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B-2016-0401CITY OF CUPERTINO BUILDING PERMIT BUILDINGADDRESS: 19025 PENDERGAST AVE CUPERTINO, CA 95014-3516 (375 37 043) CONTRACTOR: D W K PERMIT O: D-2016-0401 CONSTRUCTION CUPERTINO, CA 95,014 OWNER'S NAME: XIE, YUCHENSEPARATE PROPERTY TR 11/16/12 DATE ISSUED: 08/15/2036 OWNER'S PHONE: 408-768-7530 PHONE NO: (408) 429-8503 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class GENERAL BUILDING CONTRACTOR Lic. #22DO27 Contractor D W K CONSTRUCTION Date 05/31/2017 _BLDG _ELECT PL UMB I hereby affirm that I am licensed under the. provisions of Chapter 9 (commencing _ _ . MECH X RESIDENTIAL 0MMERCIAL with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: DEMOLISH EXISTING HOME 814 S.F.); GARAGE (225 S.F.) I hereby affirm under penalty of perjury one of the following two 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 Code, for the i performance of the work for which this permit is issued. �2.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. Sq. Ft Floor Area: Valuation $8000.00 APPLICANT CEKTIFICATION [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 APN Number: Occupanc Type: and state laws relating to building construction, and hereby authorize 375 37 043 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 WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS F 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 Z.�, Date 8/15/2016 Issued by: AbbyAyende OWNER-BUILDER DECLARATION Date: 08/15/2016 I hereby affirm that I am exempt from the Contractor's License Law for one of the ' following two reasons: All roofs shall be inspected prior to e ny roofing material being installed. If a roof is 1. 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 structure is not intended or offered for i nspcction. sale (Scc.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed Signature of Applicant: contractors to construct the project (Scc.7044, Business & Professions Code). Date: 8/15/2016 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERING TO BE CLASS "A" OR BETTER 1. 1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. HAZARDOUS M ERIALS DISCLOSURE z. I have and will maintain Worker's Compensation Insurance; as provided for by I have read the hazardous materi ds 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 Cup rtino Municipal Code, Chapter 9.12 and the 3. I certify that in the performance of the work for which this permit is issued,I Health & Safety Code, Section 25532(a) should I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally, should I us 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 Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety Code, Sections 25505, 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall 1�_, be deemed revoked. , Owner or authorized agent: APPLICANT CERTIFICATION ` bate: 8/15/2016 I certify that I have read this application and state that the above information is CONSTRUCTI DIN LENDING AGENCY correct. I agree to comply with all city and county ordinances and state laws t hereby affirm that there is a cons ruction lending agency for the performance relating to building construction, and hereby authorize representatives of this city of work's for which this permit is issued (Sec. 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 regulations per the Cupertino Municipal ARCHI, EC T'S DE LARATI Code, Section 9.18. 1 understand my plans shall be used as public records. Licensed Signature Date 8/15/2016 Professional DEMOLITION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 +CE PERT NO (408) 777-3228 • FAX (408) 777-3333 • buil ding(cricupertino.orq -Dqo l PROJECT ADDRESS ® P a APN #� 1 OWNERNAME Yu d4,?,h lle– PHONE E-MAIL STREET ADDRESSr�� CTTY> STATE, ZIP � � FAX CONTACT NAME 9 v PHO Q �e E -MA �. �I % C. O P ��+ C-- it �l J / [� err STREET ADDRESS A Q n 4j +Y CITY, STATE, ZIP f � ( FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT [11 ENGINEER ❑ DEVELOPER. ❑- TENANT CONTRACTOR NAME r R fi4AS C GI% A NSE NUM..BER BUS. L # 2- m__A 41L LICE LICENSE TYPE COMPANY NAME EL FAX \ n1i5ft STREET ADDRESS ITY, STATE, ZIP PHO&S) � ®IeS8! P� DESCRIPTION OF WORK d f/ ene FLSIDENTIAL # OOR AREA �b UNITELLING USE OCC OF C USE O SQ ET N VA%UA7IOIIk i COMMERCIAL TYPE OF CONSTRUCTION I - # STORIES AQMD JOB NUMBER J #: 4-UTM '1;-1`1,C1 TY!") y= ti T TAL UMATIO (./•�C-� By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner'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 agre to comply with all applicable local ordinances and state laws relating to buildin construction. I authorize representatives of Cupertino to enter the above-identjhcd property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL ORMATION REQUIRED PRIOR TO ISSUANCE OF DEMOLITION RMIT ox CE �s �.oNLY PLAN CRE,__ TYPE ,/provide Job Number from Bay Area Air Quality Management District www.baaamd.org @ 415-7494762. ❑ Liss Z Provide three for trees 10" in diameter 3' copies of a site plan showing protection any or more at above grad . ❑ STANDARD rovide letter from PG&E (408-725-3325) stating all gas and electric has been disconnected. W21anning ❑ LAI2CE Dept clearance to verify building is not considered an historical landmark. Allow 10 business days ©1vlAaol� , Provide letter of clearance of all vermin from a licensed pest control contractor. 46C� A plicant all call the PI}b ' ��VVpprks Department at 408-777-3104 and schedule a "habitable dwelling" insp ction. r k Provide Constfuction and Demolition Recycling Diversion signature form. — Commercial Buildings Only: Provide Fire Dept clearance for fire suppression l alarm system review. 2016.doc revised 05110116