15020072I CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10750 S BLANEY AVE I CONTRACTOR: SIMON ZHANG I PERMIT NO: 15020072 1
OWNER'S NAME: TILL KEVIN AND XU CHANGYING TRUSTEE 118488 PROSPECT RD I DATE ISSUED: 05/08/2015 1
OWN"'S PHONE: 4088580987 I SARATOGA, CA 95070 I PHONE NO: (408) 887 -0591 I
h I` LICENSED CONTRACTOR'S DECLARATION
License Class Lic # 0
Contractor O
1 hereby affirm that I am licensed un1pine
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.
1 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
K erflonnance of the work for which this permit is issued.
ave 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. �- ---- -- �- � 1�
Signature- ate
❑ OWNER- BUILDER DECLARATION
1 hereby affirm that I 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.
Date
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
CONSTRUCT A ONE STORY ADDITION (827 SQ FT);
BATHROOM REMODEL (50 SQ FT); ELEC PANEL
UPGRADE
(200 AMP); INSTALL (N) FURNACE IN ATTIC.
Sq. Ft Floor Area:
Valuation: $100000
APN Number: 36923056.00 1 Occupancy Type:
PERMIT EXPIRES IF
WITHIN 180 DAY
180 D
NOT STARTED
ISSUANCE OR
) INSPECTION.
5/s / /.5__
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 Applicant: 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.I2 and the
Health & Safety Code, Section 25532(x) should I 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 Code, Chapter 9.1 and
the Health & Safety Code, Sections 25505,2_S and 25534. n I
Owner or authorized agent:
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
I understand my plans shall be used as public records.
Licensed Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
D�
i
CUPERTINO (408) (cD
777 -3228 • FAX (408) 777 -3333 • buildinacupertino.org
❑ NEW CONSTRUCTION [Z /ADDITION ❑ ALTERATION I TI ❑ REVISION I DEFERRED ORIGINAL PERMIT 4
PROJECT ADDRESS r7��'Li nS i
/-
APN 4 �6q_ Z Z -v -r
/
OWNER NAME PHONE / Y 4� k aJ E -MAIL ii t? 4w'
STREETADDRESS CITY, STATE, ZIP /.'2 e� „ ` GtJ D �� FAX
CONTACT NAME i � PHONE p C' � GrL� � %
E -MAIL C
� L
STREET ADDRESS i, � f � /' � �G
CITY, STATE, ZIP
❑ OWNER ❑ p'VNER- BUn.DER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTORAGENrr ARCHR`ECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER LICENSE TYPE
BUS. LIC 9
COMPANY NAME
E -MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCATECT/ENGINEER NAME LICENSE NUMBER
BUS. LIC #
COMPANY NAME �� /- i l�d 607
E'I IAIL I <L.li� �� i `i cif�i
FAX�O r.°
yt
v 'f ,'J
6
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
V" kre lm-1 kr?-ym f..-0-) uy'i'�
EXISTING USE PROPOSED USE CONSTR TYPE ISTORIES
Y
USE
TYPE
OCC.
SQ.FT.
VALUATION (S)
EXISTG
AREA
NEW FLOOR
AREA ���
DEMO
AREA
TOTAL
NET AREA
/
BATHROOM
KITCHEN
OTHER
REMODEL AREA jv
RE AODEL AREA d
REMODEL AREA
PORCH AREA
DECK AREA
OTAL DECK/PORCH AREA
GARAGE AREA: D�i'ACH
O
_ -_-
3l TTACH
R DWELLING UTTI'S:
OND UNIT ❑ YES
±.ENGAI)DED?
SECOND STORY ❑ YES
/
1p NO
ADDITION? NO
PRE. APPLICATION ❑ YES IF YES, PROVIDE COPY OFF
IS THE BLDG AN ❑ YES
REGEIVED . ¢
-- ,� , _t';
TOTAL VALUATION:
PLANM. NG APPL 0 P NO PLANNING APPROVAL LETTER
EICHLER HOME? NO
By my signature below, I certify to each cfthe following: I am the property owner or authorized agent to NtQz the ro ehalf. I have read this
application and the information I have provided is correct. I have read the Description of'Vork and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building constructi0 . I authorize representatives of Cupertino to enter the above - identified property for inspection purposes.
SignatureofApplicant/Agent: Date:
SUPPLEMENTAL INFORA ON REQUIRED
� =
New SFD Or Multifarnily dwellings: Apply for demolition permit for
°,b
0\ ER 1COTJhTER
t s
�BUILDIj4GPLAN REVIEW
- .
existing building(s). Demolition pennrt is required prior to Issuance of building
h
hZ
permit for new' building.JEaPRESS#
❑ P�AAINGFPLANFiEi7ER 1 t
Commercial Bldgs: Provide Hazardous Materials Disclosure
; VF �
❑ s �
_ a completed
S RD
r�i7Bircrt�o �x
form if any Hazardous Materials are being used as part of this project.
xz
_ Copy of Planning Approval Letter or Meeting with Planning prior to
DR��'4
x,Y
CI
submittal of Building Permit application.
2AJO
F$AhTlARYSEtiERDISTRICT r
�g
BldgApp_2011.doc revised 06121111
Fm_ff CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
OCCUPANCY TYPE:
ADDRESS: 10750 S Blaney Ave
DATE: 02/11/2015
REVIEWED BY: SEan
1W
ANN:
BP #: �'
''VALUATION: $100,000
xPERMIT TYPE: Building Permit
PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex
USE:
2nd Unit? Yes No
OTC. Ci Yes : �No
PENTAMATION 1 R3SFDADD
PERMIT TYPE:
WORK
Construct a one story addition 827 sq ft); bathroom remodel 50 sq ft).
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,111- B,IV,V -B
827
$2,654.00
IR3PLNCK
$1,666.00
IRMNSP
PME Plan Check:
$0.00
Permit Fee:
$1,666.00
Suppl. Insp. Fee:Q Reg. Q OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
TOTALS:
827
$2,654.00
$1,666.00
MECH, HO RLY D Yes 0 No
PLUMB, HOURLY Q Yes No
ELEC, HOURLY Q Yes Q No
MISC ITEMS
Plan Check Fee:
$2,654.00
= s.f.
$645.00
Remodel, Bath (< =300 sf)
IREMRESBAT
Suppl. PC Fee: 0 Reg. 0 OT
Lj
hrs
$0.00
PME Plan Check:
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 addn'1 info.
FEE ITEMS (Fee Resolution 11 -053 Eff 7/!/13)
FEE
QTY /FEE
MISC ITEMS
Plan Check Fee:
$2,654.00
= s.f.
$645.00
Remodel, Bath (< =300 sf)
IREMRESBAT
Suppl. PC Fee: 0 Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$1,666.00
Suppl. Insp. Fee:Q Reg. Q OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
0
0
Work Without Permit? 0 Yes (j) No
$0.00
Advanced Planning Fee: 1PLLONGR
$115.78
Select a Non - Residential
Building or Structure
E)
Q
Strong Motion Fee: 1BSEISMICR
$13.00
Select an Administrative Item
1
B1dV Stds Co mission Fee: IBCBSC
$4.001
SUBTOTALS:
$4,452.78
$645.00
TOTAL FEE:
$5,097.78
Revised: 01/06/2015
670
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: I 05o o S Blaiieu
Ave IkD
PERMIT #
OWNER'S NAME: d r,
PHONE #
GENERAL CONTRACTOR: }/YYL f (!/►n
BUSINESS LICENSE #
ADDRESS:I U
CITY/ZIPCODE:
*Our municipal code requires allibusinesses woriking in the city to have a City of Cupertino busiJess license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTIONS) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
V
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
on
Electrical
D p ELECTK«Al CO
2 J_Z qeS
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
ZkH Pl i?dianiat (a6.
344 S
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
MWAIL INC .
p D
Tile
Owner / Contractor Signature
[ I i �-/ IS-
I Date I
no