribution component openings shall be covered during construction. 4.504.2.1 Adhesives, sealants and caulks. Adhesives, sealants and caulks ❑ snall be compliant with VOC and other toxic compound limits. 4.504.2.2 Paints and coatings. Paints, stains and other coatings shall be ❑ ❑ compliant with VOC limits. 4.504.2.3 Aerosol paints and coatings. Aerosol paints and other coatings shall be compliant with product weighted MIR Limits for ROC and other toxic ❑X ❑ compounds. Page 3 of 5 CalGreen_2014.doc revised 01115114 o. 4.504.2.4 Verification. Documentation shall -be provided to verify that ❑ ❑ compliant VOC limit finish materials have been used. 4.504.3 Carpet Systems. Carpet and carpet systems shall be compliant with ❑ ❑ \10C limits. 4.504.4 Resilient flooring systems. Eighty (80) percent of floor area receiving resilient flooring shall comply with the VOC-emission limits defined in ❑ the Collaborative for High Performance Schools (CHPS) Low -emitting ❑X Materials List or be certified under the Resilient Floor Covering Institute (RCFI) FloorScore program. 4.504.5 Composite wood products. Particleboard, medium density ❑ fiberboard (MDF), and hardwood plywood used in interior finish systems shall X❑ comply with low formaldehyde emission standards. Interior Moisture Control 4.505.2 Concrete slab foundation. Required vapor retarders and capillary ® ❑ breaks are also required to comply with CalGreen Section 4.505.2.1. 4.505.3 Moisture content of building materials. Moisture content of building ❑ ❑ materials used in wall and floor framing is checked before enclosure. Indoor Air Quality and Exhaust 4.506.1 Bathroom exhaust fans. Exhaust fans which terminate outside the ❑ building are provided in every bathroom. Environmental Comfort 4.507.2. Duct systems are sized and designed and equipment is selected using the following methods: 1. Establish heat loss and heat gain values according to ACCA Manual J or equivalent. ❑ ❑ 2. Size duct systems according to ACCA 29-D (Manual D) or equivalent. 3. Select heating and cooling equipment according to ACCA 36-S (Manual S) or equivalent. INSTALLER AND SPECIAL INSPECTOR QUALIFICATIONS Qualifications 702.1 Installer training. HVAC system installers are trained and certified in ❑ ❑ the proper installation of HVAC systems. 702.2 Special inspection. The Licensed Professional responsible to verify CALGreen compliance is qualified and able to demonstrate competence in the ❑X ❑ discipline they inspect and verify. Verifications 703.1 Documentation. Verification of compliance with CALGreen may include construction documents, plans, specifications, builder or installer certification, inspection reports, or other methods acceptable to the enforcing M ❑ agency which show substantial conformance. Implementation verification shall be submitted to the Building Department after implementation of all required measures and prior to final inspection approtal. Page 4 of 5 CalGreen_2014.doe revised 01/15/14 'roject Name: roject Address. -'reject Description: CALGREEN SIGNATURE DECLARATIONS RESIDENCE RENOVATION 18790 NEWSOM AVENUE ADDITION / REMODEL SECTION 1 - DESIGN VERIFICATION Complete all lines of Section 1 — "Design Verification" and submit the completed checklist (Columns 1 and 2) with the plans and building permit application to the Building Department. The owner and design professional responsible for compliance with CalGreen Standards have revised the plans and certify that the Stems checked above are hereby incorporated into the project plans and will be implemented into the project 0 acc nce with the requirements setfiorth in the 2013 California Green Building Standards Code as adoptedby th ity of yupertino. t I n Y . Qwn's Signature Ownef�s Narpe (Please Print) Design\�rofessional's Signature Narry45'7Please Print) Signature of License Professional responsible for CalGreen compliance Miles Hancock Name of License Professional responsible for CalGreen compliance (Please Print) energy@pacbell.net Email Address for License Professional responsible for CalGreen compliance SECTION 2 — IMPLEMENTATION VERIFICATION Date I 1 45 Date 04/30/2015 Date (650) 804-9063 Phone Ccmplete, sign and submit the competed checklist, including column 3, together with all original signatures on Section 2 to the Building Department prior to Building Department final inspection. I have inspected the work and have received sufficient documentation to verify and certify that the project identified above was constructed in accordance with this Green Building Checklist and in accordance with the requirements of the 2013 California Green Building Standards Code as adopted by the City of Cupertino. Sic nature of License Professional responsible for CalGreen compliance Date Name of License Professional responsiblS for CalGreen•compliance (Please Print) Phone Email Address for License Professional responsible for CalGreen compliance °age 5 of 5 CalGreen-2014. doc revised 01/15/14 M