15010064I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 10860 JOHNSON AVE
CONTRACTOR %{ K C)fy1_(,d[WMIT NO: 15010064
I OWNER'S NAME: 10860 JOHNSON AVE CUPERTINO LLC I I DATE ISSUED: 01/12/2015 1
OWNER'S PHONE:
X..gqLICENSED C'ONTRACTOR'S DECLARATION
License Class G�� f"1
!Lic. #
N �p�/(5 1�V(,f(
Contractork61� Date_
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
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.
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,
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 AW/V/"Date___/ �5
❑ OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons:
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 (Sec.7044,
Business & Professions Code)
1, as owner of the property, 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:
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.
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.
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
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,
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.
, I PHONE NO:
JOB DESCRIPTION: RESIDENTIAL COMMERCIAL
DEMO (E) 1400 S.F. SFD
Sq. Ft Floor Area: I Valuation: $10000
1 APN Number: 37530022.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OL,PERMIT ISSUANCE OR
180 DAYS LLED INSPECTION.
Date:
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.
Signature of Appl
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
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 compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should 1 store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Codr, Chapter 9.12 and
the Health & Safety Code, Secti s 25505 25533, and
Owner or authorized agent: Date: (-
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records.
Licensed Professional
CUPERTINO
DEMOLITION PERMIT APPLICATION
h�
COMMUNITY DEVELOPMENT DEPARTMENT a BUILDING DIVISION `V
10300 TORRE AVENUE a CUPERTINO, CA 95014-3255 O
(408) 777-3228 • FAX (408) 777-3333 • building a@cupertino.orQ
PROJECT ADDRESS O
APN # 3 9- S 0 —
OWNER NAME
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FAX
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CONTACT NAME
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E-MAIL r
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STRE j D S
CITY, STATE, ZIP r
FAX
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❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTORAGENT ❑ ARCHITECT ❑ ENGINTER ❑ DEVELOPER ❑ TENANT
CONT CTOR NAME r a / r
cil to
LICENSE NUMBER
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LICENSE TYPE
BUS. LIC #
COMP Y NAM
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FAX
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STREET ADDRESSO
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DESCRIPTION OF WORK
(t t t '
RESIDENTIAL
# DWELLING OFFICE USE ONLY
FLOOR AREA IO voUNITS
USE OCC. TYPE so. Fr. VALUATION
COMMERCIAL
FLOOR AREA
TYPE ��ONSTRUCTION
# STORIES
AQMD JOB NUMBER BY:TOTAL
VALUATION:
D too
By my signature below, I certify to each of the following: I am the property owner or zed agent prope owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and ven It is ura agree to comply with all applicable local
ordinances and state laws relating to buil g onstruction. I authorize re esentatiyes of Cupertino to enter t ove-identified property for inspection purposes.
Signature of Applicant/Agent: Date: 1 -12 -
` 1"SUPPLEMENTAL
SUPPLEMENTAL IN O ATION RE UIRED PRIOR TO ISSUANCE OF DEMOLITION PERMIT
OFFICE USE ONLY
Provide Job Number from Bay Area Air Quality Management District www.baagmd.org @ 415-749-4762.
PLAN CHECK TYPE
Provide three copies (Residential) or six copies (Commerical) of a site plan showing protection for any trees 10"
❑ ExPREss
in diameter or more at 3' above grade.
ElSTANDARD
\// Provide letter from PG&E (408-725-3325) stating all gas and electric has been disconnected.
El LARGE
Provide a letter of inspection, tests, and abatement of any Hazardous Materials. Letter to be initiated by person(s)
El MAJOR
certified in asbestos, mercury and/or hazardous material examination.
fanning 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.
X/ Provide signed Debris Bin and Recyclable Materials form.
DemoApp_2013.doe revised 02/13/13
a
CITY OF CUPERTINO D
FEE ESTIMATOR - BUILDING DIVISION
iaADDRESS: 10860 JOHNSON AVE
FEE
DATE: 01/12/2015
REVIEWED BY: MELISSA
APN: 375 30 022 BP#: ,� �(P
'VALUATION: 1$10,000
~PERMIT TYPE: Demolition Permit
PRIMARY
USE: SFD or Duplex
PENTAMATION
PERMIT TYPE: 1SFDWL-DE i
WORK
DEMO E 1400 S.F. SFD
Permit Fee:
SCOPE
Suppl. Insp. Fee -(j) Reg. Q OT
0,Q
FEE ID FLR AREA
s.f.
1DEMORES 1,400
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 preliminary information available and are only an estimate. Contact the Dept for addh 7 info.
FEE ITEMS wee Resolution 11-053 E . ?,`1'13)
FEE
QTY/FEE
MISC ITEMS
Permit Fee:
$574.00
Suppl. Insp. Fee -(j) Reg. Q OT
0,Q
hrs
$0.00
Strong Motion Fee: IBSEISMICR $1.30
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $576.30
$0.00 TOTAL FEE:
$576.30
Revised: 01/06/2015
City of Cupertino
Public works Department
Environmental Programs Division
10300 Torre Ave
'.-�. - Cupertino, CA 95014
CYf8RnM06W@HN
Program (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 16.72.050. At the conclusion of the project
a Construction Recycling Report must be riled with the Public Works Department/Environmentat Division
showing the tons recycled and disposed by material type. Use tonnage information from weight tags provided
by facilities to quantify 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 bin service provider franchised to do business in
Debris from a project 3,000 square feet or more in Cupertino can be collected and
disposed by using:
Please check all that apply:
❑ lam not using a Recology debris bin, however, the project is less than 3,000 s.f., e.g. buildings, patios,
sidewalks, driveways.
❑ 1 will use a Recology debris bin. By Agreement with the City, Recology will prepare my required
Waste Management Plan & Recycling Report. Contact :Recology: (408) 7254020.
❑ I am not using a Recology 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 building permit
application. No fee for this plan. Forms are available at the Budding/Public Works counter and online
at www.cupertino.org/environmental. Report the tonnage recycled and disposed, by material type.
Recycling facilities must be selected from the City's approved list of Recycling Resources.
✓ Submit a Construction Recycling Reportjbrrn. The report is required before the Building
Department will schedule a final inspection. The report form is available at the Building/Public
Works Counter and online wwvw.cu ertino.or /environmental.
Signature:
Name: (printed) 84A.1C � m
Title: G r u tom I U , c mr-
Phone: Yo 8, 6 ro C— 1.7 S.5
Project Address: log 60 71 o LOAS C"U �f .
This form to remain in the project's building permit file for the duration of the project.
Revised 317112 1
Date:_ I' J- 20
Pacific Gas and
Electric Company'
DATE: January 5, 2015
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:
December 29, 2014 @ 10860 JOHNSON AVE CUPERTNO CA
SUBJECT: ELECTRIC SERVICES WAS CUT AT POLE ON:
December 22, 2014 @ 10860 JOHNSON AVE CUPERTNO CA
If you have any question contact us at (408) 725-3325
Sincerely,
John Gambucci
Pacific Gas & Electric Company
DeAnza Service Planning Dept.
JV
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BAY JA
PEST CONTROL
Bay -Valley Pest Control
120 Kennedy Ave.
Campbell, CA. 95008
RODENT INSPECTION REPORT
(408j 370-1603
(408) 244-6744
(650) 966-1313
^
I nspacdon Date lazi;i- 14
Customer Name: � ay n f--e-kz- a �n Account #:L r�
Service Address: 1 d 27klb Map Grid:
A 50\4
Identification: Rats Mice Other
Points of Access
Recommended Repairs and Suggestions:
Balt Stations Located:_
NOTE 1: If You (the homeownerlmanagerltenant) have elected to do the repairs necessary to prevent rodents
from re-entering the structure:
o Above repairs, must be done 10.14 days from the Inspection date (not before, unless your technician
states differently). These room must be done timely.
If no activity has been seen or heard, begin repairs. If any questions prior to repairs, call our office.
o You will be notified by phone approximately 4-6 weals following the original Inspection dale
for a -no charge follow-up service'. If repairs are complete and correct, we will remove and dispose of
any left over bait.
o If repairs are not done on time the guarantee will be compromised.
NOTE 2: If you elect Bay -Valley Pest Control to perform the repairs necessary to exclude rodents from the home:
o Call to set-up or confirm an appointment for the work to begin.
o Costs quoted on this report are for the above found repairs Including materials, labor and guarantee.
if any new or additional conditions to this report are found they will be discussed with the homeowner
and quoted separately.
Rodent Exclusion Quote$
Estimated RepairTime
Customer Authorization for Repair Work
(you will be notified by phone for scheduling)
Guarantee and Repair information: Refer to your contract for spedflc guarantees.
o In some cases, certain repairs rhay need to be done by a contractor -or other suitable business, If this is the
for. repairs done by Bay -Valley Pest Control. The above quote will Include
only repairs we are qualified to do, the technician will advise you If these cirbumsstances appear: remptos of -
work Bay -Val ley Pest Controfwoutd not perform, but may be mentioned in this report are; TreeBushiShrub
trimming or removal, Garage door replacement, Roof work, Dry Wall or Siding, Painting of repaired areas, etc..
o Repairs not to be done by Bay -Valley Pest
o Recommendations:
Additional Comments, if
MAW
Customer Signature Technician Signature
1 d BLEL99880b1 XH3 13rd3SHI dH EO:Z 6102 61 oa0