15060194I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 1199 STAFFORD DR
OWNER'S NAME: JACK TSAI
OWNER'S PHONE: 4089378871
R LICENSED CONTRACTOR'S DECLARATION
License Class_ 13 Lie.#
Contractor 6�1 (Z,`jf(w �� Date C
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.
2. I have and will maintain Worker's Compensation Insurance, as provided for by
Se ion 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.
. IMMIA
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
t. I, 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)
2. I, 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:
t. 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.
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
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,
Date
CONTRACTOR: DIANLI CHEN PERMIT NO: 15060194
CONSTRUCTION
10181 EMPIRE AVE DATE ISSUED: 09/15/2015
CUPERTINO, CA 95014 PHONE NO: (408)888-2898
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
ADD 798 S.F. TO CREATE (N) BEDROOM & LIVING RM.
ADD (N) PORCH (38 S.F.), RELOCATE & REMODEL (E)
KITCHEN (100 S.F.) & BATHROOMS (50 S.F.) REMODEL
Sq. Ft Floor Area: I Valuation: $100000
APN Number: 36211028.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAVS FROM LAST CALLED INSP C ION.
Issued by: lv'""I` ��' { Date: I ✓
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 9.12 and the Health &
Safety Code, Section 25532(a) 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 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent: /
ate• ��
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
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 O
(408) 777-3228 • FAX (4 8) 777-3333 • buildingCcDcupertino.orcl 6 V
❑ NEW CONSTRUCTION 9 ADDITION ❑ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT
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El OWNER O OWNER -BUILDER - ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
LICENSE NU1,1BER / LICENSE TYPE
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ARCHITECT/ENGINEER NAME LICENSE NUMBER
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DESCRIPTION OF WORK
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PROPOSED USE CONSTR TYPE I STORIES
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VALUATION (S)
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DEMO
TOTAL
AREA
AREA •� q V
AREA
NET AREA
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BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA t�
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
❑ ATTACH
I
I DWE INGUNrrS:
IS A SECOND UNrr ❑ YES
SECOND STORY ❑YES
BEING ADDED? NO
ADDITION? ❑NO
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN
- -- -- TOTAL VALUATION:
PLANNINGAPPLS ❑NO PLANNDQGAPPROVAL LETTER
EICHLERHOI<
By my signature below, I certify to each of the following: I am the property oxo aut
Ized aeent e property owner's beh If. I have read this
vverify
application and the information I have provided is correct. I have read the Description
n it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives -of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent:
Date:
SUPPLEMENTAL INFCTkMATION REQUIRED
P A�,c> cxTiPE
_ xouTinc sL>P s
❑ o«R r> couLTER
❑ Buu nLnc PL NREVIE«!�
g
New SFD or Multifamily dwellings: Apply for demolition permit for
building(s). Demolition is to issuance building
existing permit required prior of
permit for new building.A.
❑ EXRRE S
�
❑ PLA'�'ITLRGPLA.T�
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
1111 -STAND ARD
❑ PUBLIC w oRI
form if any Hazardous Materials are being used as part o this project.
LARGIi
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❑'FIRED]^P7;*'1� �"f
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_Copy of Planning Approval Letter or Meeting with P arming prior toy
❑
submittal of Building Permit application.
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_AL -J ENVIROXMENTAL HEAliTii
BldgApp_2011.doc revised 06/11/11
1
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
OCCUPANCY TYPE:
DDRESS: 1199 STAFFORD DR
DATE: 06/30/2015
REVIEWED BY: MELISSA
W
N: 36211028
BP#:
"VALUATION: $100,000PE:
Building Permit
PLAN CHECK TYPE: Addition
PRIMARY
USE: SFD or Duplex
2nd Unit? Yes • No
OTC? 0 Yes ®No
PENTAMATION
PERMIT TYPE: 1 R3SFDADD
�
WORK
TO CREATE N BEDROOM & LIVING RM. ADD N PORCH 38 S.F.
���.F.
SCOPE
50 s.f.
$645.00
OCCUPANCY TYPE:
TYPE OF
CONSTR.
FLR AREA
s.f.
PC FEES
PC FEE ID
BP FEES
BP FEE ID
R-3 (Custom)
II-B,III-B,IV,V-B
836
$2,654.00
IR3PLNCK
$1,666.00
IR3INSP
PME Plan Check:
$0.00
50 s.f.
$645.00
Remodel, Bath (<=300 sf)
1 IREMRESBAT
Permit Fee:
$1,666.00
Suppl. Insp. Fee.S Reg. 0 OT
0,0
hrs
$0.00
= s.f. Remodel, Other
$431.00 IREMRESOTH
PME Unit Fee:
$0.00
PME Permit Fee:
$0.001,900
s.f. Re -roof
$323.00 IREROOFRES
Construction Tax:
TOTALS:
836
$2,654.00
$1,666.00
MECH, HOURLY 0 Yes O No
PLUMB, HOURLY 0 Yes Q No
ELEC, HOURLY 0 Yes 0 No
MISC ITEMS
Plunah. ;'
Plan Check Fee:
011ier alecri. Incl
;rlier Plumh Inst.E]__L_
/firer 1;r."ec. l��sf.
Li
:Lfech. h:sT.
,lsp. I c<-
1.1oc. Insp. Fec.
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
Dictrirt. otr L Thow feoc are hasod on the nreliminary information available and are onlv an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff 7;7.73)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$2,654.00
= s.f.
$645.00
Remodel, Kitchen (<=300 sf)
IREMRESKIT
Suppl. PC Fee: Q Reg. 0 OT
0,0
hrs
$0.00
PME Plan Check:
$0.00
50 s.f.
$645.00
Remodel, Bath (<=300 sf)
1 IREMRESBAT
Permit Fee:
$1,666.00
Suppl. Insp. Fee.S Reg. 0 OT
0,0
hrs
$0.00
= s.f. Remodel, Other
$431.00 IREMRESOTH
PME Unit Fee:
$0.00
PME Permit Fee:
$0.001,900
s.f. Re -roof
$323.00 IREROOFRES
Construction Tax:
0
0
Work Without Permit? Yes (F) No
$0.00
Advanced Planning Fee: IPLLONGR
$117.04
Select a Non -Residential
Building or Structure
E)
A
Trovel Documentation k'ees:
Strong Motion Fee: IBSEISMICR
$13.00
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$4.00
SUBTOTALS:
$4,454.041$2,044.00
TOTAL FEE:
$6,498.04
Revised: 05/07/2015
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS:O( �/
PERMIT # 60�Q
OWNER'S NAME: t.PHONE
# l —
GENERAL CONTRACTOR: gAAlL' Lp t/1
BUSINESS LICENSE # ),-
ADDRESS: o j (
)f e
CITY/ZIPCODE: C14 I -TO
*Our municipal code requirts all businesses
NO BUILDING FINAL OR FINAL OC(
GENERAL CONTRACTOR AND ALL S
BUSINESS LICENSE.
I am not using any subcontractors:
kidg in the city to have a City of Cupertino business license.
INSPECTION(S) WILL BE
ACTORS HAVE OBTAINED
Signature
SCHEDULED UNTIL THE
A CITY OF CUPERTINO
Date
Please check applicable subcontractors and complete the following information:
atu re
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
_
Tile
atu re