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B-2016-1799 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1799 21152 MCCLELLAN RD CUPERTINO,CA 95014-4265(359 03 052) OWNER'S NAME: Mrs Tracy Hsu DATE ISSUED:04/20/2016 OWNER'S PHONE:408-464-5030 PHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic.# Contractor Date X BLDG X ELECT —PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X 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: INSTALL TEMPORARY POWER POLE(100 AMPS) 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. 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 permit is issued. Sq.Ft Floor Area: Valuation:$150.00 APPLICANT CERTIFICATION I certify that I have read this application and state that the above APN information is correct.I agree to comply with all city and county ordinances Number: Occupancy Type: 35903 052 and state laws relating to building construction,and hereby authorize 359 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 PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 4/20/2016 Issued by:Alex Vallelunea Date:04/20/2016 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is i. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for compensation,will do the work,and the stricture is not intended or offered for inspection. sale(Sec.7044,Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed Signature ofApplicam: ' contractors to construct the project(Sec.7044,Business&Professions Code). Date:4/20/2016 l` I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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. HAZARDOUS MATERIALS DISCLOSURE z. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)should I store or handle hazardous 4/ shall not employ any person in any manner so as to become subject to 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 Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Co tapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sect' s 25505,2553 , d 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. mw mru�ri"r dilautltan%eellage Ot: APPLICANT CERTIFICATION Date:4/20/2016 I certify that I have read this application and state that the above information isN TR TI LE A EN Y correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a constructioending agency for the performance relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued ec.3097,Civ C.) to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabilities, judgments,costs,and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source re ions per the Cupertino Municipal ARCHITECT'S DECLARATION Code,Section 9.18. 1 understand my plans shall be used as public records. Licensed S;'I ,: tures Professional Date 4/20/2016 ..._._................:......... GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 CUPERTCNU (408)777-3228• FAX(408)777-3333•buildingCcDcupertino.org misc lb- '2 01 � ❑PLUMBING ❑MECHANICAL p,� ❑ELECTRICAL ❑MISCELLANEOUS PROJECT ADDRESS24-1 1 'r 2- ��i�1. �� , APN# // �Q OWNERNAME PHONE E-MAIL STREET ADDitM? �® CITY, S TE,ZIi�� \rto F CONTACT NAME � � PHONE Q E- STREET AD RESS Al� CITY TATE,ZIP \yL. CA FAX ❑ OWNER OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGNEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBERLICENSE 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 USE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN ❑ YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO DESCRIPTION OF WORK TOTAL VALUATION: � !• RECEIVED BY r By my signature below,I certify to each of the following: I am the property ownSeT or authorized agent to act on the froperty owne behalf. I have read this application and the information I have provided is correct. I have read the De pt' Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building cons ction. I authorize rep. Iv of Cupertino to enter the above-identified property,for inspection purposes. Signature of Applicant/Agent: Date: 42,6 4 SUPPLFAENTAL INFO ATION REQUIRED � „OFFICE USE:;ONLl; ,, W ❑ OYER THE COULTER" F" ❑�EaPRESS,,Y,4� ) L„ 5 x ❑ STANDARD a ❑ LARGE ' ❑ MAJOR n s MEPMiscApp_2011.doc revised 06/21/11 i' OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 (408)777-3228 - FAX(408)777-3333 • buildinona cuoertino.ora — CUPERTItdO Dear Property Owner(s): An application for a building permit has been submitted in your name lisping yourself as the builder of the property improvements specified at: - SI T j ADDRESS - _ :.:: _ ...J.APIC.. I BPS OWNc E _ . .. OWNER ADDRESS: DESCRIPTION OF WORK: a� 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 properly 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.) 1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner- Bui der" 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. 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor to assume this responsibility. #3. I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may prtect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 4. I understand Contractors are required by law to be licensed and bonded in California and to list their license n mbers on permits and contracts. 5. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the to al 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. I understand if I am considered an "employer" under state and federal law, I must register with the state and fed rat 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. 7. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family r idential 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, oral[ of the work is performed under contract with a licensed general building Contractor. 48. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for a �financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwnerRuilderForm 2010.doc reidsed 0'/1!/10 _ _019. I understand I may obtain more information regarding my obligations as an"employer" from the Internal ReTenue Service, the United States Small Business Administration, the California Department of Benefit Payments, and the California Division of Industrial Accidents. I also understand l may contact the California Contractors' State License Board (CSLB) at 1-800-321-CSLB (2752) or wwv.cslb.ca.gov for more information about licensed contractors. 010. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that I am The parry legally and financially responsible for proposed construction activity at the site address listed above. 11. I agree that, as the party legally and financially responsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Cwner-Builders as well as employers. 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the int rmation I-have-provided on this form. Licensed contractors are regulated by-laws designed to protect.the..public. If you contract with someone who does not have a license,the Contractors' State License Board May be unable to assist you with any financial loss you may sustain as a.result of a complaint-Your only remedy against unlicensed Contractors maybe in civil court. Itis 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 perr6it-as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not-- those otethose Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS:Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued,this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note:A copy of the property ov✓ner's drivel's license, form notarization, or other verification acceptable to the city, y be required to be presented when the permit is issued to verify the propeity owner's si natur Property Owner's Signature: Date: ------------------------------------------------------- ------------------------------------------------------------------------------------- (NOTE: The follov✓ing Authorization Form is r qui to be completed by the property owner only when designating an agent of the property owner to apply for a construction permit for the Owner-Builder). AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby authorize the following person(s)to act as my agent(s) to apply for, sign, and file the documents necessary to obtain an Owner-Builder Permit for my project. Scope of Construction Project (or Description of Work): Project Location or Address: Name of Authorized Agent: Tel No ;"\ddress of Authorized Agent: I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the above information and certify its accuracy. Note:A copy of the property ov✓ner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the pen-nit is issued to veriy the property ov✓ne>'s signature. Property Owner's Signature: Date: OwnerBuilderForm ?010.doc revised 04,114110 WEC and Associates, Inca April 23, 2016 �2 ��f City of Cupertino Community Development Building Division 10300 Torre Avenue Cupertino, CA 95014-3202 Subject: Survey Report 21152 McClellan Road Cupertino, CA To Whom It May Concern: This letter is to confirm in writing that WEC and Associates, Inc provided a staking survey for the foundation line on the subject property. The stakes have been placed in accordance with the plans approved by the City of Cupertino both horizontally and vertically. The horizontal control is established by the county recorded tract map(s) and/or Record of Surveys) and the monument line established along McClellan Road. We subsequently paid a site visit on 4/23/2016. From our professional point of view, the contractor formed the foundation walls in accordance with the horizontal setback requirement as shown on the city's approved plan. The finish floor elevation, based on the top of form measurement, is 103.2. We make no warranty, expressed or implied, as to the services rendered except that our services are performed in a manner consistent with that degree of care and skill ordinarily exercised by members of the same profession currently practicing under similar circumstances at the same time and in the same or similar locality. r If you have any further questions regarding this matter, please contact me at your convenience. Sincerely, WEC and Associates, Inc. RAN SGS -' -2- X cgs x. 8235 OF CAtW— Yi-Ran Wu, PE., LLS 2625 Middlefield Road #658 m Palo Alto; CA 94306® Tel: 650-823-6466 © Fax: 650-887-1294 I I I I � I I � - I I I I I I � I �-z-_ I I N.0'02'52"W. 110.00' I I -- -- -- -- -- -- -- -- I I . I I I � Ln I m Q i 6' i i 6' i Ln I NEW RE51DENCE i I o I FF=103.2 I n W I c W 00oq 69 z U oil --- --- --- ----- I ' / D=89'53'59" — --�-- -- -- -- -- -- -- �� L=31.38' R=20.00' S.0°08'53"E. 90.03' ROSE BLOSSOM DRIVE - - - - - - - - - - - dL_ANDS RAN ��QL U cp L.8235 OF CALF- STAKING DIAGRAME C 2625 MDDLEFIELD RD#658 TEL: (650) 823-6466 21152 McCLELLAN ROAD W CUPERTINO CA A ASSOCIATE $ PALO ALTO,CA 9430.6 FAX: (650) 887-1294 �*� TM dlsclosures.com California Property Tax Disclosure Report Property Address: VACANT LAND, APN: 326-16-094 CUPERTINO, SANTA CLARA COUNTY, CA Report Date: 03/26/2013 Report Number: 1301406 AGENCY DESCRIPTION AMOUNT CONTACT PHONE TOTAL DIRECT ASSESSMENTS $582.50 Indicates Mello Roos or 1915 Bond Act Assessments. See Part 2 "Notice of Special Tax/Assessment"for additional information regarding these items. t. Available Senior Citizen Exemptions Certain districts that levy special taxes or assessments may offer exemptions to Senior Citizens.These exemptions. can result in substantial savings to qualified tax payers.The filing of an application along with annual renewal may be required. Below is the contact information for requesting details on filing exemptions for districts that may offer a Senior Citizen Exemption.Additional Direct Assessment Districts may offer exemptions. Therefore you may.want to contact the districts to determine their policy on Senior Citizen Exemptions AGENCY DESCRIPTION AMOUNT CONTACT PHONE CFD 2005-1 SANTA CLARA COUNTY To provide all or a portion of the public library $33.66 (408)293-2326 LIBRARY DISTRICT services X3003 See Part 4B for additional information on other exemptions that may be available to Buyer. Page 5 of 12 ©2013 —JCP-LGS Property Disclosure Reports-200 Commerce Irvine,CA 92602 Phone:(800)748 5233 Fax:(800)329 9527 FIL C'APEX ENGINEERING INS`. Q.6- ;2 PO BOX 14198.FRE.—MONT.CA 94539 Tel:(5 10)668-1815 Fax:(510)490-8690 April 25, 2016 Project No. 10645 Building Department City of Cupertino 10300 Torre Ave. Cupertino, CA 95014 Subject: Proposed New Residence at 21152 McClellan Rd. Cupertino, CA FOOTING EXCAVATION (GRADE.BEAMS & SPREAD FOOTINGS) AND PREPARATION OBSERVATION REPORT Dear Sir: CAPER ENGINEERING INC., has provided inspection service for footing excavation and preparation. Footing depth and width were excavated adequate in accordance with approved foundation plan and specifications. The exposed soil conditions of excavated foundation are beyond design bearing capacity and acceptable. Any questions,please call our office at your convenience. Sincerely, ,APEX E GINEERING INC., Gary. s , RE pig � - Principal �, Von OF CAPEX ENGINEERING INC. FILE PO BOX 14198,FREMONT,CA 94539 �� Tel;(510)668-1815 Fax:(510)490-86901 April 25, 2016 Project No. 10645 Building Department City of Cupertino 10300 Torre Ave. Cupertino. CA 95014 Subject: Proposed New Residence at 21152 McClellan Rd. Cupertino, CA SITE DEMOLITION AND BUILDING PAD GRADING OBSERVA'T'ION REPORT Dear Sir: CAPEX ENGINEERING INC., has provided observation service for site demolition, primary and final grading of building pad. On the basis of our observation and testing, we concluded building pad, compaction operation were performed in general accordance with recommendation of soil report and compacted to a minimum of 90% relative compaction. If you have any questions, please contact our office at your convenience. Sincerely, C PEX ENGINEERING INC., Gary H PIE Vg)FESS�� Principal a� YIr UJ Nm m = O