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D-2016-0361CITY OF 10200 EMPIRE AVE CUPERTINO, CA 95014 (326 23 045) OWNER'S NAME: OWNER'S PHONE: III (It em a] 1XV-91cm ym.Kim Klivau_ s� License Class Lic. # P) q sy�I _ Contractor ( BEYOND BUILDERS ) Date I,I Zj I ( /w 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, pp jj z I have and will maintain Worker's Compensation Insurance, as provided for ov`r by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION certify that I have read this application and state that the above nformation is correct. I agree to comply with all city and county xdinances and state laws relating to building construction, and hereby sulhorize representatives of this city to enter upon the above mentioned nrpery for inspection purposes. (We) agree to save indemnify and keep mmaless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against saA City In consequence of the granting of this permit. Additionally, t pplicant understands and will =ply with all non-poTource rag aaj erns per the Cupertino Municipal :ode. Section 9.1 E. �i l Date I 21 1 I o I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. 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 (Scc.7044, Business & Professions Code) z. I, as owner of the properig 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: r. 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 Cade, for the performance of the work for which this permit is issued. z. 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. a. 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 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 ertify that I have read this application and state that the above information is tract. I agree to comply with all city and county ordinances and state laws sting to building construction, and hereby authorize representatives of this city enter upon the above mentioned property for inspection purposes. (We) agree save indemnify and keep harmless the City of Cupertino against liabilities, Igments, costs, and expenses which may accrue against said City in nsequence of the granting of this permit. Additionally, the applicant iderstands and will comply with all non -point source regulations per the ipertino Municipal Code, Section 9.18. Date BUILDING PERMIT CONTRACTOR: PERMIT NO: D-2016-0361 ( BEYOND BUILDERS) SAN MATEO, CA 94401 DATE ISSUED: 01/21/2016 PHONE NO: BUILDING PERMIT INFO: _ BLDG —ELECT -PLUMB _ MY CH X RESIDENTIAL _ COMMERCIAL JOB DESCRIPTION: DEMO (E) 1,008 S.F. SFD Sq. Ft Floor Area: Valuation: $10000.00 APN Number: Occupancy Type: 326 23 045 R-3 (Custom) PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DA F PERMIT ISSUANCE OR 180 DAYS $-�LED INSPECTION. / / ZC P 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. "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read fire 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 enry hazardous air contaminants as defined by the Bay Area Air Quality Mannin fit District I will maintain compliance with the Cupertino Municipal Code the 9.12 and the Health & Safety Code.Stkktfons 2540k 25533, it 5534. >wner or authorized agent: K--�ZfA /J!/"tiI/liln� )ate: 11 Z( // L tO CONST CE ON LENDING AGENCY hereby affirm.that there is a construction lending agency for the performance f work's for which this permit is issued (Sec. 3097, Civ C.) .ender's Name ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional 64 U-C ormf lCl Scope,a��srepiZ��V�°��r��tq sl�td 1 P nl 3 Llo - Z?i 0`4 S (;Op ■ r �� Y l� 10100 erylplre- Ave- CO'TQ-o- ylo 6Ar °ision} -I5(� I I, 60 $ SqFi- ®C-VLA-b Gam) 5F-D �jE, Ls R c"t 7a n(..nc CUPERTINO Building Department JAM 2 12016 FOR CODE COMPLIANCE '-d By. r� usr�,4 0 P'r 7 !^ trrl r70 _ L4e or .., 4ny front ` PA! o Im DEMOLITION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildina ouoertino.orq LJ Pt OJECT ADD SS � APN # jj ((�� OWNERNAME �� Llsl,O [, PH N - 4[tI.... 9 1 ILK tti� I L IIL.. e) F.tV_CJL '�'l LCa STREETADDR- S i Sid v4 � � l� t-�t✓,wtat� C ,STATE, ZIP WL d1 3 FAX 5t'}-4�S�-aavt� t CONTACT NAMEFM �ll�(rn `^ STFvcTAnna cR ATE. cT� r¢rY-(vs 0% I o---M(O--g 61 ❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER Cl DEVELOPER ❑ TENANT CONTRACTOR NAME Sri LICH SE NUMBER LICENSE TYPE '� BUS. LIC # i COMPANYNAME E-MAIL FAX 60rA NIA STI f ADD SS ^,,. CI94C, STAT IP PHONE- '` `T�� �°' � r 10 DPSCRHTIONOPWORK RESIDENTIAL R #DWE.LLING ` FLOOR AREA OO V tJ UNITS r 5 ;�n;g � ( � R COMMERCIAL FLOOR AREA TYPE OFCONSTRUCTION #STORIES -1 — "AQMDJOHNUMEER -_--_-_-��l TOTALVALUAnON: �qr� J #: a Q ca 6 By my signature below, I certify to each of the following: 1 am tho property oth gen act on perty owner's behalf. r have read this o application and the information I have provided is correct. 1 have read the D I�SCt'pdon Work an it' s`:urata. I agree to comply with all applicable local ordinances and state laws relating to builds g construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of ApplicantlAgent: Date: SUPPLEMENTAL INFORMATION REQUIRED PRIOR TO ISSUANCE OF DEMOLITION PERMIT ' 3 - _ Provide Job Number from Bay Area Air Quality Management District www baagmd ore @ 415-749-4762. Provide three copies (Residential) or six copies (Commerical) of a site plan showing protection for any trees 10 in diameter or more at 3' above grade. #+ FF 4 Provide letter from PG&E (408-725-3325) stating all gas and electric has been disconnected. _ Provide a letter of inspection, tests, and abatement of any Hazardous Materials. Letter to be initiated by person(s) certified in asbestos, mercury and/or hazardous material examination. Planning Dept clearance to verify building is not considered an historical landmark. Allow 10 business days. Provide letter of clearance of all vermin from a licensed pest control contractor. Applicant shall call the Public Works Department at 408-777-3104 and schedule a "habitable dwelling' inspection. - Provide signed Debris Bin and Recyclable Materials form. Lc DemoApp_2013.doc revised 02113113 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION 10200 EMPIRE AVE DATE: 01/2112016 REVIEWED BY: MELISSA kirADDRESS: APN: 326 23 045 — — — 7BPH,, *VALUATION: *PERMIT TYPE: Demolition Permit PRIMARY SFD or Dup PENTAMATION lSFDWL-DEM USE: PERMIT TYPE:lex WORK DEMO (E) 1,008 S.F. SFD SCOPE FEE ID FIR AREA (S-f-) IDEMORES 1,008 Vach Plan Chrck I'lurid, Plan Nwi Check IPe"la I ee: I Pluplh Permit —I— I kige. jlcrw0 kee 0zh-"r.Wth hup. El--L- 0i,'Wr!'h1m,5jnq' E—j offle, ln.a). Ej I 1.1fech. In'sp. I'(,. Afnmb, 11mv, j,", k!"(" lasp, tire: I NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Kre, Sanitary Sewer District, School IRviriet.elp-h These fees are hased on the nreliminary information available and are only an estimate. Contact the Dept for (uldn'l info. FEE ITEMS fL,'ge Resolution 11-053 Ej� 3 FEE QTY/FEE MISC ITEMS Phan Check Fee: Supl)L N."I'(11le Permit Fee: $574.00 Suppl. hisp. Fee:(D Reg. 0 OT FO—OT-11—fs $0.00 kce: Conswuclion 7kiw; Jhrfinivrofhv Tee. if"ork Without PernO,, Fees: TraiW Documentation beew. Strong Motion Fee: IBSEISMICR $1.30 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $576.30 T,, $ 0. 0 01 ":, ' -, T-LEE;-L576.30 Revised: 01/01/2016 CUPERTINO PURPOSE PROCEDURE CHECKLIST FOR DEMOLITION PERMITS COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION ALBERTSALVADOR, PE., C.B.O., BUILDING OFFICIAL 10300 TORRE AVENUE + CUPERTINO, CA 95014-3255 (408)777-3228 • FAX (408) 777-3333 • buildingNcupeflino.org The demolition application should be applied for before or at the same time as the new construction permit application (these are separate permit applications and fees). Permit fees are due at the time of the application/plan submittal. The new construction permit will not be issued until the demolition permit is issued, unless a -letter obtained from the Building Department is submitted stating that "The existing house will not be demolished until the new construction permit is issued". The letter needs to be signed by both the property owner and general contractor. REQUIREMENTS To obtain a demolition permit in the City of Cupertino, please complete a Derolition errnit application along with each of the following requirements as it applies to your specific project. 1. Three (3) copies of a Site (Demolition) plan for Residential or six (6) copies for -Cmumeivial will M mquacd shuRM6 any lees inches in diameter at feet above grade on the subject property, and what means will be taken to protect these trecs. /Q+ C- - 2. PG&E must be contacted AS EARLY AS POSSIBLE prior to demolition to t^ schedule the abandorunent. Contact PG&E at (408) 725-3325, A letter from PG&E shall be provided to the City, stating that all gas and electric has been disconnected. (This step can be time consuming, so it is important to begin the process inumd ately) 3. Provide Job Number from Bay Area Air Quality Management District rir i.,www.baaamd.aovCup, 415-749-4762. 1 �G' 4. 'Check to see if the building is considered an historical landmark, Obtain Clearance !4 ✓f "e from the Community DevelopmentPlaruring Department. Allow.10 working wo days. 5. Provide a letter of clearance of all vermhi from a licensed pest control contractor. YW W- 6. Important: Prior to the issuance of the demolition permit, the applicant must call14AX 01L the Public Works Department at (408) 777 3104 and arrange -a "habitable dwelling"�t " inspection 1t� O OYt_SVtkVv �L P Ot�4Jty J O l 7. Debris bin and Recycling sheet, read, sign and date. The sheet will remain in the project's building perrnitfile for the duration of the project, 8, Commercial only -prior to issuance of the demolition permit, the Fire Department; must review the plans for fire suppression/alarm systems that shall remain hi service or be modified during Demolition, or that shall be replaced with the new construction. D¢moProeedure:docrevised 2113113 PJE Pacific Gas and Electric Company' DATE: I I S^ 16 CITY OF CUPERTINO 10300 TORRE AVE CUPERTINO CA 95014 10900 No. Blaney Avenue Cupertino, CA 95014 SUBJECT: REMOVAL OF GAS SERVICES (CUT @ MAIN IN THE STREET) ON: 0106 Ewn( (2-1 �l I /s' SUBJECT: ELECTRIC SERVICES WAS CUT AT POLE ON: 10zC)0 Gvtlm,, I / CG If you have any further questions, please contact me at (408) 725-3325 Sincerely, L,w Aafl , Pacific Gas & Electric Company DeAnza Service Planning 408/725-3325 _ I_ y ® Peae d , 9 c A 4Y !ltiiP 'Y Wqf 1fCK Killroy Pest Control 1175 Dell Avenue, Campbell, CA 95008 408-378-0441 To Whore It May Concern, Killroy .Pest Control: has inspected the property at 10200 Empire Ave., Cupertino for pest infestation. No infestations werefound during the inspection. If you have any questions please call me at (408) 378.0441 vm 105. Sincerely, a�Lo Andrews Gibson Pest Management Professsional Killroy Pest Control, Inc. www.killroy.com City of Cupertino NIS Public works Department ®� Environmental Programs Division 10300 Torre Ave ! Cupertino, CA 95014 CUPEREWOOREEN PrO910m (408) 777-3354 Construction and Demolition Recycling Diversion Requirements and Instructions Covered projects, or all construction, demolition and renovation projects that are 3,000 square feet or more are required to complete a Waste Management Plan for the City of Cupertino demonstrating that 60% of the -material generated is recycled, in compliance with ordinance CMC 163Z,050. At the conclusion .of the project a Construction Recycling Report must be tiled with the Public Works Department/Environmental Division showing the tons recycled and disposed by material type, Use tomrage information from weight tags provided by facilities to quantity total estimated waste and percentages for materials. Weight Tags of all material recycled and disposed must be submitted with the final report in order to receive a Final Building Inspection. Debris from -a project 3,000 square feet or more in Cupertino can be collected and disposed by using: Pleas check all that apply: //rI am not using a Recology debris bin, however, the project is less than 3,000 s.%, e.g. buildings, patios; sidewalks, driveways. 0 I will use a Recology debris bin. By Agreement with the City, Recology will prepare my required Waste Management Plan & Recycling Report. Contact Recology: (408) 725-4020. 13 I am not using a Reoology debris bin. I will provide the following submittals to the City's Public Works Department, showing that I have recycled at least 60% of all construction demolition material: Ask for the Construction & Demolition Recycling Packet from the Building Department and complete the following: ✓ Submit a Construction and Demolition Waste Management Plan -with your buildingpermis application. No feefor this plan. Forms are available at the BuildinglPublic YVorks counter and online at wu+w.enapertino.orglenviroirmental. Report the tonnage recycled and disposed by material €ype. Recyalingfacilities must beselecteelfrom the City's approved list of Recycling Resources. ✓ Submit a Construction Recycling Report forn. The report is required before the Building Department will schedule aft inspection. The reportform is available at the BuildinglPublic Works Counter W. online cut7erturoorrleraviron rental Signature: Name: (pridi6d) IY \1 r l (A M Title: a _ Phone: Project Address: i 62 n_ C 1 K Thisform to remain in the project's building permit file for'die duration of the project. Revised 317112 1 Date: Slog gulation 11, Rule 2 =; COMPLIANCE & ENFORCEMENT Acknowledgement of B A. Y AREA Notification and ArRCZuAUTY DIVISION Payment of Fees MAN AG rim r N"f D I S "r K 1 C l' Peninsula Hauling & Demolition 839 Cherry Lane San Carlos, CA 94070 1/13/2016 Job No: 4S283 Invoice No: 3SN95 The Bay Area Air Quality Management District (BAAQMD) acknowledges receipt of your payment and your Asbestos Removal or Demolition Plan described as: Demolition Site address 10200 Empire Ave Cupertino, CA 95014 Start Date February 8, 2016 Completion Date Febntary 28, 2016 Removal amounts of friable ACM 0 linear feet 0 square feet 0 cubic feet Should it become necessary to revise this plan, please do so in the spaces provided below and immediately copy the District by fax or by mail. REGULATION 11-2 REVISION BAAQMD J# 4S283^� REVISION # START DATE COMPLETION DATE 1 2 / 3 _ 4 5 --I NOTE: This form is not intended as a verification of either the completeness ofyour original notification or of its compliance with BA4QMD Regulation 11-2. If you have any questions about this acknowledgment, please call our office at (415) 749-4762.